Why does your knee keep on hurtin’?

As the adage goes “ The more treatments we have for something, the more we don’t understand the cause”, it seems that anterior (front) knee pain or patellofemoral (kneecap) dysfunction would fall into that category. We understand that a torn meniscus or torn anterior cruciate ligament requires surgery. So how about that nagging, chronic pain in the front of your knee. The kind of pain that returns on a whim and makes you think twice about returning to your break-dancing hey day at your nephew’s wedding. The kind of “twinge” that shrinks your confidence on the 18th hole of your company’s summer, for-boasting-rights golf outing. The reason—not as obvious. So here’s one for you, for boasting rights, of course. In Dye et al (AJSM 1998), the lead researcher decides that he would be the guinea pig in a “mapping” of pain responses during arthroscopic probing, WITHOUT anesthesia, of his anterior knee and patellofemoral joint. Ouch!! The authors rated the level of conscious awareness from no sensation to severe pain. They also subdivided the results based on the ability to accurately localize the sensation. So what did they find? They found that palpation to the anterior synovial linings and capsule (front aspect of the inside of the knee joint), retinaculum (ligament on either side of the knee cap), and fat pad (underneath the patellar tendon) produced moderate to severe pain. The most interesting thing about this study, besides the masochistic aspect, is that NO sensation was detected on the patellar articular cartilage (the underside of the kneecap) even in high level “chondromalacia” or arthritis of the undersurface of the kneecap. The implication of this study is that anterior knee pain is NOT caused by the patellofemoral or kneecap joint.

To take it a step further, Faulkerson et al (Clin Orthop 1985) reported a direct relationship between the severity of pain in the anterior knee and the severity of neural damage within the lateral retinaculum (ligament on the outside of the kneecap). They found that patients presenting with moderate to severe pain were found to have the highest degree of change in the neural tissues of the lateral retinaculum. Very interesting! I’m sure you would agree.

What this means for your therapy is that we can utilize manual therapy and taping strategies to address the neural and soft tissue changes in the lateral retinaculum.  KinesioTaping techniques can produce a “proprioceptive override” effect in which the stimulation of the tape on the skin can override and cancel out the pain receptors. This, of course, is an adaptive process that occurs through consistent intervention and compliance with a home exercise program. Let us show YOU how to get back control of your knee pain.

So what’s up with the Shape-Ups?

So what’s up with the claims made by these toning shoes??

I’m sure that you all have seen advertisements for the new rage in footwear…”toning” shoes. Several manufactures such as Shape-Ups by Skechers, MBT shoes, and EasyTones by Reebok have made unsubstantiated claims of increased gluteal activation and improved muscle tone as a result of wearing their products. A recent study sponsored by the American Council on Exercise compared 12 patients walking in “toning” shoes to 12 patients walking in traditional walking shoes. Researchers used electromyography (EMG) to evaluate muscle activity in several muscles of the lower extremity including the calf, quad, hamstrings, glutes, low back paraspinals, and the abdominals. The results indicated that none of the 3 studied brands of “toning” shoes exhibited a statistically significant increase in muscle activation. The researchers concluded that there is “simply no evidence” in their study to substantiate the “toning” claims made my the 3 shoe manufactures.

So why is that some patients feel better in “toning” shoes? These shoes are constructed with a rounded or rocker-bottom sole. This type of sole is designed to allow you to “roll” from one step to the next. It would thereby get you to transition more quickly from heel strike to toe-off and, as a result, decrease the amount of time that you are bearing weight on your midfoot. It would lessen the impact load on an arthritic or painful midfoot. It may also limit the amount of bend that is occurring in a painful or arthritic toe.

And: The heels of these shoes are very soft and may decrease the impact load on a painful heel.

And: Because of the raised apex of the rocker-sole, it feels to some of my patients that they are bearing more pressure against their arches thereby decreasing the weight bearing on the heel and the forefoot.

And, lastly: If you watch someone with “toning” shoes walking from behind, you will notice how their ankles tend to look a little unstable due to the softness of the heel and the rocker-bottom effect. This may predispose the patient with a chronic weak ankle to acute sprains. However, it may also have a positive impact on neurologic retraining ie proprioceptive retraining of the foot and ankle. Pre and post balance testing for “toning” shoe wearers would be an interesting thing to test.

But anyways, “Different strokes for different folks”…just don’t be fooled by the claims.

How “HIP” is your knee pain?

