Archive for March 24th, 2008

This is just to start us off with a wonderful picture of a really good quadriceps muscle. One that, unless we are in sports medicine, we may not often see but clearly discernible here on the medial side of the knee is the VMO and on the lateral side the vastus lateralis. When knee pain is felt to have a component of patellofemoral pain it is also important to understand that there are conditions which actually affect the compression of the patella against the femur. Increased knee flexion and increased quadriceps tension can independently increase this compressive force. Alignment of the patella on the femur and the congruence of the patella in the trochlear groove also are part of the total picture of compression and pain. For example, when we walk, compressive forces are about 3/10ths our body weight, but this increases to seven times body weight when we squat and have excessive knee flexion.
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In summary, when we look at the knee, we need to keep in mind that the knee connects two long lever arms and is affected by local, proximal and distal events. It depends on soft tissue, not bony configurations, for stability and also for the mobility that we need. It is full of complex joints and relationships. There are actually 14 muscles that control the knee; six act only at the knee but seven also act at the hip and this is often forgotten, but won’t be today. And one also at the ankle. So thinking about the knee and the kinetic chain as a closed kinetic chain, which we see here, where there is at least partial weight-bearing and the feet are in contact with a weight-bearing surface. Whether it’s a closed kinetic chain or an open kinetic chain, which we see here, and although many people discuss what is an open kinetic chain, I think when you can see the soles of their feet it’s pretty much assured that you are talking about an open kinetic chain. But whatever the case, open or closed kinetic chain, what we need to remember is that we must consider the knee in terms not only of what it does and where it is, but also as a response to forces and conditions in its environment. I’ll now turn the podium back over to Bob and we will begin our vignettes, interestingly enough, with a sports-related case.
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Our first patient is a case of knee pain in a 35-year-old female jogger. She has complained of anteromedial knee pain, worse on the right. Present over the past couple of weeks of gradual onset. Improved with rest additionally, and now constant. Worsened by running, especially by longer runs. Thighs and shin pain on non-running days. Her goals are the discover the source of the pain, fix it and get on with her training. This occurs in the background of the fact that she is just beginning to train for a marathon and she has recently increased her mileage from four to five miles three days a week, to five to 12 miles five times a week. She has run a marathon before, some ten years ago and two children ago. She ran in college as a middle distance runner and some sort of knee problem then that was eventually arthroscoped, and she recovered from that sufficient to undertake day-to-day activities. Her physical exam, as she came in, was examined by the house officer. She showed medial peripatellar tenderness and patellofemoral crepitus. Was tender to deep palpation of the quads, hamstrings, anterior calf at rest and with contraction. Upon further review it was noted that she also had normal patellar tracking. when she extended her leg the patella stayed right in the midline. There was a tender medial synovial plica, just medial to the patella. There was no tibial femoral crepitus, no crepitus rising from the weight-bearing compartment. She had no focal tenderness over the tibial tuberosity where the patellar tendon inserted.

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A famous pill used in impotence treatment. The name of the medicine comes from the unification of vitalis and Niagara words. It’s a revolutionary innovation because before Canadian Viagra the lack of sexual reaction could be treated only with long lasting psychotherapy, injections or with artificial penis implants.

What can we call Impotence? Not only the complete lack of sexual reactions but also the difficulties on achieving and maintaining erection.

What should we know about Canadian Viagra? Canadian Viagra is a medicine, so it can be used only with caution. There’s a long list of medications that are dangerous to be taken with Canadian Viagra, because of this if you’re on Canadian Viagra and you need to take any other drugs, doctor must be consulted first.

How is acting? The Canadian Viagra increases the efficiency of hormones produced by sexual desire, which will cause better blood supply in penis, relaxing smooth muscle. So if there’s no desire, Canadian Viagra is useless.

