Coordinated Health

VideoMarch 13, 2015

Dr. James Sunday: Runner’s Seminar Part II


(lively music) – So, patellofemoral pain is also known as anterior knee pain, chondermalacia, or patella tracking problems. So if you’re any of those, that all kinda falls under that umbrella. And it’s probably the most common cause of knee pain across the board and also in runners. And it’s a little bit poorly understood, what causes the pain, but in my experience in seeing a bunch of people that have this problem, it seems that the kneecap becomes sensitive. So like when your knee’s straight, there’s no real load on the patella. So it’s part of what we call our extensor mechanism, the quadriceps muscles attach to the quad tendon through the kneecap, attached to the leg bone. So those are really the biggest muscles in your body and as soon as we bend our knee a little bit, it gets locked in the trochlear groove. That’s just a groove on the end of your thigh bone. So even with simple activities, kneecap sees a lot of stress. It really can be a nuisance. Sometimes it’s real painful, but more often it’s more a nuisance and be difficult to treat. So it’s frustrating for both physicians and the patient. The kind of symptoms we have are pain in the front of the knee, no acute injury, things that tend to make it worse are climbing stairs, kneeling, and for then running, more uphill running. So with all these overuse injuries, basically it’s overused. Too much, too far, too soon for a person’s level of conditioning. So someone who runs 80 miles a week, they’ve built up to that and they tolerate it. It’s when we change our mileage, change the terrain that we’re running on, people like to put their treadmills on an incline, puts more stress on the knee, it’s like uphill running. Then we see a lot of anterior knee pain. The other thing we sometimes call it, people refer to movie theater knee. Whenever you sit for prolonged time with your knee bent, if you have these symptoms, you often have pain there. And then when you get up, your first couple steps are start up pain. First few steps tend to be painful. So what I really look for when people come in is tenderness behind the kneecap, and they often describe their pain as being behind the kneecap. And it can be in the inside part or the outside part of the kneecap. Generally there is no swelling associated with most of these overuse injuries. If you have fluid in the knee, or water on the knee, knee swells, it’s usually something to be more concerned about. So we also look for muscular tightness, and for me I like to look for quadriceps tightness with anterior knee pain. Because that often, if we address that, that can often correct problems. I put this picture in because you don’t always think about it, but these major muscles, they all go across the knee joint. So the quadriceps muscles through the kneecap go across the knee joint. The hamstring muscles also go across the kneejoint and attach to the leg bone. And even your gastroc, the calf muscle, goes across the knee joint. The deeper muscle, the soleues, doesn’t. And I’ll just point out something quick I think is important to me. When we stretch our calf muscles, that runner’s stretch, I do the leg straight to stretch the gastroc and then with the knee bent to stretch the soleues, cause the one goes across the knee and the other one doesn’t. So, when we take x-rays of people with patellofemoral pain, they’re usually normal, unless there’s some associated arthritic changes. And with most of these overuse injuries, we talk about activity modification, that’s the doc, if it hurts what should I do? Don’t do that. Hurts when I do this, don’t do it. So relative rest and then physical therapy is probably the mainstay of our treatment. Like to stretch, especially the quadriceps. Then we like to strengthen some of the muscles, quadriceps, but especially your hip abductors and core muscles. And Kat’s gonna talk about that. So we talk about a kinetic change. So basically, we talk about, basically the hip bone’s connected to the knee bone’s connected to the ankle bone. And we really like to focus on the joint above and below in treating some of these problems. Question comes up about orthotics. Can sometimes be really helpful with treatment of pattelofemoral pain. Especially if you have flat-foot are you pronate. – [Woman] What if aren’t flat-feet or if you pronate? – Yeah. – [Woman] Okay. – Yeah, so, you know like most of the time I’ll try stretching, some therapy. If things just aren’t going well, you can always try orthotics. But if someone has flat-foot or tends to pronate orthotics can be really helpful. Sometimes that does the trick. And then, what I find in myself sometimes, (clears throat) when my shoes become worn, my knees start to hurt. That’s when I generally know it’s time for new shoes. But, I probably should do it before that, but. Or different kind of shoes are a good idea. Like Scott brought up this idea of minimalist shoes and barefoot running. It’s very interesting topic. You know, different shoes might be a good idea as well. So the next thing we’ll talk about is iliotibial band friction syndrome. The iliotibial band is a thick band of tissue, goes