“The knee bone’s connected to the…hip bone” may be your therapist’s greatest clue to solving your knee pain.  How many patients have gone to physical therapy for knee pain and received an ultrasound & quad exercises only to be disappointed in his or her outcome?   What exactly is the link between knee pain and hip weakness?  What does the research tell us?

Patello-femoral pain syndrome (PFPS) (pain under the kneecap) is the most common condition seen in an orthopedic practice.  It is the most prevalent injury in persons who are physically active.  Iliotibial band syndrome (ITBS) is the second most common overuse injury in runners.  Anterior cruciate ligament (ACL) injuries are one of the most common ligament injuries in people who engage in athletics.  What common factor contributes to ALL of these orthopedic conditions?  You guessed it!!  Weak hips!  Read on for the proof.

In a recent review of the literature, Reinman cited 51 articles that provide some degree of evidence correlating hip weakness to knee loading and knee injury.  The position of the knee relative to the hip during weight bearing activities is a predictor of dysfunction.  Excessive hip adduction and internal rotation (turning in of the knee such as being bow-legged) can adversely affect the motion and forces that act upon the entire lower extremity.  This combined motion produces a “dynamic” knee valgus.  A valgus force places a tensile strain on the iliotibial band as well as the soft tissue restraints on the inside of the knee, particularly the ACL and medial collateral ligament. Claiborne et al and Hollman et al have reported that reduced hip strength is related to greater knee valgus angles.  In the presence of hip abductor weakness (muscle that raises your leg out to the side), the opposite hip may drop during single-leg support causing a Trendelenberg sign.  This is especially apparent during a slow, “controlled” descent down a step.  A great functional test!

Why is it that the incidence of ACL injuries and PFPS is greater in women?   Prins et al concluded that females with PFPS exhibit impaired strength of the hip extensors, abductors, and external rotators.  Chen and Powers report that females with PFPS exhibit excessive “dynamic” Q-angles, especially with descending stairs.  Pollard et al states that females demonstrate insufficient utilization of the hip extensors due to decreased knee and hip flexion during a jump squat for example.  This leads to increased quad activation in the presence of a valgus knee and localizes the impact load onto the patella to a much smaller surface area.  Hence, more pain!

So what if you’re a runner?  Ferber et al looked at 283 studies that examined running-related injuries and concluded that the connections between weak hips and running were far more conclusive than the connection with flat feet (over-pronation).  Interestingly, Earl et al prescribed a hip strengthening program to healthy female runners for 8 weeks and, in addition to improved hip strength, they measured a 57% decrease in pronation (flat foot) while running.  Strengthen the hips and ditch the orthotics?  Maybe.

If it hasn’t become obvious yet, hip weakness has been proven as a predictor of knee dysfunction.  So in addition to your runs or to your crunches, you need a hefty dose of hip resistance training.  Call us and we can get you started!!

Kinesio Taping – How does it work?

Kinesio Tex tape is the world’s #1 elastic Kinesio tape. It is used by 78,000 practitioners in the United States and 150,000 worldwide.  It is being used by professional athletes and Olympians such as Kerri Walsh of the gold medal winning US women’s beach volleyball team.  Here at OrthoWell/WalkWell, we are KT1 and KT2 certified in the Kinesiotaping Method.  How does Dr. Kenzo Kase , the inventor of Kinesio Taping, explain the concept of Kinesio Taping?

“ The concept of Kinesio Taping is the replication of the therapist’s hands on the patient’s skin using Kinesio tape.   The Kinesio tape mimics the qualities of the patient’s skin and success of the Kinesio Taping method depends on two factors.  One , proper evaluation of the patient’s condition by the therapist.  Two, proper application of the Kinesio Taping technique.”

So how does Kinesio Taping work?

AFFECTS ON MOVEMENT

Proprioception is our ability to sense our body’s static position in space.  Kinesthesia is our ability to sense how our bodies move through 3-dimensional space.  This “sense” occurs through several different types of sensory organs under our skin and around our joints that provide our brains with information about pressure, vibration, touch, temperature, and tension.   The effectiveness of the Kinesio tape lies in its ability to alter the sensory feedback that enters your nerves in the area that the tape is applied.  The contact of the tape on the skin appears to increase the ability of the joint and/or tissue to detect movement and to respond to outside forces.  As a result, this has a positive effect on the communication between your brain and the affected tissue which, in turn, could enhance athletic or movement performance.

