Dooley Noted: 4/24/2017
On Friday morning, I found myself in a stressful situation. I was running around an airport with a 40-pound kettlebell in one hand, and dragging 50-pound luggage behind me in the other hand.
This inefficiently loaded and unsupported system, when matched with velocity, showed itself in something I rarely experience: medial knee pain.
Gasp! It’s true – therapists aren’t perfect.
I am not scared – nor discouraged – by pain. It is a gift of sorts, an afferent expression of a system that alarms of perceived threat and possible intolerance.
Without a solid rehabilitation specialist on the island, I had to insource.
I went through my basic checklist of any of my patients that have knee pain. I always check in this order, first starting local and then going global.
1. What is the femur doing at the knee and hip in its accessible planes?
2. Is the femur attempting to move in planes where it doesn’t have access, particularly at the knee?
3. What is the foot – especially the hindfoot – doing relative to these planes of access?
4. Are the core and opposite shoulder moving in normal synchrony with these accessible planes of movement?
I first assessed my femur at the hip, since the femur has three planes of accessibility. I noted a block in the coronal (frontal) plane, otherwise known as side-to-side movement.
I realized my femur had created a fixed point now for movement to occur at the knee in that same plane.
Only trouble is that the knee doesn’t move in that plane. It has zero frontal plane capabilities. Thus, when you ask it to move in that plane, it tends to irritate the tendons of the medial tibial and femoral condyles, which are separated from the bone by bursae on their path.
These tendons all flex the knee, so terminal knee flexion can be quite painful. Also, the infrapatellar plexus of nerves is located here, so irritation of these nerves can create medial knee pain that radiates to the anterior knee and under the kneecap.
So, I got to work.
I dropped into half-kneeling and worked on femoral adduction at the hip with a knee blocked in the frontal plane.
I checked my foot to make sure it was properly supporting this movement with well-controlled hindfoot pronation.
Then, I went for a long walk with my husband, during which I focused on my hip moving well in all three of its planes without demanding my knee to flex too much.
The next day, 95% of my discomfort reduced and I was back to doing pistol squats (lots of knee flexion).
Assessment and awareness can really help pain that is produced by biomechanical discrepancies.
Some additional tips for the therapist who’s assessing their own – or someone else’s – knee pain:
1. Make sure the hip and foot are moving well, and that the knee is not attempting to enter planes to which it does not have access.
2. Slow walking with lots of hip awareness can help with better patterning for the hip relative to the knee and foot.
3. Don’t try to tune the pain out. Use the pain as a guide to educate you on the body’s current tolerances.
4. Avoid direct pressure on the knee bursae. They have enough pressure on them already. Just because they are painful to the touch, it doesn’t mean you need to press on them!
5. Stop calling pain at the medial knee “medial meniscal pain.” The medial meniscus is fibrocartilaginous and barely has any nociception (pain reception). The high level of discomfort for you or your patient is much more likely to be due to bursitis or synovitis.
6. Look at the anatomy of the knee and its bursae and infrapatellar plexus of nerves. Understand that bursitis can create 10/10 pain referrals, but the diagnosis is not serious and can be relatively easily corrected with good movement.
7. Consider doing assessment and correctives barefoot. Watch how the dynamism of the foot affects knee movement.
8. Use all of your clinical auditing tools to help determine the causative agents, and don’t be afraid to look away from the knee and cases of knee pain. You’re not crazy!
As always, it’s your call.
– Dr. Kathy Dooley
P.S. DISCLAIMER: This post is not intended to diagnose medial knee pain, but to guide one towards an auditing process to improve motion. See a qualified therapist to help you with your knee pain!