from your pelvic bone down to your knee, and across the knee and it attaches to Gerdy’s tubercle, it’s a little bump on the outside of the top of the leg bone. And it’s classically described as repetitive friction over the lateral epicondyle. And that’s basically this little bump on the end of your thigh bone, located right where that red spot is. And that’s where you’ll generally have pain with it. So the idea of the friction band is from zero to 20 degrees ITB is actually anterior to the epicondyle and acts as a knee extensor. But when we bend our knee, it assumes a posterior position and acts as a knee flexor. So it actually glides across that area, pretty much with every step. So when we have iliotibial band symptoms, the pain’s in that lateral aspect of knee, no acute injury, and it’s worse with activity, but this tends to be worse with downhill running, and people talk about issues with the road camber. So the roads have to drain so they all have a kind of a peak in the middle and the water runs off the sides. So when we run on the side of the road, which typically you do running into traffic, we always run on the left side of the road, it makes our right leg a functional leg length discrepancy, making our right leg a little shorter, or our left leg a little longer. On examination, basically a very tender, right at the lateral femoral epicondyle. And we check for tightness iliotibial band. Some question whether that really contributes to problems, but with therapy we definitely like to stretch it, and the question is, how do you stretch it. It’s a little bit difficult and I think the therapists sometimes get frustrated by that. And some of them are questioning, should we really worry about it. Normal x-rays and if you do get an MRI, usually see some fluid signal out in the lateral aspect of the knee where we have the pain. So again, we’re talking about activity modifications, relative rest, like to use ice a lot with ITB issues, and those nonsteroidals like ibuprofen. Somebody asked about Meloxicam. I think all those medications are relatively similar whether they’re over the counter or prescription. Some work better for others. You know, one might work good for one person, the other better for another person. There’s dosing issues, with the Meloxicam’s once a day, ibuprofen three times. So again with the therapy, we like to work on the core and hip abductors. Should we do ITB stretching, might as well. And then the soft tissue mobilization with the rollers or more of a Graston technique. We like orthotics too because flat feet and overpronators tend to put our whole kinetic chain a little bit more stress on it. And then cortisone injections actually tend to work pretty well for ITB problems. And if someone comes in with ITB problems, I’m okay offering them a cortisone injection the first time. If they want to try some therapy first, that’s great. But some people like more of a quick fix, so we tend to offer them that. And then surgery is very rarely indicated and different methods are used. Most series report good results, but they’re all small, it just doesn’t, there’s not a lot of surgery being done for ITB problems. But it involves excision of the bursa or inflammatory tissue in that lateral aspect of the knee. We call a Z lengthening of the IT band, where you cut like a Z into it and you put the middle part together and make it longer. And then another tendonitis, bursitis kind of problems. Pes bursitis, and this is pain just below the knee on the inside part of the knee. The anatomy of the pes tendon is somewhat interesting. So pes anserinus actually means goose foot. And there’s three muscles, they’re all innervated by different nerves. The sartorius, which is the longest muscle in the body. It forms a wide fascial attachment. And then the two other tendons, which are more normal tendonous attachments to the gracilis, which is a hip adductor, and the semitendinosis, which is a hamstring tendon. So basically, any kind of -itis is an inflammation. So inflammation of the tendons or bursa, that underlies those tendons and allows them to glide over the bone there. So again, relative rest, like the ice and NSAIDS, stretching, iontophoresis that Dr. Sauer talked about, is a topical steroid treatment. Tends to work pretty well for that. And it tends to respond well with cortisone injections and that’s another area where we don’t have an issue injecting with cortisone, where, as like Dr. Sauer said, the Achilles, no injections there. The patella tendon, no injections there, cause it’s associated with tendon ruptures and those ruptures are catastrophic ruptures. You know they pssht, whole thing pops and patella tendon you’re definitely talking about surgery. Achilles, probable surgery too. So really stay away from injecting some areas, but like these pes tendons we tend to use for tendon grafts for other surgeries, we don’t think they’re super important, even if they would rupture. So I just want to talk a little bit about knee arthritis. Basically knee arthritis is wear and tear or thinning of the articular cartilage, or the joint surface. So this is a pretty normal looking knee here, it’s arthroscopic pictures. And this