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1. Patients post meniscectomy exhibited decreased knee flexion moments during walking compared to contralateral limb – knee flexion moment increased over time from 3 months to 2 year follow up. This made me think of Heiderscheidt’s videos of ACL-R patients with decreased knee flexion moments years out from surgery and long after being allowed to return to sport. For the patient post meniscectomy, who is progressing well, but still walking with mildly decreased knee flexion on the operative limb – I may spend more time using a mirror or video of their gait to make sure they understand the compensation taking place and try to prevent it from becoming an unconscious habit.
2. Radial tears of the lateral meniscus resulting in no increase in contact pressure until they reached 90% or 100% of the width. These stats may be helpful in educating the patient with knee pain/dysfunction who has already had an MRI showing meniscus tear and has questions about why physical therapy can help or if they need surgery to address the tear.
3. Root avulsions can lead to meniscal extrusion, loss of circum. fibers, and inhibit the creation of hoop stresses, serving as a functional meniscectomy. I found this helpful in visualizing the impact of a root tear/avulsion on the function of the meniscus.
4. Partial meniscectomy involving up to 50% of the width of the posterior horn of the med. meniscus does not increase contact pressure in the knee joint vs. a complete med. meniscectomy can more than double contact pressures. No increase in contact pressure in this type of partial meniscectomy was surprising to me.I read the Lancet reviews first before taking a look at the BBC link. I’m glad that the BBC article is encouraging exercise/staying active and makes multiple points about decreasing the fear of movement/activity. Some of the BBC article points could use just a little more explanation(even though its purpose may be to oversimplify the lengthy topics in the Lancet reviews). For example, the BBC article states that scans/imaging is rarely indicated because it’s often inconclusive. Whereas, the Lancet article talks at length about how imaging findings in people with LBP can be found in asymptomatic people – no evidence exists that imaging improves patient outcomes – liberal use of imaging triggers additional medical care and increased risk of adverse outcomes.
I guess I should probably just be glad that information discouraging unnecessary use of imaging, medications, and medical procedures is reaching the general public and hopefully encouraging people to learn more about their medical care.I really enjoyed the Running Med Conference.
Bryan’s lectures were very helpful in demonstrating a simple, structured format to video gait analysis. I think screening patients based on overstriding, bounce and compliance will make it easier to review video with runners and explain to them what I’m seeing without going into too much excessive detail. Another take away was the use of a 3 or 5 point system when analyzing gait vs. drawing lines on the ipad and relying on the angles(due to user error, lack of specific landmarks, clothes moving on anatomical landmarks, etc.) He also made a good point about being careful when judging calcaneal eversion in frontal plane view (eg if the runner’s foot is externally rotated, then the camera angle will not be perpendicular to the motion you are trying to estimate, thus adding error to your estimate). In general, I’d like to standardize the distance from the treadmill I use for frontal and sagittal plane video so that I can more accurately compare videos.
Similar to what Katie said, the video of athletes 1-2 years after ACL-R was eye-opening.I feel like I came away with a much better understanding of external KAM and how that relates to compression at the medial compartment of the knee. I think it will help me pick up on compensations in the gait patterns of some of my patients with OA related symptoms at the medial knee.
Hi Sarah,
I’ve never worked with a patient status post PAO, so I can’t offer any personal anecdotes.
In terms of D/Cing her cane – What does her gait look like now with the cane? Has it normalized or do compensations persist?
If the patient is eager to ditch the cane, but her gait is still antalgic, I may consider showing her video on the ipad of her gait before and after increased activity. Or perhaps you could set a benchmark distance/time that she needs to be able to walk without increased pain/worsening gait before discharging the cane.As for cues/strategies to decrease hyperextension and fat pad irritation- I usually try to make sure they understand how their standing static posture may be contributing to that irritation. I ask pts to pay attention to how they stand and make sure they aren’t hanging out in hyperextension. One idea I’ve heard, but haven’t tried, is to use a piece of kinesiotape with very little tension on the posterior knee/thigh just to give the patient a tactile reminder when they hyperextend.
