Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Crepitus Knees p/w Pain

Discussion in 'General Issues and Discussion Forum' started by Kahuna, Jun 2, 2009.

Tags:
  1. Kahuna

    Kahuna Active Member


    Members do not see these Ads. Sign Up.
    Hi all

    I have a case I'm stuck with...

    a 35 year old lady (teacher)

    overpronated feet... (no medial knee pain)... but both knees are so LOUD when she walks. When she walks down stairs she gets some minor patello-tibial pain bilaterally.

    Her GP, Ortho and Osteo have all recently tried to treat her for this embarassing crepitation! She has had the symptoms as far back as her teens.

    She had an XR last month on both knees - NAD, no remarkable features.

    Where from here !!!???

    Tx
     
    Last edited: Jun 2, 2009
  2. Griff

    Griff Moderator

    What on earth does this mean?
     

  3. Kahuna,
    Firstly, editing your post in the way you have after someone has replied is not very good manners. Your rationale being: "Last edited by Kahuna : 2nd June 2009 at 10:31 AM. Reason: original phrase seems to have confused first reply post!" In your editing you have now made Ian's post completely confusing to anyone else who reads the thread. I suspect Ian did understand your statement perfectly, he was trying to get you to realise that saying things like "slight over pronation" is a bit ambiguous (how much is slight?), as such he was adopting a somewhat Socratic teaching approach (right Ian?).

    Back to your case. Is the sound coming from within the joint or is it coming from one of the ligamentous / tendinous structures surrounding the joint? Can you isolate it's location more precisely please?

    As the patella doesn't articulate with the tibia, I'm not sure what you mean by patella-tibial pain. Did you mean patella femoral pain? Do you mean the pain is both in the patella and tibia; the pain is in the patella tendon, fat pad etc?

    You may want to examine the knee more thoroughly and gives us a bit more to go on.

    We all get educated here, I was going to suggest things like the Clarks test and went hunting for a reference for you. Unfortunately, I found this:

    http://www.scribd.com/doc/4703827/D...linical-Tests-in-Patellofemoral-Pain-Syndrome

    In the meantime, give her an oil can ;)
     
  4. Griff

    Griff Moderator

    Thats what I was going for Simon. Perhaps no suprise to me that you pinged it but I had hoped it was a bit more obvious to all.

    Kahuna,

    Your terminology did not confuse me, (I know exactly what you think you mean), but as Simon says it is the ambiguity which prompted me to respond. Guess what...

    ...I'm still not massively keen on this term. What does it mean? How much pronation is 'over' pronation by the way?
     
  5. Truly the path to knowledge is as a naked wander through waist high stinging nettles.

    C'mon guys. Tx is obviously not up on the up to date thinking. Don't mean we can't try to help her. Some come here to learn, others want help from the learned. Lets not get elitist (although overpronation one of least favorite words in the world!)

    As my learned ;) colleagues have intimated, we need more information to help you here tx.

    For myself, I'm less interested in how much pronation (yes Simon, I know) as the knee itself. Lets not get too hung up in being PODiatrists. If you have a hammer everything starts to look like a nail!

    I'd like to know, (for starters)

    1. Where exactly is the pain? don't try to locate it by dx, just say where it hurts. Better yet, sketch it.

    2. What kind of a noise? Does it clunk? Click? Crunch? Crackle? Is the noise worse on going up stairs? Down stairs? On flat ground?

    3. This one is important. Is the noise / pain reproducible on non weight bearing palpation? If so what reproduces the pain / noise?

    4. Does the noise vary Dependant on footwear?

    Seek ye first the diagnosis and yea, the treatment will be added unto thee also.

    Regards
    Robert
    Feeling mellow
     
  6. Kahuna

    Kahuna Active Member

    Hey Thanks Robert,

    Your insightful help is genius!

    Thanks for looking at the big picture and not the semantics.

    In reponse to your questions...