guy’s developing some wear of the cartilage and here is bare bone. The bone’s actually a different color than the cartilage, kind of a yellowish color as opposed to this nice white color. But that’s a little cartilage rim there and that bone is completely exposed. So it can affect inside, outside, or front of the knee. Or you can have it in all three compartments. Tends to be an insidious or slow onset, associated with more achiness, stiffness. And that’s where we talk about the water on the knee. Often we’ll see that with arthritis and it’s worse with activity. So on x-rays, this is a pretty normal looking x-ray, and then this we see the joint space narrowing. Sometimes we see big bone spurs, we call them osteophytes. Though there’s a lot narrowing on this one, there’s a little bone spur there probably, but not real dramatic. And then, when the cartilage isn’t taking some of this stress, the bone sees more stress, tends to get thickened, we call that subchondral sclerosis. So that bone looks a little thick and a little stiffer there. Now an interesting thing I think to talk about a little bit while we’re here, is does running cause knee arthritis? Is it possible physiologic loads associated with running are actually healthy for the knee? So I don’t think we can completely answer those questions, but I’ll try to get into it a little bit. You know, it’s kinda like use it or lose it. We know, like, if you don’t stress your bones, they become weak. If you don’t use your muscles, they get smaller and atrophy. So if you don’t put any loads on your cartilage, is that actually not a good thing? You know, is running maybe not, is running maybe actually good for healthy knees anyway? So what factors are strongly associated with arthritis, especially knee arthritis? Well, increased uh, bone mass, uh, BMI… – [Woman] Body Mass Index. Body Mass Index, right? So people that are big for their height and obesity. Prior knee injuries and heavy manual labor are strongly associated with arthritis. So when people look at studies of running and arthritis, it doesn’t seem to be particularly good for gerbils that run on treadmills. They tend to develop arthritis if they run a lot. The good news though, is that the majority of studies, like observational, or what we call epidemiologic studies on humans, don’t show an increased risk of arthritis. What is running associated with? Well, it’s associated with less physical disability, increased bone density, lower body weights, and less frequent need for medical care. So older runners tend to be healthier than their nonrunning counterparts. And I think another good question is, should you run if you have arthritic knees? So although we think at least low or moderate volume running is not detrimental to knees, what if your knees aren’t so good? Well, I don’t know if we have any evidence that really shows that it’s bad for knees that aren’t so good, but a normal synovial joint, like a knee, has a coefficient of friction seven times less than ice on ice. So when we start to develop some of those cartilage changes and wear, that coefficient of friction is adversely affected. So I tend to worry a bit about arthritic knees and putting a lot of stress on them. But, that being said, you know it often leads to people stopping running and often because it’s painful and it’s no longer enjoyable. So when your knees become fairly arthritic, we say it’s self limiting. And arthritic joints, especially knees, are more tolerant of lower impact activities, like walking. And we recommend walking for people with arthritic knees. I think it’s good, even for people with bad arthritis. Elliptical machines, swimming, and quite a few of my patients with arthritic knees actually say their knees feel better when they cycle. So last thing I want to touch on is meniscal tears. Again, it’s not something you probably cause by running, but if you do have a meniscal tear for whatever reason, it tends to limit your running. So pain at the medial or lateral joint line, tends to be worse downhill than uphill. Symptoms are exacerbated by running. And there’s often that knee effusion associated with it, or swelling in the knee. We often diagnosis them on clinical exams, best way to confirm it is with an MRI. There’s an obvious meniscal tear on MRIs. That nice white line in that black triangle of meniscal cartilage. So the meniscus is a gristle cartilage, sits on the periphery of the knee. Looks just, in a human knee, looks like a lot like a turkey leg. They have a little gristle cartilage around the edge and so do we. And they make the joint more conforming, help distribute loads in the knee. You can see how this medial femoral condyle here is nice and round, the tibia is pretty flat, and that meniscus really takes up that space nice and makes that knee joint a lot more conforming. So how do we treat them? Well, you can ignore it. It’s benign neglect, is another way of saying that. Cortisone and physical therapy is an option. And then, if you’re having swelling and pain, and you’re real active on it like most runners are, we often treat it with arthroscopy. Most of the time we’re just gonna trim out the damaged part of the meniscus. (lively music)