It is true that 16 people died because of Canadian Viagra? According to rumors, yes, but they probably didn’t pay attention to the contra-indications (interaction with nitrate medications) or they overdosed Canadian Viagra. Any medication can cause death if overdosed. It cannot be taken more than one Canadian Viagra pill daily.

If I have normal erection but I want it to be better and more frequently can I take Canadian Viagra? No. In this case Cheap Canadian Viagra is strictly prohibited. It can overload your organism. If something works well why the risk to ruin it?

Is it true that Bob Dale, USA senator, took part in Canadian Viagra experiments? Yes. Bob Dale has prostate-cancer and to cure it, he had to take female hormones, which caused him erection problems. He was helped by Canadian Viagra. Of course he respected the dosage.

Are men affected psychically if they can make love only with a pill trough a lifetime? The answer is in the question! Most of therapists say that Canadian Viagra online can be useful temporarily but the long-term usage isn’t indicated. It damages the self-confidence if somebody can make love only with a medication, the person can feel that he is less valuable as a man than others. But it’s better to have a pill than nothing. The self-confidence is even more damaged if somebody can’t make love at all, so it happens often that this blue pill has positive effects on men’s morale too.

Have the Canadian Viagra side effects? Yes. Sometimes it can cause headache, low blood pressure, nausea and even color diffusion. There were cases when the patient’s perception of blue and green colors was switched by the Canadian Viagra.

So Canadian Viagra can be used as a narcotic too? Only sometimes because regularly Canadian Viagra doesn’t acts in this way. Generic Canadian Viagra is a medication not a dope and it’s over dosage is very dangerous. Anyway it’s better to avoid any kind of narcotics not to become dependent.

How many men are struggling with this problem? According to estimative numbers in USA, Europe and Japan are 50 million men suffering in impotence. Apparently this is another modern-age disease. Sexual-therapists are saying that the “spread” of impotence is caused by the subsistence, stress, sex without emotion and alcoholism.

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The first thing is that when we are weight-bearing we define the kinetic chain as being a closed chain anchored by the floor or the surface upon which the foot is resting. In the closed kinetic chain the relationship of the foot to the ground is of paramount importance to the knee. This photo shows calcaneal or rear-foot valgus – sometimes called eversion – and the common accompanying condition of excessive pronation or pes planus. Valgus refers to the relationship of the calcaneus to the tibia. We will be referring to this relationship frequently in this presentation. I wanted you to see clearly what we were talking about. This slide and the next illustrate common patterns of lower extremity alignment and we present them here to reinforce the fact that the knee is acted upon, and may compensate for, conditions both up and down the kinetic chain. Genu valgum, for whatever the cause, is usually associated with a lateral position of the patella, hip adduction, excessive pronation at the foot and an increased Q angle. All of these are implicated consistently in knee pain and are amenable to change.

The second common pattern is genu varus, also accompanied in this case by medial tibial rotation, hip abduction and compensatory pronation at the foot. I’m sure we are all used to seeing both of these painful conditions resting in the middle of both of these arrangements.

Now to look at the knee itself. This illustration depicts the expected path of the patella during knee motion. It moves vertically between flexion and extension and we expect it to move in a smooth, sinusoidal path. We will be addressing patellar tracking in the upcoming vignettes, however it is important that we all recognize that cases and cases of diagnosed patellofemoral pain, patellar abnormalities actually appear in only about half of the cases, so it’s not a universal problem. Of course, the quadriceps. Books are written on the quadriceps. We only have one picture. A central focus in any knee discussion is the quadriceps and the forces formed by its muscular components. It’s important for its crucial role in knee extension and sometime forgotten in its importance as a shock absorber during weight-bearing activities. However, it is also important for its role as a dynamic stabilizer of the patella but virtue of its various force vectors. Although there is controversy still – and probably always will be – regarding the details of the vastus medialis obliquus and vastus lateralis activation timing and strength. It’s fairly well agreed now that something going on here does contribute in many instances to understanding and treating patellofemoral pain.

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