    1. she says the pain hurts around the tibia/patella... and it presents rather similar to a presentation of pre-patellar bursitis (without the kneeling commonly associated with a 'housemaids knee.')

    2. the noise is like an ongoing 'crunch', like lots of constant plucking of guitar strings! worse going down stairs.

    3. the noise (but not pain) can be reproduced whilst non weight-bearing. When seated in a chair if she bends her knee and extends/straightens her leg, it happens. Likewise, when seating, if she 'cycles in the air' it also happens.

    4. The noise does not vary dependant on footwear.

    One other point from my assessment: if you hold the knee with the palm of your hand whilst she is seated and flexing/extending the knee, you can hear the noise and feel lots of very small "lumpy" movements on the medial and lateral aspects of the patella.... (although she doesn't get the pain in these locations as mentioned earlier)

    Thanks for your mellow approach and help Robert.
     
  7. Sounds to me like good ole garden variety chondromalacia Patella. If the patella has been running rough for long enough it can cause cartiledge in the patella groove to be damaged. This can have a genetic component so if its been that way since childhood its probably knackered! The loose / rough cartiledge can present with a distinctive rice crispies type snap crackle and pop (tm pat pending) and is often asymptomatic.

    Try manually controlling the patella on NWB flexion / extention of the knee. If you can reduce the crepitus by applying medial or lateral force, or rotational force then thats your puppy. You then need to work out how, with specific quad set exercises or orthotics, how you can acheive this long term. Or follow the patient around with your hands on their kneecaps for the rest of their lives, that works too!;)

    If it is that longstanding it might be that they need an ortho referral for a lateral release or to have the patella / groove reshaped / washed out. Depends how much is functional malalignment and how much is structural bony remodeling / loose cartiledge. If its the latter and not the former then all the osteopathy and orthotics in the world won't solve the problem.

    That would be my surmise for what its worth. An MRI scan would confirm.

    Hope this helps

    Robert
     
  8. Griff

    Griff Moderator

    Kahuna,

    Far from being semantics or pedantry this is something which I feel is very important. Spending day after day trying to debunk the myth of 'overpronation' (whether talking to athletes, running stores or consultants) to then hear Podiatrists perpetuate it makes a little bit of me die inside*. We should be educating others in appropriate and up to date terminology/theory in my opinion. If the 'big picture' is the knee status then why was the foot the first thing you mentioned after age and occupation?

    Nothing personal of course - and my apologies for not being as mellow as Rob (its not the first time he's told me to wind my neck in a bit)

    All the best

    Ian

    *possibly some exaggeration for emphasis
     
  9. True enough! It may not be an exaggeration. I think its about 10 million brain cells die every day anyway, I'm certain this accelerates the process!

    You are, of course, dead right. Overpronation is horribly imprecise, to the point of being both meaningless and useless as a descriptive term. We, as a profession, should be striving to challenge it wherever we find it! Howsomever.


    One of Craigs posts from way back has stuck with me and served me well. Paraphrased from memory...

    So often we dive gleefully into the biometrics without pausing for a diagnosis, or do the biometrics first then try to make the diagnosis fit them. This was bourn in upon me when I spoke at a hip study day recently along with a consultant orthopaedic Surgeon and an extended scope practitioner physio. The breif was the same for each of us, the hip in gait.

    I spoke of rotation curves of the hip, end range structures and the kinetic chain. Beforehand I asked the audience (mostly physio's) to list the muscles which externally rotate the hip during gait. Not one of them, nor the surgeon, considered the tibialis set. They left with the puzzle of how the big toe externally rotates the hip.

    The physio had a selection of x rays of assorted variations of bony and other deformations and abnormalities. He spoke of the ligaments and muscles AROUND the hip.

    The Surgeon spoke on the criteria for surgery and the success rates thereof.

    Same breif, but the approaches were radically different! Sometimes its good to think outside of our specialism (overpronation ;)) and think like a physio, or even an orthopod.