AFFECTS ON PAIN

The sensory feedback from the tape has been hypothesized to reduce pain by stimulating large nerve fibers under the skin.  The input from these nerves fibers travels more rapidly to the brain than the input from pain receptors.  This is the concept of the Gate Control Theory of pain in that the sensory input overrides the pain input, thus, reducing the sensation of pain.

AFFECTS ON SWELLING

An important concept of applying Kinesio tape is “less is more”.  Athletic taping is used with tapes of high tensile strength in order to stabilize and/or reposition a joint.  Once applied, the tape resists being stretched.  Kinesio tape is applied with low levels of tension.  In most applications, the tape is applied with the affected tissue in a stretched position so that the tape has a convoluted appearance when the tissue is at resting length.  As a result, the tape has a “lifting” effect on the skin which improves circulation and lymphatic drainage below the level of the skin.  This effect can create channels of low pressure in a congested area as well as assist in opening the epithelial flaps that are present on lymph vessels resulting in a significant reduction in swelling.

“>Check out our You Tube video link in the slider on the bottom of this page to see a Kinesio Taping technique for reducing knee swelling.

Check out our post on the research behind KinesioTape.

IT HURTS!! HEAT or ICE?

As your therapist, one of my most important roles in your recovery is teaching you the fundamentals of proper healing.  Healing of injured tissue is a physiological process that can be inhibited by many factors.  Pain management strategies, activity modification, and proper exercise are three such factors that need to be examined.

PAIN MANAGEMENT

All new injuries or aggravation of old injuries need to be addressed with the acronym P.R.I.C.E.  –  Protect, Rest, Ice, Compress, Elevate.  We will talk about the protection aspect in the next section on activity modification.  After an acute injury, there is resulting tissue trauma and inflammation.  Inflammation is part of the healing process as the body attempts to bathe the injured tissue with protein rich fluid as well as cells that cleanse and repair the injured tissue.  Inflammatory cells can be present up to 21 days after an injury, but are the most prevalent during the acute inflammatory stage i.e. first 7-10 days.  Uncontrolled inflammation is what delays healing and it is what we attempt to control with R.I.C.E.  Ice should be applied for 10-15 minutes only in order to prevent frostbite.  You can use soft, gel cold packs, bags of frozen peas or ice, or submerge the injured part into an ice water bath.  You can ice every hour if you wish, but at a minimum of 2-3 times per day, for at least the first 7-10 days.  Remember that the inflammatory process (in the controlled environment) can last 21 days.  The adage “ice for the first 48 hours only” does not make physiological sense.  Icing is not only anti-inflammatory, but it is also a great pain reliever.  You should also consult with your physician regarding an anti-inflammatory medicine.  Examples would be medicines such as Aleve 2x/day or 600-800mg of ibuprofen i.e. Advil or Motrin 3x/day for at least 7-10 days.  Compression and elevation of the injury helps to prevent uncontrolled inflammation as well.  Athletic taping, neoprene or Acewrap sleeves for ankles or knees, and back braces are examples of compression as well stabilization of an injury.  Heating tissue can be relaxing and pain relieving, but it also causes the blood vessels to dilate, hence, increasing the flow of fluids to the area.  If you wish, heating for 15-20 minutes can be added after the first 7-10 days as long it does not increase the swelling.

ACTIVITY MODIFICATION

Protecting the injury will prevent uncontrolled inflammation, thus encouraging proper healing.  Pain is a warning sign.  It is your body’s attempt to remind you that something is wrong.  Pushing “through the pain” is NEVER a good idea.  When a lower extremity joint is injured and walking becomes painful or limited, we advise and instruct patients in using crutches or canes.  This is a temporary modification of activity in order to prevent reoccurrences of pain as the body is healing.   Our patients use an assistive device as long as is needed, but most typically for the first 7-10 days.  Proper posture and body mechanics are also very important in removing the stresses to an injured back or spinal condition.  Remember that causing pain during activity is like taking a hammer and “banging” on the injured tissue.  Take frequent breaks and pace your activity as to not provoke your pain.  It is important to wean slowly back into walking or running.  We will help to guide you in that process.

PROPER EXERCISE

Proper exercise can be initiated after the acute inflammatory stage.  Movement of joints and tissues during exercise causes a mechanical “pumping”.  This “pumping” can help to “push in the good and push out the bad”, prevent post-traumatic stiffness, and encourage a quicker return to function.  Proper technique in these early stages would entail pain free, high rep, and low weight exercises.  We will guide you in that process.  Creating a global circulatory effect via pain free cardiovascular exercise is also beneficial to healing as it helps to cleanse and nourish the injured area.

