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Knee pain in swimmer, orthosis prescription

Discussion in 'Biomechanics, Sports and Foot orthoses' started by CatHutch, Oct 25, 2012.

  1. CatHutch

    CatHutch Welcome New Poster

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    I am due to see a 13 year old boy who has been suffering from knee pain whilst swimming (he swims competitively) for around 4 - 6 months. He has been attending a sports physio who has advised that he is having growing pains, the physio is seeing him regularly. He has had X ray to both knees and hips which have been clear (no issues noted).
    The boy toes in on the right foot (and his mum advises that this has been the case as long as she can remember). The physio has advised the patient (and his mum) that he should see a Podiatrist to have a casted custom made orthotic (but to avoid off the shelf orthoses). I have spoken to the mum on the phone and she has confirmed that he has no pain at all when walking only when swimming.
    I have explained that I am not in a position to cast and make an orthotic device but the patients mother is nervous about paying to have an orthotic made anyway if there is no guarantee that this will solve the problem whilst swimming (the main issue).
    Has anyone experienced issues like this before (i.e. recommending an orthotic when there is no pain or discomfort during gait). What advice can you give around orthoses for toe in at that age (I was thinking that it would possibly correct itself over time as part of the growth of the limbs?). I appreciated that it would possibly be best to do my full assessment then ask for advice, however it would be great if you could give me some guidance in advance. I am just a bit perplexed as to the benefit of an orthosis for issues that occur outwith gait. Any help would be appreciated.
  2. Craig Payne

    Craig Payne Moderator

    I have no idea why you would even want to come close to consider using a foot orthotic in a situation like this. Advise them to get another physio as what they have got is NOT "growing pains".
  3. Athol Thomson

    Athol Thomson Active Member

    Yep I agree.

    Is the boy mainly swimming breast-stroke? Medial knee pain can be an issue with this stroke.

    Am J Sports Med. 1980 Jul-Aug;8(4):228-31.
    Breaststroke swimmer's knee. A biomechanical and arthroscopic study.
    Keskinen K, Eriksson E, Komi P.

    The cause of the breaststroke swimmer's knee with medial pain of the knee joint has not been clearly identified. Breaststroke swimmers with knee pain were, therefore, examined arthroscopically. None showed any other disorders of their knees than medial synovitis in seven of nine swimmers. Since structural abnormalities could be ruled out, biomechanical analyses utilizing cinematographic techniques were used to study patients swimming in a special flume with the speed set at 90% of their best competitive performance. The results indicate that the extension and flexion and also in some cases the hip abduction and adduction movements of the whip kick were performed with high peak angular velocities. No significant differences in swimming technique among the six patients studied and three controls could be observed. It is concluded that a combination of high angular velocities at the hip and knee and external rotation of the tibia relative to the femur repeated in excessive amounts might be the primary cause for the medial synovitis documented in these patients. The breaststroker's knee thus seems to be an overuse syndrome.

  4. Griff

    Griff Moderator

    I agree with above comments. Orthoses probably not top priority here....

    Refer them to a Physio that understands swimming (or at least one that understands knees!)

    I can give you the names of two friends of mine who are both ex-swimmers at a very high level, and happen to also be very good Physio's if that would help?

    Edit: Just seen you are in Falkirk...probably won't help in that case...
  5. RobinP

    RobinP Well-Known Member

    Another shining example of the immense faith patients have in physios whether they are good or just downright awful(as would appear to be the case here)

    Totally agree with the above - orthosis is of little importance here. But isn't it amazing that the mum is not prepared to spend money on an orthosis (rightly) because it might not work yet has been seeing a physio for months with no improvement.....at what cost?

    Anyway, it would be good to know what stroke he does -suspect breast stroke as if he were a back stroker or a freestyle, the intoeing is less likely to be problematic.

    Conclusion: get a new physio. Worth a trip to London for the peace of mind of someone very capable looking at the problem?

    I used to support Falkirk Football Club ......it was a dark period in my life
  6. Boots n all

    Boots n all Well-Known Member

    Now now, be nice, you are all wrong... just because you dont have an orthosis to sell that can be worn during swimming, doesnt mean there isnt one out there.

    l bet CP's mate Brian R has one just for such an occasion:pigs:
  7. davidh

    davidh Podiatry Arena Veteran

    What a strange thread.

    I have a question for the OP - WHY are you not in a position to cast a foot?

    On to the case. I would want to talk to both the physio and the patient before making any decisions. Presumably all the info has come from the mum, and the mum may not have given the full, complete, or even honest picture.

    But if she has then I agree with everyone here.
  8. James Welch

    James Welch Active Member

    Once again, agree with all the above postings, but have chucked in a few questions of my own....

    What type of stroke are they doing (I'm not making any assumptions here). Is the knee pain unilateral or bilateral and whereabouts anatomically on the knee? When does it occur during swimming (As in during the pull phase, glide phase, during a tumble turn pushing off the wall, etc...)? Prior to his 4-6/12 knee pain, what has his training programme been like and has it suddenly been altered?
    Last edited: Oct 26, 2012
  9. I wouldn't necessarily rule out that other weightbearing activities may be exacerbating this patient's knee pain even though the primary source of irritation is probably a faulty swimming stroke. In cases such as these, I will generally trial a medial arch and medial heel varus adhesive felt temporary pad inside the shoe, preferably adhered to an over-the-counter orthosis to see if this improves the pain or not during their weightbearing activities while also recommending icing, Voltaren gel applications four times a day and a visit to a swimming coach to see whether their swim stroke is the culprit. I don't charge extra for felt wedging placed inside the shoe so there should be no problem in at least giving it a try to see how it helps. You may be surprised at how decreasing knee joint loads during walking and running activities with a simple varus heel and arch wedge inside the shoe helps even pain caused by swimming.
  10. Craig Payne

    Craig Payne Moderator

    A TDT ! ;)
  11. HansMassage

    HansMassage Active Member

    An iliosacral upslip could be causing the problem. If all the attention is focused on the knee and the in turned foot the cause for the pattern is often overlooked.
    Recommend the Phiso get the Dynamic Body book from http://erikdalton.com/
  12. markjohconley

    markjohconley Well-Known Member

    Hasn't the breast-stroke kick changed recently to mostly rotation at the knee and less at the hip?

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