    Regards
    Robert
     
  10. drpsnell

    drpsnell Welcome New Poster

    Hi Kahuna,
    My first post here, although I've been a voyeur for years. Disclaimer...I'm a chiropractor, not one of the weird ones! My focus is in evidence based practice of sports med, spine rehab and myofascial pain. I have personal and clinical experience with this type of knee pain.

    Your patient sounds as if she has patellofemoral tracking disorder which in some circles is still referred to (somewhat errantly) as chondromalacia patellae. Age related degeneration of the patellar cartilage is normal and as that cartilage does not contain nerve fibers, it is an unlikely source of pain unless pathomechanics have progressed to the point of bone on bone contact. Your Xray (assuming "sunrise" view was included) findings and patient young age make that circumstance unlikely barring hx of severe blunt trauma to the patella.

    A much more common source of the pain is in the medial and lateral peripatellar retinaculae. Fulkerson's text, Disorders of the Patellofemoral Joint describes the surgical findings on such anterior knee pain. Surgeons frequently find poorly formed granulation tissue, invested with swollen "small nerve fibers" in the retinacula of these knees. Debriding the tissue is effective surgically. I have had personal and clinical success with cross fiber friction (I use Graston instruments) to be effective, but quite painful to endure. I would be surprised if on return palpation to these structures, perhaps with traction of patella med/lat to better evaluate the retinacula, you didn't find your pain source.

    Pathomechanics involve poor gluteus medius tone, resulting in internal rotation of the thigh. Eccentric force of the ITB on the patella results in oblique tracking of the patella across the femoral groove, over the retinacula, and resulting in the offending trauma. Think of a train running off of the tracks. Removal of the granulation tissue addresses the sx but if biomechanics are not addressed, sx will return. Quad sets are somewhat dated in the rehab literature with better effects found training the glutes (esp medius) and training the patient to avoid valgus knee position. To further assist, if eversion of the ankle in static is noted as in your patient, orthosis or training of the musculature to resist that tendency is usually helpful. Hope that helps!

    Phillip Snell, DC
    Solutions Sports and Spine, Inc
    Portland, OR, USA
    www.fixyourownback.com
     
    Last edited by a moderator: Jun 5, 2009
  11. drsarbes

    drsarbes Well-Known Member

    Hi:
    If she has crepitus that has eluded Dx via clinical examination I would suggest a simple arthrogram. She may have chondromatosis or other intra-articular loose bodies which may not be evident on xray and would give the symptoms you describe.

    Steve
     
  12. Hey Phillip. Thanks for joining in! So much expertise out there and much of it from backgrounds besides Podiatry its great to see it coming out! :drinks

    I found your post most interesting and informative. I'd appreciate your enlargement on a few points.

    1.
    I'll be honest, thats a new one on me. Seems coherent enough although I would expect it to be unilateral (medial OR lateral) based on the anatomy? Perhaps thats just my mechanical bias coming through. Few questions, this being a new concept for me,

    a. would that cause the crepitus mentioned or do you suggest that the patient has patellofemoral tracking disorder AND PPR trauma? I was not clear from your post on whether you were offering PPR as an alternative to patellofemoral tracking disorder or as an adjunct.

    b. Would PPR that not cause more consistant pain? Our patient only has slight pain on stairs.

    c. Would that be a new Dx or is this something which can be present from childhood along with the patellofemoral tracking disorder.

    d. What is the clinical test for PPR strain?


    e. Honest question, how much of the internal rotation of the femur (I assume you mean femur when you say thigh) do you feel is down to poor glut tone? To put it another way, how much of the external rotation moment in the leg during gait do you feel is down to glut medius? We've had this discussion on here before and its one which interests me greatly. I nearly had a psychotic breakdown trying to generate a finite element analysis on this.

    f. When you say internal rotation of the thigh, what you you mean exactly? A more internally rotated range? A more internally rotated internal end range? Faster internal rotation to the same degree? A leg which is internally rotated for longer?

    g. Could you point me at that literature please? I've been disagreeing with a colleague on the relevance of muscle training for this sort of thing for years (and great fun its been too)! Be great to have some new meat to chew on!

