Look at a biomechanical intervention

14 April of 2008

We are going to look at a biomechanical intervention first for his knee, and we can consider three different things. An OA knee brace, sometimes called an unloader brace. It is designed specifically for knee OA. We can look at a compression sleeve with a patellar support, since he does seem to have some tracking abnormalities. We can also look at a medial heel wedge or part of an insole that goes inside your shoe. This is what a knee unloader brace looks like. It can be designed for either medial or lateral compartment osteoarthritis and is designed to change biomechanically the joint. This is an example of the knee compression sleeve. They cost around $30 to $40. You can often buy them off the counter. This is essentially a soft brace with probably a polypropylene ring that helps capture the patella and not let it go just where it wants to go. So what is the evidence on that?

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So we use corticosteroids

So we use corticosteroids. We generally give them intraarticularly. And the patients very often do feel better, sometimes for quite a while. But, are there other ways to do it? Well, yes. This is from an article from down under by Sanbrook that looked at whether it matters that you inject into the joint. In fact others have found that we don’t always hit the joint when we try to aspirate and inject the knee. Even experienced rheumatologists, and yet you actually do have a better result if you get the cortisone in the joint. Sanbrook here says that the pain arises from structures besides those inside the knee, and half of his treated patients received a periarticular injection, like this around the patella, and the other half had intraarticular corticosteroid injections. After 12 weeks there was really quite a difference favoring this treatment. So now and then in a patient with knee pain, you might want to inject in a somewhat different route. Now, there are other reasons to aspirate and inject. In this particular gentleman who we wanted to send to physical therapy, removing the effusion can also improve his quadriceps strength, his quadriceps function temporarily which is inhibited by an effusion, and temporarily the corticosteroid may help him participate better in physical therapy.

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And from the physicians point of view

03 April of 2008

And from the physicians point of view, aside from being grateful for a successful physical therapy intervention, it also reminds us that many of the spots that seem to be sources of pain and pathologic are in fact just merely showing the effects of disordered biomechanics, which are maybe a temporary disorder and can corrected by specific exercise interventions.

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Relaxing way to stretch the iliotibial band

01 April of 2008

I just want to show you here a very nice and relaxing way to stretch the iliotibial band. It is a little more effective than some of the standing, weight-bearing positions that you often see. Although it does require that the person think ahead and not think that they are going to do it right before the hop on the track or head out in the neighborhood. Another good way to stretch hamstrings is just to lie up against a wall. We encourage people to maintain these positions for 15-30 seconds and practice some relaxation breathing. You can do the hamstring stretch bilaterally as well as unilaterally. Much better than having an assisted hamstring stretch.

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Activity modification

We also need to do the activity modification to give her time to get better and stronger. We are suggesting that she modify her training until her symptoms actually resolve. To move to three times a week, only one long run a week, and to be sure to include a pre-run stretch. We also are talking about five minutes of a walking warm-up for a musculoskeletal warm-up in her active muscles and also to choose run/walk intervals so that she doesn’t get into the pain cycle. We are also suggesting to her, anecdotally I might add, that she look for places that she can run and consider alternating right and left sides on the pitched running surface. People often do this as a way to use the surface to actually supinate the foot for most of the gait cycle. And people tell you that it’s effective for them. Also we will try to educate her so that she can develop some good self-management skills to replace her competitive athletic collegiate mind set of “no pain, no gain.”

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Prospective orthopedic surgery

31 March of 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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Our thought was that she had anterior knee pain

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.

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This is just to start us off with a wonderful picture

24 March of 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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The first thing is that when we are weight-bearing

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.

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