Not too sure about special questions to help narrow down PFPS.Hi Katie,
I think I would consider an orthotic for this type of patient presentation if they did not respond to treatment strategies addressing the more obvious impairments over the course of 2-4 weeks. I think the dynamic knee valgus, signif. quad and hip abduction weakness, and poor control of loading the foot during single leg activities are all things that may respond to teaching and cuing proper movement patterns. If she wasn’t able to improve her control and decrease symptoms over multiple sessions, then maybe I think about an orthotic. My personal bias makes me hesitate to turn to an orthotic too quickly for someone who is 14 and may still be able to improve/change the way they move to address their symptoms. I’d also want to see how she moves/transitions to the squatting position for catcher and determine if that has some role vs. just the demanding position of squatting for long periods.
Hi Tyler, thanks for the post –
1. Regarding more info I’d like to know – I’m curious about rectus femoris tightness and iliopsoas. And soft tissue mobility of quad and suprapatellar pouch?
2. As for taping, I’ve had some success with kinesiotaping for patellofemoral pain. A medial and lateral “C” taping around the patella – easier to demonstrate than explain.Hi Katie,
1. Nature of Sx seems consistent with athletic pubalgia(despite not being a high level athlete, or was he?). Diff Dx: Si joint dysfunction, pudendal nerve entrapment, pubic symphysis dysfunction, FAI, iliopsoas tendinopathy.
2. I think the family history of CA and chronic nature of symptoms could contribute to hyper awareness concerning his pain.
3. Aggravation of symptoms with emptying a full bladder is concerning. I assume he’s seen a urologist? Is he being followed by other Dr.’s besides his primary care? He sounds appropriate for PT but I would want to make sure he has been completely worked up by his referring physician. Any imaging?
4. If I’m unfamiliar with a patient’s presentation, I try to make sure I explain well what I think is going on and make sure the patient understands the plan and what the next step will be if that plan does not work.
5. This one’s hard to answer. I would probably address a movement pattern that he has to do for work (eg squatting) and try out a couple of exercises that may improve that movement pattern or decrease symptoms with that movement pattern.As for subjectively, I’d want to know the specifics of her left shoulder injury and how she arrived at surgery, as well as her rehab post surgery.
Objectively, I have the same question as Katie – ER/IR AROM/PROM?
As for treatment strategies, I try to teach the caregiver how to use their body effectively for transferring their family member so they can decrease unnecessary stress on the shoulder. Kinesiotaping as a proprioceptive cue for posterior tilt of the scap has been helpful at times.Hi Sarah,
Great summary of your case.
1. For a patient like this, I would likely try some scapular mobilizations first day, assuming that she doesn’t tolerate Glenohumeral mobilization as well. I might try ice with the shoulder positioned and supported by pillows – and instruct the patient to try the same at home when symptoms are aggravated. I’ve had some success with taping the shoulder encouraging posterior tilt of the scapula, which could be an option to help decrease pain with ADL’s. In terms of activity modification, I try to encourage the patient to be mindful of how they move. I try to express that I understand they have to do certain movements, and that’s okay, but I’d like them to be more aware of how they are moving during those challenging tasks. In this example, I would look at her movement pattern with lifting an assistive device. It’s awkward placing a rollator or wheelchair into a car, so I think it can be tweaked to avoid a long lever arm at the shoulder. Depending on the specifics of her car, there’s usually an easier way to get a device loaded that hasn’t occurred to the caregiver.Hi Jen,
Primary Hypothesis: L5-S1 disc pathology.
Differential Diagnosis: L5/S1 facet w referred painSome questions that come to mind that you may have checked: Observationally, is there any type of lateral shift in standing? Is her gait normal? Do her symptoms peripheralize or centralize with AROM? Repeated motion? Any LE weakness?(did you mean weakness with heel raises?) I know she reported numbness/tingling intermittently – Is dermatomal sensation intact?
Manually, I may try uni or central p/a’s above the painful segment depending on how she tolerates it. I may try some extension PPIVM’s in sidelying.
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Objective: Progressively loading the system during the exam and looking for movement patterns or compensations that may explain why the injured region was overly stressed. Palpating in a methodical, repeatable pattern to improve accuracy.Treatment/education: Making sure the patient understands that returning to running without re-injury requires appropriate loading. Prescribing cross training options to help increase compliance with a gradual walk/jog program. For the patient with history of multiple stress fractures, keeping a training log would be beneficial to help them regulate their mileage.
Subjective: This article reminded me of the importance of getting a clear picture of how the symptoms have changed/progressed over the course of the injury. Specifically asking if the symptoms improve during the run or improve with warming up could be a helpful question when trying to rule out BSI. I think I can do a better job of getting more diet/nutrition information from the patient, especially when BSI is higher on the differential.
to be cont’d