    Thanks for taking the time. Its a breath of fresh air to get a more top down perspective!:drinks.

    Regards
    Robert

    PS
    LMFAO!!!
     
  13. pgcarter

    pgcarter Well-Known Member

    I'm a podiatrist....not one of the weird ones......there it out of the bag now, there may be some weird ones out there, I think it probably applies to every profession, I'm sorry you feel the need to apologize in advance for some of your colleagues. I would not hold you responsible for their strangeness anyway, just as you don't need to blame anyone else for my variation from the norm.
    As far as this kind of knee trouble goes I've been living with it for 17 years. The noise is just that, noise. In and of itself not painful but a sign of ongoing degen of the integrity of cartilage on all the surfaces that rub against each other alot. The pain on use of stairs is about degree of knee flexion. I am pain free on walking and even low grade exercise like playing table tennis, but the moment knee flexion approaches 90 deg they just about collapse from pain, this is just the simple joint compression physics. I have full thickness cartilage loss in 3 locations in one knee and two in the other. Very hard to do anything about, but I am better with less eversion/pronation, if I take my orthotics out I get more medial knee pain than when I use them.
    regards Phill
     
  14. drpsnell

    drpsnell Welcome New Poster

    Gentlemen I owe you a collective apology. Mea culpa! Being somewhat ignorant of my settings on this forum, I figured that I once I posted, my email would be alerted for other communication on the thread. I'll try to remedy that. Sooo, if there is continued interest after a month (I get monthly alerts of topics of conversation here), I'll do my best to respond after a big fat gin and tonic at the end of a hectic day.

    Per pgcarter, "As far as this kind of knee trouble goes I've been living with it for 17 years."
    My sympathies, I can relate. I'm s/p 25 years on grade 3 ACL on one side, not repaired for 10 years and now s/p 15 years on reconstruction which has been mostly good. Actually have more consistent pain in the other knee with PFTD, which I had to troubleshoot on my own given that my orthopod told me I was old and shouldn't run with my son. With a combo of cross fiber friction, Pose running style and gluteal exercise to improve mechanics of the femur and I can now run 15-25 mi/week with little discomfort in the knee. My residual positional pain is likely full thickness cartilage loss in the subpatellar cartilage in some regions.

    To respond to robertissacs:
    "a. would that cause the crepitus mentioned or do you suggest that the patient has patellofemoral tracking disorder AND PPR trauma? I was not clear from your post on whether you were offering PPR as an alternative to patellofemoral tracking disorder or as an adjunct." I am suggesting concomitant PFTD AND PPR trauma as the PFTD is often causal for the PPR trauma.

    "b. Would PPR that not cause more consistant pain? Our patient only has slight pain on stairs." That might depend on the degree of scarring/fibrosis in the affected areas of the PPR. Most severe compressive force in the knee occurs between 20-30 deg of weightbearing flexion. Observation of patient report of pain at that degree of flexion with provocative activities like stairs, single leg squat, lunge is likely. Manual or tape assisted medial deviation of the patella with those activities usually reduces/removes the pain with those activities. In my experience, if the clinician cues the patient to fire the glute med by providing a valgus force at the lateral knee, then the pain is also greatly reduced or removed. That method is very powerful clinically as it demonstrates to the patient a way that by activating specific muscles they can control their pain. Empowerment! Cool!

    "c. Would that be a new Dx or is this something which can be present from childhood along with the patellofemoral tracking disorder." If we are to believe the collective research of Tim Hewett, Greg Myer and Mark Paterno as well as others, then the tendency towards valgus knee with squatting and "ligament dominance" might be predicted by her gender alone. As you're likely aware, young female soccer players (sorry, footballers) are 4-6X more likely to suffer ACL injury than their male counterparts. The MOI for ACL tear and PFTD are the same...that is, knee flexion+internal rotation+valgus force. A hard quick load ruptures the ACL while a low repetitive load results in fibrosis over the PPR and wear of the patellofemoral cartilage as the patella tracks obliquely across the femoral groove.



