Posted by Canadian Pharmacy
Monday, Apr. 21st 2008
Now for this particular person, we aspirated and injected her knees and also injected her pes anserine bursa but still said there were some issues which she should address with a physical therapist.
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Our biomechanical findings in this person were much like some of the others that we have seen. Bilateral knee and plantar flexor weakness in this case as well as lack of ankle dorsiflexion. She has bunions as well. She also has more pronounced calcaneal valgus on weight-bearing and does have pronounced pronation. Her body mass index is over 30, which we know puts her well in the range of being obese. What we plan to do is address the foot posture and lack of dorsiflexion that contribute to her knee pain and bunions. She has problems with lower extremity alignment and strength that produces and unstable knee and poor shock absorption, which contributes to joint stress and damage, we speculate. She is sedentary, deconditioned, overweight, possibly depressed judging from her posture and her affect, and at high risk for secondary illnesses related to inactivity. Our goal is to reduce her knee pain, protect her joints, improve function and get her involved in daily physical activity. We are going to look at customized orthotics for this person rather than just off-the-shelf because of her weight and also because she more pronounced biomechanical problems there, and also try to get her fitted in athletic shoes that have a continuous rocker-type sole, which require less extension at the metatarsal joints and will allow her to move with less pain and less stress on that area. Also shoes that have adequate depth and room for her forefoot so she doesn’t continue to get pressure on her bunions.
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Here’s some examples of what we call semi-rigid orthoses and you can see here these all have an example of not only having some kind of control of the rear foot but also to support the medial longitudinal arch. They are worn easily in extra depth shoes. You can see here an example of what happens. What you can see here is the same person with a semi-rigid orthotic that has been customized for them and does support their medial longitudinal arch. So you can look very easily and see what happens when you change and control the foot, what happens at the knee. This is an example of a rigid foot orthoses which is not being used in arthritis as much but we are trying some trials of it at our institution now. It doesn’t give at all. It’s heavy, tough plastic, and what you see in there that people talk about as being the golf balls they have to walk on, are actually inserts that are firm and fit up right under the sustenaculum talus to actually mechanically support that bone so it doesn’t drop during weight-bearing. To wear orthotics like these is quite … people need a lot of support for the break-in period and they certainly need shoes like this to be able to accommodate them. I wanted to show you the shoe on the right, the white one, the Good Guy. That gives you an idea of a rocker-bottom sole that’s available commercially. The heels are often notched and the toes are up a little bit and it makes it easy for the person to progress over their forefoot, so they can be very comfortable and not expensive
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Posted by Canadian Pharmacy
Monday, Apr. 21st 2008
As clinicians who look begin to realize is there are lots of tender spots around OA knees in patients complaining of pain. What might they be? Well, orthopedists have long considered focal joint pain tenderness at the joint line as meniscus disruption. That may not be so. They’ve examined that themselves and have found that to actually be a pretty poor predictive sign. Talk about osteophytes stretched in the capsule causing pain, all the various insertions of muscles and tendons about the joint in the capsule can be irritated and inflamed and sources of pain. There are several bursae besides the pes anserine bursa. There is on under the medial collateral ligament. Of course there is the prepatellar bursa and the infrapatellar bursa. Tender points can serve as being referred from other areas and other things such as bony problems can sometimes have focal superficial tenderness. Here’s an indication of what an orthopedist thinks of when they palpate on the joint line, thinking that may indicate meniscal disruption underneath. In several prospective studies they have found that this is sensitive but poorly specific because osteoarthritis without meniscal disruption also has a tender joint line, very commonly.
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Here we see some common tender points and all the places they correspond to. This is the enthesis of the tibial fibular joint, the insertion the origin and insertion of the medial collateral ligament, later collateral ligament, insertion of the quadriceps muscle onto the superior popliteal patella, the medial synovial plica, sometimes there are lateral plica, joint line, tibial tuberosity for parapatellar insertion. In the back we have some other insertion sites, joint line and popliteus muscle. But when other cultures have addressed the tender points … well, before we get to that. Tender points have been examined fairly systematically in a recent study, a small study. When they looked at the effect of intraarticular anesthesia on patients with knee pain – simple study of 40 patients with knee pain, 10 they injected with lidocaine. They carefully examined the knees beforehand and then after. They also had patients complete questionnaires. This is actually … their main take-home point was that not everybody with a sore knee gets better after the injection, but most do and thus a lot of the pain really is mediated from intraarticular structures. Yet, if we look here at the various tender points that they found at baseline – and most of the patients had most of the tender points present – that not all of them are obliterated by intraarticular anesthesia, particularly this last one. Five centimeters before the medial joint line, or pes anserine bursa, nine had that before and seven had that later. So that’s an extraarticular source of pain that’s not modified by intraarticular treatment. The savvy old clinician will sometimes inject all these other tender points too, and I’ll confess to doing that myself, from time to time. The justification really isn’t in the form of data but in a few very old descriptions in the back of some foreign medical journals. But perhaps there are quite a few out in the audience that do the same thing.
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Other cultures pay attention to tender points about the knee and modify them in different ways. Notice how Ling Lang Kwan _ corresponds quite well to the pes anserine tender point. There is growing literature on the use of acupuncture in the treatment of osteoarthritis knee pain. The latest coming out of Baltimore published earlier this year, in which they took eight of these spots – and I confess, I don’t know which eight, but these are at least four – and subjected half their group to acupuncture treatments twice a week for eight weeks, and their control group was a similar group of patients with knee OA and pain who went about their conventional therapy with the same number of follow-up visits. So they had some observational effect. Certainly the acupuncture people had quite a significant reduction in their pain scores, compared with those who went on with medical therapy. Their pain began to rise a little bit after the completion of the acupuncture treatment, but overall it was an effective way of reducing their knee pain.
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