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Friday, February 6, 2015

Patella (kneecap) Problems: General Thoughts

  1. Patellar Tracking Problems (kneecap)

Probably the most common knee complaint that a podiatrist 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

  • All patients with Patello-Femoral Dysfunction should be treated with core strengthening especially external hip rotators, Quadriceps strengthening especially VMO with short arc single leg press and quad sets, and
  • Vastus Lateralis Quad Stretching, Knee Brace to better patellar tracking, and foot stability with orthotic devices, stability shoes, and power lacing.   


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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.
Current symptoms:
- Clicking knee cap
- Kneeling on carpet, great pain until the knee cap pops into place from pressure upwards
- Grinding knee upon flexing
- Pain on the inside of the rt knee and lower left quandrant of patella
- Pain and tightness from right side of knee up to the hip
- Pain behind my knee at the back (anterior)
- Extreme pain in knee and hip when rising up from a kneeling position
dreamstime_m_23929938.jpg
Wonder what he did??

- Pain and tightness on the inside of my thigh at the knee
- Feeling of being swollen in the knee itself
- Walking in running shoes with support is OK at best
- Walking in dress type shoes with no support results in pain after 25 yards or so
- When I use to take spin classes, the instructor noted an outward or inward? movement of my leg/knee and asked me to keep it straight, which I could not.

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.
I am self pay ~ no health insurance.
What would the cost range be for a diagnosis by you, treatment and possibly orthotics?
How long would it take, should we work together, to know if your regiment for me is working?
At what point would it be wise to pony up for an MRI?  Do I need one?
I am 53, and until recently, in good shape if not great shape.  I need help!
Best always and Happy New Year!
Robert
Robert, Thank you for the email. This is definitely a question about timing of treatments when both can be very helpful.
  With that much knee pain, you are really in the immobilization/anti-inflammatory phase. Orthotics would be part of a restrengthening/return to activity phase. The immobilization is anything that creates a pain free environment, from braces, to shoes, to activity changes, and yes, to orthotics if that is what it takes.
   I would tend to have a PT cool your knee down first, and then add orthotics when you are ready to increase your activity again. Orthotics can play a role when you are throwing everything into the treatment arena but the kitchen sink (an approach used with unlimited funding).
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This is why the kitchen sink is not included
Definitely, cool the knee down with PT and Icing. The icing for the knee must be 30 minutes 3 times a day. Yes, 30 minutes is normally needed to get deep into the knee.   Try to stay away from anti-inflam meds since they can slow bone healing. Get an MRI, around $500 self pay, if your symptoms plateau (look at it one month at a time). Try to create a pain free environment over the next month, which may mean staying in your most stable shoes. You can also try Sole over the counter Arch Supports (get one of the soft athletic versions). These are easy to adjust. You have already established a relationship between your feet and knees, but see if you can get them calmed down, less fragile, over the next several months.

    The top 10 initial treatments of Patella problems are:
  1. Create a pain free environment.
  2. Ice 30 minutes 3 times daily
  3. Start Quadriceps strengthening painlessly on day one
  4. Stretch the quadriceps and hamstrings 3 times daily, although avoid knee flexion over 45 degrees.dreamstime_m_15225478.jpgToo much knee flexion for kneecap pain
  5. Knee Brace for Patellar stabilization like Bauerfiend Genutrain Knee Brace
  6. McConnell knee taping with Leukotape and underwrap or KT taping.dreamstime_m_36278072.jpg
  7. Core Strengthening for external hip rotators, including gluts, iliopsoas and piriformis muscles.dreamstime_m_17645150.jpg
  8. OTC or Custom inserts to stabilize any overpronation tendencies, or just varus cant. Goal is to get the knee to function in the center and not internally rotated.
  9. Use activity modification to get cardio without irritating the knee. Consider raising the seat in cycling to prevent too much flexion (over 45 degrees the patella starts pushing hard on the femur). dreamstime_m_18879601.jpg
  10.  If it is a running injury, shoes are crucial for stability. Have a good running shoe store help you pick out a great stability or motion control shoe for you.
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Your shoe selection should help avoid the heel valgus seen here where the heel rotates outward driving the knee inward too far.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.