I hope that helps!!

Chris Dukarski, PT

The importance of closed-chain exercise.

Closed chain exercises for the lower extremities (exercise with you feet contacting the floor) should be an integral part of your rehabilitation program.  They are important in terms of regaining dynamic stability and improving neuromuscular control.  Co-contraction of the muscles on all sides of a joint occurs only thru closed chain or weight bearing activities.  An effective program for a patient with an ACL tear of the knee should include exercises such as squats, lunges, and step-ups.  A patient recovering from an ankle sprain should perform balance board activities.  In terms of patello-femoral dysfunction or pain in the region of your kneecap, the literature describes a strong link between hip weakness (especially the hip abductors and external rotators) and P-F pain.  Open chain exercises such as straight leg raises should be performed in every plane of motion.  Closed chain exercises should incorporate multi-planar strengthening as well.  The following exercises include hip abductor resistance during a functional squat exercise and hip adductor resistance during a lunge.  Creativity is the key to devising a more functional and sport specific program.

At OrthoWell/WalkWell, we use evidence-based and creative strategies to get you better- FASTER!  The following testimonial is from a recent “graduate”.

“I’ve had major ankle issues for over 15 years and have seen several PT’s and specialists but saw no progress until I came to WalkWell.  After only 10 visits, I have made more progress than in the 15 years combined.  The individual attention and rehab is without peer.  And on the 8th day, God created WalkWell!” – Tom Lynch, Ipswich, MA

Patellar Tendinopathy – The role of Eccentrics.

Patellar tendinopathy can be a resistant and recurrent condition in running and jumping sports. An important part of your patient’s physical therapy program should include eccentric exercise. What are eccentrics? Eccentric contractions occur when the muscle-tendon unit LENGTHENS during exercise, producing so-called “negative work”. Squatting down is an example of a quad eccentric. Eccentric force production may exceed concentric (shortening contraction) and isometric (tensing without motion) forces 2-3 times. (Stanish et al) Eccentric training drills stimulate mechanoreceptors in tenocytes to produce collagen. (Khan et al) This effect helps to reverse the tendinopathy cycle.

The eccentric exercise commonly recommended for the patellar tendon is the squat. What kind of squat is best? A mechanism that may decrease the eccentric load on the quad is active or passive calf tension. This tension may limit the forward movement of the tibia over the ankle while performing a squat. This effect can be minimized, and load on the patellar tendon maximized, by performing a squat on a 25 degree decline. (Purdam et al) In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced good clinical results in terms of pain reduction and return to function. (Purdam et al) In the flat-footed squat group, the results were poor.

The eccentric training protocol for patellar tendinopathy should include 3 sets of 15 reps, 2 times per day, for up to 12 weeks.

“I started therapy at a rehab close to home but was not getting results after 12 visits. I then came to Chris and within 2 weeks (4 visits) the results have been substantial. What a difference!” — Kristin M.

CLOSED CHAIN CREATIVITY

Closed chain exercises for the lower extremities should be an integral part of your rehabilitation program. They are important in terms of regaining dynamic stability and improving neuromuscular control. Co-contraction of the muscles on all sides of a joint occurs only thru closed chain or weight bearing activities. An effective program for a patient with an ACL tear of the knee should include exercises such as squats, lunges, and step-ups. A patient recovering from an ankle sprain should perform balance board activities. In terms of patello-femoral dysfunction or pain in the region of your kneecap, the literature describes a strong link between hip weakness (especially the hip abductors and external rotators) and P-F pain. Open chain exercises such as straight leg raises should be performed in every plane of motion. Closed chain exercises should incorporate multi-planar strengthening as well. The following exercises include hip abductor resistance during a functional squat exercise and hip adductor resistance during a lunge. Creativity is the key to devising a more functional and sport specific program.

At OrthoWell/WalkWell, we use evidence-based and creative strategies to get our patients better- FASTER!   The following testimonial is from a recent “graduate”.

“I’ve had major ankle issues for over 15 years and have seen several PT’s and specialists but saw no progress until I came to WalkWell. After only 10 visits, I have made more progress than in the 15 years combined. The individual attention and rehab is without peer. And on the 8th day, God created WalkWell!” – Tom Lynch, Ipswich, MA