Case Study – Knee Tracking, By Sports Podiatrist Karl Lockett

Initial Consultation with Sports Podiatrist – Knee Pain

A 34-year-old male runner arrives at the clinic for an initial consultation and reports to the Sports podiatrist that he has acute knee pain. The pain is in his left leg and has been a problem for approximately 4 months. The patient informs that podiatrist that he recently increased his mileage and frequency of runs and at this point he started to feel a burning sensation in and around the knee cap. Nothing else had changed for this patient – his running shoes, speed, cadence, running surface and route were all the same. He runs on hard, flat man made surfaces such as pavement or tarmac and uses a supportive Asics Gel Kayano. The patient informs the Sports podiatrist that he rarely runs up hills and trains in an area of Sydney that is mostly flat. He runs a sub 5-minute kilometre and would usually run 3 times a week. However, he increased this to 5 days a week and not long after, he started to feel the knee pain. This patient, who we will refer to as Mr BM, informs the podiatrist that the burning sensation gradually became a sharp pain that would affect him during the run, as well as afterwards.

Once warmed up, Mr BM was able to run without too much discomfort, but after 2 Kilometres the pain would start to develop. Once he settled into his usual pace he would experience even more pain and at times would have to stop. Following the run, the knee pain would get worse and the whole of his knee joint felt hot and restricted. He would limp, especially after being sat down. He informs the Sports podiatrist that the application of ice packs onto the knee joint were beneficial and this would allow him to walk a little more easily.

Before coming to see the Sports podiatrist, this patient had 4 sessions of physiotherapy. He was given exercises to strengthen his quads and was treated with ultra sound. He was also given some calf and hamstring stretches to do, but he was not seeing sufficient improvement. As is the case with most runners, Mr BM was still running and decided not to rest or take a break for a while to help reduce his pain. He informed the Sports podiatrist that stopping training was a last resort as he was preparing for a half marathon.

Physical Assessment by Sports Podiatrist

The Sports podiatrist carried out a thorough physical assessment which included range of motion tests at the joints of the foot, knee and hip. Pressure was applied to all anatomical structures of the knee joint including the patella, the patella tendon, the knee ligaments, joint line, meniscus and the peripheral / articulating surfaces of the patella. (Posterior surface of the patella is unreachable but compression of the bone can elicit pain as it is forced toward the femoral groove – the articulating surfaces of the femur). When the latter of these tests was carried out the patient confirmed a sharp pain, similar to the pain he feels during and after running. The Sports podiatrist informed the patient that he most likely has a condition known as chondromalacia patella – wear and tear of the posterior surface of the knee cap itself. Most commonly, there is a tracking problem, related to a bio mechanical anomaly, that can wear down the cartilage, leading to arthritis. Inflammation can form in the joint space and an x ray would confirm the extent of damage. Mr BM was referred for an x ray and was asked to come back to collect results a week later.

Biomechanical Assessment with Sports Podiatrist

This patient was asked to run bare foot on a treadmill and the Sports podiatrist recorded his bio mechanics using digital software. Markers were drawn on the posterior aspect of his Achilles tendon and heel bone. The amount of pronation / supination was observed as was running style, heel strike, heel lift, foot position, internal / external rotation. When played back in slow motion it was clear to see extreme over pronation in both feet, left more than right. The Sports podiatrist explained to the patient that this over pronation causes excessive internal rotation which causes a Q angle at the knee joint. This could be the cause of a tracking problem with the patella, causing knee pain.

Mr BM was then asked to walk towards the podiatrist so his knee joint movement could be observed. During mid stance, it was clear to see a Q angle at the knee joint due to excessive internal tibial rotation, caused by over pronation at the sub talar joint.

Treatment

Mr BM was scanned and measured for prescription orthotics that would be made from Carbon Fibre. These would be firm and controlling orthotics with slow release poron added for shock absorption. The orthotics would reduce and slow down pronation and prevent the knee from rotating excessively. The patella would then track in a more normal fashion, straight up and down and not side to side.

(This patient’s x ray report confirmed mild wear and tear to the posterior surface of the patella and some inflammatory change)

During the fitting appointment, the orthotics were inserted into Mr BM’s Asics trainers and the Sports podiatrist assessed these shoes while he ran on the treadmill. Alignment appeared to have improved although some mild shoe compression was still apparent, left more than right. It was decided to keep these running shoes for the first 4 weeks and possibly change them at a later date.

The Sports podiatrist asked Mr BM to continue his stretching and icing programme, and to maintain his quadriceps strengthening regime.

4 Week Follow Up With Sports Podiatrist

Mr BM reported mild improvement. He had not reduced his training programme and was running 5 days a week. He informed the podiatrist of approximately 15% improvement over all. To this end, it was decided to replace the running shoes with the same model.

8 Week Follow Up

The patient had been compliant with ice packs and physiotherapy at home and was comfortable in his new shoes with orthotics. He reported significant improvement and described mild pain during and after running. The onset of pain was now delayed and developed in the final 3^rd of his run.

12 Week Follow Up

Mr BM returned to see the Sports podiatrist for the final time after 12 weeks, whereby he very happily reported he was able to run, without knee pain. He was able to pull back on the home physiotherapy. He did not report any other problems associated with his orthotics or running shoes. The patient could enter the half marathon but was advised to return to the clinic if he felt the knee pain returning.

NB: The information contained in this case study should not be taken as general advice, as it is specific to one particular individual. If you have knee pain you should consult with a Sports podiatrist or a suitably qualified health practitioner.