CARING FOR ATHLETES
You Don’t Have To Live with Knee Pain
Knee pain is the most frequent patient complaint treated at our sports medicine practice. It is not uncommon for patients to state that their knee pain has been persistent and frustrating. Many times the patient is disgruntled and complaining of knee pain that prevents them from taking part in the daily activities, which he or she may desire.
Chondromalacia is frequently the source of knee pain. Chondromalacia is a medical term specifically referring to a softening of the articular cartilage on the underside of your knee cap where it comes in contact with the distant end of your thigh bone (femur). There are many conditions that can attribute to knee pain, however, this discussion is reserved for conditions that involve the most common causes of knee pain.
Chondromalacia is most frequently the result of malalignment of the knee cqp and its articulation with the femur. Anatomically, the underside of our kneecap has a ridge that is supposed to align directly into a groove in the distant end of our femur. However, it is not uncommon for the kneecap to be malaligned or malshaped whereby the underside of the knee cap does not align in the intended groove of the femur. This malalignment results in increased pressure, friction and degeneration of the back of the knee cap which causes pain and dysfunction.
Athletes as well as non-athletes suffer from this malalignment condition that manifests as frustrating and persistent knee pain. The condition is not that difficult to evaluate. However, treatment is frequently ineffective and varies from one practitioner to another, based upon their philosophy. This squinting of the knee caps may be accompanied by the characteristic appearance of “knock knees”. Most often there are other associated biomechanical malalignment signs that appear. It is not uncommon for the sufferer to ambulate with feet that pronate (appear to flatten and roll inward) and the lower leg bones may be bowed and tend to rotate inward. However, the biomechanical malalignment does not stop there. Classically there is torsion placed upon the hip and pelvis which frequently can result in causing low back pain.
The causes of malalignment are not totally agreed upon nor understood. Certain theories believe that a sufferer genetically inherits this malalignment through his or her family chain. Another theory believes that the position that a fetus lies while in the uterus determines the future skeletal structural alignment whereby interuterine malpositioning can result in malalignment. It is widely accepted that women suffer more frequently than men as a result of women having a wider pelvis that results in magnifying the degree of malalignment of the knee cap. Usually the sufferer of the malalignment syndrome is in his or her teens or early twenties and is usually athletically active at the onset of painful symptoms. However, adults into their sixties and seventies may have this condition. Trauma may be associated with the onset of the initial episode of pain and frequently misleads the examiner to think that it is a traumatic condition plaguing the knee when in fact it is a congenital malalignment condition that has been lying dormant until the initial trauma triggered the symptoms. Most patients have pain in only one knee at a time although usually the malalignment involves both knees.
Needless to say it is important to have this condition evaluated by a practitioner who is familiar with biomechanics. There are a variety of basic in-office examination tests that can be performed to determine if you suffer from this malalignment. Careful biomechanical analyses need to be performed while walking and maybe even during running. A complete history needs to be performed to include questions regarding crepitation. Crepitation is a grinding and frequently an audible clicking experienced about the knee during bending and straightening of the knee. In most cases of malalignment there is some degree of crepitation present. Crepitation usually becomes more apparent as the severity of the symptoms increase.
In addition to a thorough history and physical examination of the knee, the examiner should carefully evaluate the patient’s hip and feet. It is important for the examiner to develop a plan of care that will treat the cause as well as treat the painful symptoms. In an effort to develop a plan of care that will treat the cause, the hip and feet frequently shed significant insight into the biomechanical cause of knee cap malalignment. Frequently, hip stretching exercises can allow the knee cap to become better aligned. If the feet are evaluated and found to be excessively pronating, specifically prescribed stretching and strengthening exercises for the feet may also have a profound effect on better aligning the knee cap. In-shoe orthotic devices have proven to particularly useful in knee cap malalignment conditions.
It is most important that the mainstay of treatment for malalignment of the kneecap be conservative treatment. Conservative treatment is defined as non-surgical treatment. Research tells us that patients who have surgery for malalignment of the kneecap do not always fair as well as patients who have been treated conservatively via the utilization of stretching, strengthening, and physical therapy. Pharmaceuticals have limited value in malalignment conditions as they may only camouflage the symptoms and give us false confidence that the condition is truly rectified. Early intervention is encouraged especially in prepubic and adolescent athletes. Some studies suggest that biomechanical correction may result in permanent resolution of a problem that otherwise would remain persistent and reoccurent. However, a biomechanical treatment approach designed to treat the causative factors as well as remove the painful symptoms is the initial treatment of choice.