Archive for March 31st, 2008

This is one of the few prospective orthopedic surgery studies involving arthroscopy in which patients with persistent pain and medial plica and arthroscopy were randomized to either have it resected to simply lavaged. The dark line on top are the folks that were resected and it denoted their likelihood to preserve a good or excellent result. So this in one of the intraarticular processes that one encountered in a person with chronic knee pain, that probably should be treated arthroscopically with resection. However, this was an early case. She wasn’t too far along and she had not had the benefit of a physical therapy evaluation and approach, so that’s what we did with her.
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Okay, so she is at physical therapy. We are going to do a biomechanical evaluation here and when we do we find that she has some tight structures, not unusual for a young person, even a runner. Iliotibial band, hamstrings, gastrocnemii soleus tightness. We find relative weakness and some imbalance in her quadriceps and hamstrings. A little bit, about five degrees, of that rear foot valgus we showed you before, and she does seem to have excessive pronation on weight-bearing, particularly when she is running. Generiс Bactroban online

Our evaluation of this is that what we are seeing is an athletic or overuse injury due to an increase in training intensity and relative lower extremity deconditioning. So that relatively minor impairments are exacerbated by increased demands. Our goal we developed with her is to reduce impairments, improve the mechanics, do some temporary activity modification to allow time for the tissue to repair and for training adaptations to occur, which will protect her in the future. The first thing we will look at is ankle and foot control and we thought we would try a trial of arch taping or commercial orthoses for arch support and some shock reduction, to see if that would help. We also have encouraged her and told her how to choose running shoes that are designed for stability and pronation control, rather than for flexibility and light weight. This is an example of the kind of patellar taping that can be done in the clinic. It’s nice to do, not just because people with do this regularly, but to do this once and then try weight-bearing and different activities, you can very often get a good idea of whether supporting the medial longitudinal arch is going to be effective or not. In this case, she chose to try some insoles or foot orthotics. You can see her standing here without the orthotics, with a Band-Aid on her knee, and here just standing on the orthotic. You can see the fairly pronounced change in the alignment of her feet just by changing the relationship of her foot to the ground, and therefore her ankle.
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Our thought was that she had anterior knee pain that was exertion related. Once upon a time this would have been put under the umbrella of chondromalacia patella, a term that fortunately is just about dead. There are conditions in which the patellofemoral articular cartilage degeneration is an important part of the process. This patient has a more advanced case of it. It’s a process that you can’t see well on an A-P x-ray, perhaps in the lateral. But with prolonged patellofemoral mis-articulation there can be fairly severe patellofemoral osteoarthritis develop, with this person with lateral subluxation. She has worn a new groove in her trochlear sulcus and has a large osteophyte. Other consideration for her, but was probably ruled out by the physical examination, was patellar tendonitis and that is largely made by physical examination looking for tenderness at the tibial tuberosity.

Another intraarticular anatomic process that she might have going on is a problem with the fat pad. This is a shot looking down from the suprapatellar pouch, underneath the patella, trochlear groove below, patella above and that little white thing in the middle is a fat pad. That’s a normal structure in all knees, but with some overuse syndromes it can become impinged, inflamed and a source of pain. This schematic shows about where it lies.

Another intraarticular structure that could be deranged here is the synovial plica, I mentioned in the physical examination. If you reach down with your thumb medial to your patella and rub back and forth, a good three-fourths of you should be able to feel something twanging there. It’s a common structure, a remnant of when the knee had three sections at about four months of gestation. They coalesce into one but septations remain behind. Especially between the suprapatellar pouch and the medial tibial femoral compartment. This is a normal structure, however it can become inflamed either as a primary process or in response to biomechanical forces. When inflamed it can be treated in various ways. If it persists after a simpler, conservative therapy it can be injected.

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