This is just an idea

22 April of 2008

This is just an idea of why having a pronated foot can be such a problem to the knee, and I think we should look at this as maybe why women have more knee OA than men. Floor contact forces go here, body weight forces go here. You can see here that there is a discrepancy between floor contact and body weight coming down. More body weight, a greater Q-angle, more genu varus at the knee. You are going to increase this distance here and as the talus comes down you will get more stresses on the knee. So this person particularly we really need to support the foot and try to keep that from happening. Our plan is actually to put her on a home program that was reported by O’Reilley and colleagues, which I’ll show you here in a minute. But we also need to really work on stretching her plantar flexors. What you are seeing here is the regular plantar flexor stretch but using a little rolled up towel to make sure that they get supination in the foot when they stretch their plantar flexors. Stretching over a pronated foot not only is not particularly effective but it really stretches the plantar fascia and people can end up with an awful lot of foot and heel pain.

The in-home exercise program reported by O’Reilley used a totally home-based exercise program with only four visits for instruction and they also found significant improvements in pain, physical function, Walmax score, SF-36 and anxiety and depression. The reason I show you this slide is that this woman is in this category here, at the highest risk for age-adjusted death rates and that comes from Blair’s earlier work where they showed that people with low fitness and who were sedentary have twice the death rate potential of people who are only moderately fit. And this is just the difference between people who are doing nothing and people who are doing something. The something that we will recommend for her and try to get her involved in is a physical activity for health, which is a recommendation from the Surgeon General in his report on physical activity. It’s not exercise, it’s not scary, it’s just being more active on most days of the week at a moderate level, so you can still talk to your friends and sing a song or whatever you do. The new information there for those of you who aren’t familiar with this is that people can accumulate 30 minutes of exercise during the day in as little as 10-minute bouts and get the same health effects as people who do 30 minutes continuously. For many people with lower extremity pain and arthritis, getting to 10 minutes of continuous activity is a good goal and is all they need to be able to do at one time to achieve those health benefits of moving from the low to the moderate category. We will expect to see her later and try to get her into some arthritis foundation and group programs. I think my bottom line as a therapist on this case is that in a patient with knee OA conservative management is not rest and inactivity.

We are also trying to present to you today, not always is the doctor first, but in the order that people with knee pain generally enter our lives and who they see first. In this case we have a 33-year-old fellow who is a golfer. He underwent arthroscopy about six weeks ago for unexplained knee pain and swelling. We don’t know exactly what they found. He says he was briefly shown some quad strengthening exercises that he doesn’t do very well, but he has taken to riding a stationary bike and lifting some weights because he wants to stay active and be ready for golf season again. He still has pain. It’s worse with use. Intermittent swelling and a periodic feeling that it’s going to give way. He self-referred himself to the therapist, wanting exercise and wondering about a brace. And this is the way he looked. I hope you can see this on the right knee, there is quite a difference in his ability to contract the quadriceps as compared to his left and it’s his right knee that hurts. I just want to reinforce the idea that pain inhibits quadriceps activity very dramatically. So although he tried hard to be able to contract both quadriceps and do his exercises, he physically was not able to do that. We put him on some dynamic exercise, and the reason we did is based on this finding by James and colleagues in Australia which actually showed that dynamic exercise, such as walking, cycling, actually improved synovial circulation in knees that have a fusion. As you can see here, the traditional isometric of straight leg raising or just staying in flexion actually decreases synovial blood flow. So we like to keep him moving, think his bike is good.

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