As a podiatrist dealing with foot mechanics, I am called to treat knee pain all the time. I have learned that there are many ways to help knees and understanding some basic principles can be greatly helpful. When I first joined the practice that I have enjoyed these 33 plus years, it was primarily an orthopedic practice. Most of my patients the first few years were there for knee pain treatment. I was fortunate to have Dr James Garrick, orthopedic surgeon, and Jack Rockwell, physical therapist, to help me develop my skills in treating knee pain. Of course, the patient's feedback on our treatments greatly helped me fine tune the process.
The schema below is meant to just begin to orientate you on knee anatomy. When talking about the knee, you talk about the quadriceps and patella (or kneecap) in front, the hamstrings in back, the "medial" side is closest to the other leg, and the "lateral" side on the outside of the knee. Podiatrists are not called to treat acute knee injuries initially, but need to know the mechanics when called to initiate treatment during the post surgical Restrengthening or Return to Activity phases, or when the surgeon is attempting to avoid surgery in the first place. Shifting weight, stabilizing the knee joint, strengthening the knee, etc, are all in the realm of a podiatrist during visits to help knee mechanics. Podiatrists are called routinely to treat knee injuries that are overuse in nature. This is 98% of knee pain that presents to an orthopedic practice. They are typically non-surgical problems and respond well to many general treatment principles that will be presented here.
What is the foot doing?
What is the knee doing?
Is there abnormal pronation that is effecting knee motion that can be treated?
Is there abnormal supination effecting knee motion that can be treated?
Is the foot pronation linked with internal femoral rotation, or does the knee externally rotate at that time? (indicating opposite motions)
Is there varus thrust at the knee with excessive foot supination, or with excessive foot pronation? (causing wear of the medial knee compartment)
Does the foot pronate while the knee remains straight? (where torque stress can build up in the knee joint)
Is there limb dominance to the side of the worse knee pain? (Possible sign of short leg syndrome)
Is there excessive internal femoral rotation more than foot pronation? (Possible sign of weak external hip rotators)
Is the knee functioning too flexed, instead of straightening during midstance? (Possible sign of tight hamstrings)
Is the knee functioning too straight, instead of flexing during the heel contact phase? (Possible sign of weak quadriceps)
The photo illustration above shows the upper hamstring stretch. It is so important to stretch both the upper and lower hamstrings. This athlete is quite limber, so most of my patients will put their foot up on a wall to hold it for 30 to 60 seconds. It is okay to have your knee slightly bent. You should feel it high up on your thigh.
will be called into treatment involves the kneecap.
- Also called Runner's Knee, Biker's Knee, Dancer's Knee
- Also called Chondromalacia Patellae, Patello Femoral Dysfunction, Quadriceps Insufficiency, Patello Femoral Insufficiency, Patellar Subluxation Syndrome, etc, etc, etc...
- Associated with Excessive Internal Patellar Rotation or Position produced or aggravated by the internal talar rotation with foot pronation illustrated by the young women with her right knee below
- Vastus Lateralis Quad Stretching, Knee Brace to better patellar tracking, and foot stability with orthotic devices, stability shoes, and power lacing.
|Bauerfiend GenuTrain Knee Brace for Patellar Tracking Issues|
Here is some advice I emailed a patient inquiring about knee pain and flat feet:
Dear Dr Blake:
I am in a conundrum. Spend out of pocket to see a podiatrist or spend out of pocket to see a PT.I am Flat footed.
In 1990, my right knee hyper-bent with 150 lbs of backpack weighing me down with my right foot stuck in snow as the left foot slipped downward.
- Clicking knee cap
I have sat at a desk for 8hr/day for the last two years ~ the first desk job in my life and this may be part of the problem.
Wedging of Medial and Lateral Compartments
The knee joint has 3 compartments.The anterior compartment is the patello-femoral
joint, and then you have the medial and lateral compartments. All 3 of these compartments
can get degenerative changes where possible surgeries with joint replacements are
common place. Podiatrists are typically called into this arena to wedge the foot/shoes to off
weight the knee compartment that is initially compromised. In the US, it is typically the
medial compartment, and in Asia, the lateral compartment with more knee flexion as part of
that culture. It is amazing how difficult it is to predict how effective foot wedging is on these
compartments, especially the medial side.
Podiatrists are taught to invert the wedge when the foot pronates excessively for medial
compartment disease, orthopods do the opposite. If the foot is supinated or neutral, then
both specialities valgus wedge the foot to help the knee. Both specialities do the same
varus wedging for the less common lateral compartment disease.
- Runs from the lateral pelvis, across the lateral side of the hip and knee, and attaches into Gerdy's Tubercle on the proximal lateral aspect of the tibia (in front of the head of the fibula).
- Women tend to get pain at the hip due to their wider pelvis, men at the knee.
- Ilio-tibial Band Syndrome is almost exclusively a repetitive stress syndrome caused by running.
- Excessive Pronation causes the ilio-tibial band to rub across the lateral femoral epicondyle at the knee, or greater trochanter at the hip.
- Excessive Supination strains the band as it attempts to stabilize the lateral aspect of the hip and knee from the varus stress.
- A short leg syndrome can commonly cause iliotibial band syndrome as the band attempts with every step to straighten the legs (to no avail).
- Treatment includes correcting the biomechanics, icing several times a day, strengthening the hip abductors (core in general), and stretching the IT Band alot. I especially love the lateral wall stretch and the use of the ethafoam roller on the IT Band.
|A patient with classic limb dominance to the left suggestive of short leg syndrome. It could also be excessive supination on the left only throwing the hip laterally. The IT Band can get very unhappy as it attempts to constantly stabilize the lateral hip and knee.|
Pes Anserinus Strain is another running related injury.
The illustration above shows this very unique structure on the front and inside of the knee (anterior and medial) that is designed to stabilize the knee at heel contact. I see this as a secondary help to the knee joint in high stress like running down hills when the quadriceps have to stabilize a force up to 10 times body weight. The Pes Anserinus is made up of 3 tendons conjointly attaching in the front of the knee. The 3 tendons are the Sartorius (hip flexor), Gracilis (adductor), and Semi-Tendinosis (hamstring). So the quadriceps are helped medially by the pes anserinus and laterally by the ilio-tibial band.