    "d. What is the clinical test for PPR strain?"
    I'd prefer to reserve strain for muscle tear etiology, but palpatory finding of cc pain over the PPR + findings in functional screens of squat, single leg squat, lunge, and rapid leap from sitting, etc provide cause and effect. Barring acute trauma to justify imaging or other red flags, these findings are reasonable to justify a short clinical trial to investigate.


    e. Honest question, how much of the internal rotation of the femur (I assume you mean femur when you say thigh) do you feel is down to poor glut tone? To put it another way, how much of the external rotation moment in the leg during gait do you feel is down to glut medius? We've had this discussion on here before and its one which interests me greatly. I nearly had a psychotic breakdown trying to generate a finite element analysis on this. I'm afraid I can't answer that definitively enough to help with your psychosis Robert ;-) I don't intend to wade into that foray as a spine specialist speaking authoritatively on the hip and foot to a group of what I've seen to be excitable foot specialists. :) Like much clinical practice I find the answer to be patient specific. I evaluate for excessive ankle eversion as well during the functional screens above and treat what I find. As a matter of preference, I attempt proprioceptive exercise for the affected muscles of the foot and leg first and refer to one of you guys for orthotics if that fails or if pt is poor candidate for exercise. Sorry, but I'm not aware of research suggesting percentage of IR controlled by glutes vs foot invertors/dorsiflexors.


    f. When you say internal rotation of the thigh, what you you mean exactly? A more internally rotated range? A more internally rotated internal end range? Faster internal rotation to the same degree? A leg which is internally rotated for longer?
    Given that some internal rotation is normal in the gait cycle, I guess I meant that which allows the knee/ankle/hip alignment to be disrupted and results in valgosity at the knee. Variables affecting that are the individual bony anatomy of the hip, Q angle, tibial torsion, femoral anteversion, etc..

    g. Could you point me at that literature please? I've been disagreeing with a colleague on the relevance of muscle training for this sort of thing for years (and great fun its been too)! Be great to have some new meat to chew on!


    Clin Rehabil. 2008 Dec;22(12):1051-60. The effect of additional strengthening of hip abductor and lateral rotator muscles in patellofemoral pain syndrome: a randomized controlled pilot study. Nakagawa TH, Muniz TB, Baldon Rde M, Dias Maciel C, de Menezes Reiff RB, SerrĂ£o FV.

    Arch Phys Med Rehabil. 2006 Nov;87(11):1428-35. Outcomes of a weight-bearing rehabilitation program for patients diagnosed with patellofemoral pain syndrome. Boling MC, Bolgla LA, Mattacola CG, Uhl TL, Hosey RG.

    Br J Sports Med. 2008 Oct;42(10):489-95. Epub 2008 Apr 18. Patellofemoral pain syndrome: a review on the associated neuromuscular deficits and current treatment options. Fagan V, Delahunt E.

    The first 2 are small samples, the 3rd points out that no RCTs currently exist to shed more light. To this, FWIW, I would add my personal and clinical experience that using the hip exercises improves outcomes, decreases need for treatment and improves function. I suppose that keeps me within Sackett's definition of evidence based practice, while placing me at risk of narcissism. To further risk the latter, you can check out my video explanation of this topic on my patient education blog.

    It's a pleasure to dialogue with you folks. I'm not sure how it plays out in podiatry, but I've appreciated that within the field of manual and physical medicine, having a broad perspective of worldviews is helpful. There are several separate geographic schools of thought within my field of work, central Europe, Canada, US, Aus/NZ. I've found it interesting that I think I see some differences here between different parts of the world. Cheers.

    Phillip Snell, DC
    Portland, OR
     
    Last edited by a moderator: Jul 2, 2009
Loading...

Share This Page