Case Study – A Runner with Knee Pain Visits the Podiatrist at Sydney Podiatrist Clinic

History by Karl Lockett, Podiatrist, Sydney – Martin Place

A 34 year old male presents to the podiatrist at Sydney Podiatrist clinic, Martin Place, complaining of knee pain of approximately 6 months. This person is a keen recreational runner who participates approximately 5 days per week. His usual running regime is approximately 7 kilometres, around the bay run, in Sydney. He has been running this track for approximately 4 years. He has never had any podiatry problems before and has reported good general health. This patient reports pain in his right knee just below his knee cap, or patella. He informs the podiatrist at Sydney podiatrist clinic that the pain is extremely prominent during the 1st 5 kilometres of his run and is extremely painful for the two hours that follow. He also informs the practitioner that the pain is extremely noticeable when climbing up or down stairs. He reports pain while performing any activity that involves squatting. He informs the podiatrist that the pain is a sharp pain followed by a burning sensation. This patient has attempted to carry out strengthening exercises for his thigh muscles, that were recommend to him by the local physiotherapist. These exercises proved unsuccessful and at times were increasing the pain sensation. He informs the podiatrist at Sydney podiatry clinic that the application of ice packs on the knee have provided short-term relief, and he has been using these cold packs every evening for approximately 4 weeks. In addition to the physiotherapy this patient had 4 sessions with an acupuncturist and this significantly reduced the pain. However, following the cessation of the course of acupuncture, and when returning to physical activity, the pain in the knee returned. The patient then decided to take some anti inflammatory medication, which was prescribed to him by his GP. The GP recommended the use of Mobic tablets and these were taken for 2 weeks. The Mobic tablets reduced the pain by approximately 50%, so the patient refused to continue taking the medication.

The patient was frustrated so returned to see his GP who organised a local X-ray at Castlereagh Imaging, Edgecliff. The X-ray report did not reveal anything of significance, and did not assist in the diagnosis of the patient’s condition. Following all of the above attempts to resolve his knee pain, this patient was recommended by friend to see a podiatrist at Sydney podiatrist clinic.

This gentleman arrived to his appointment carrying both pairs of his running shoes which he had been using for the last 6 months. This gentleman was approximately 175 cm tall, weighed 76 kilos, and was running with a Mizuno Wave inspire, and Asics Gel 2000.

The sports podiatrist informed the patient that he would carry out a biomechanical assessment and then advise him whether or not is running shoes were appropriate for his foot style.

Physical Assessment by Sports Podiatrist at Sydney Podiatrist Clinic

The sports podiatrist at Sydney podiatrist clinic carried out a physical assessment of the patients lower limb. The patient reported pain specifically along the patellar tendon when pressure was applied. The sports podiatrist also carried out resistance testing on the affected knee, and this elicited the same pain that the patient was reporting during and after his running. The podiatrist informed the patient that he had symptoms of patellar tendonitis, often known as runners knee. This condition involves irritation and inflammation in the patellar tendon which connects the thigh muscles to the tibia.

Biomechanical Assessment by Sport Podiatrist

The sports podiatrist created bisection lines on the patient’s foot and lower limb, and analysed the patient walking on a treadmill without shoes. The patient’s walking style was recorded using digital software on an iPad which would allow slow motion replay and detailed assessment. The patient was also asked to run on the treadmill while his foot function was recorded. The camera was placed behind the patient’s feet during this assessment and the lower leg including the tibia was also captured. The camera was then moved to a position in front of the patient so that more specific knee tracking was possible. During replay of the video it was clear that there was excessive internal rotation through the patient’s affected knee and lower leg. This excessive internal rotation creates what is known as a Q angle whereby the patella fails to track in a relatively straight line. Instead the patella moves inferiorly and superiorly as well as medially and laterally, which creates irritation. It was apparent that the excess of internal rotation of the affected leg was a result of excessive pronation through the foot and subtalar joint on the same side. The patient was informed that excessive subtalar joint pronation is one of the most common causes of excessive internal leg rotation. The patient was informed also, that in order to treat his condition he would need his foot to be supported. Realignment of the affected foot would reduce the rotation of the affected leg and therefore assist with patellar / knee cap tracking, and this would reduce the irritation through the patellar tendon. The patient was informed that overtime, his tendonitis would resolve naturally, without injections or medication.

The podiatrist took 3D foot scans of the patient’s feet and advised the patient that he would be issued with a pair of carbon fibre sports orthotics in 2 weeks time. The orthotics would be designed differently, whereby there would be significant rearfoot inversion and significant control from the right orthotic, and a more neutral orthotic with less control would be prescribed for the left foot. The podiatrist at Sydney podiatrist clinics, are not opposed to prescribe asymmetrical orthotics. Orthotics that are prescribed symmetrically, that do not reflect the difference between the left and right foot, sometimes fail to resolve the patient’s condition. The sports podiatrist informed the patient that his choice of running she was appropriate and that the lining from the running shoes would be removed and replaced with the sports orthotics.

The patient was advised to continue to apply ice packs to his knee everyday until his next appointment. He was advised to stretch his hamstrings and stretch his quadriceps muscles 3 times per day. The sports podiatrist also recommended that the patient try to use his orthotics on a day to day basis, in order to get used to them and in order to assist with the realignment of the affected knee. He was advised to avoid running for the next two weeks, and then return to be reassessed.

8 Week Follow Up with Sports Podiatrist at Sydney Podiatrist Clinic, Martin Place

The patient returned to see Karl Lockett, sports podiatrist at Sydney podiatrist clinic, Martin Place after 8 weeks so that he could have a reassessment of his knee pain. The patient reported that he was wearing his orthotics comfortably on a day to day basis and was not experiencing any fitting issues. The patient advised the sports podiatrist that he did not run for the first two weeks after receiving his orthotics. The knee pain reduced significantly during this two week period and to this end he decided to follow the podiatrists advice and carry out at 3 km run at 50% pace. The patient advised the sports podiatrist that his symptoms did not return and therefore he increased his cadence and distance. Upon assessment there was very mild tenderness of the patella and the patient reported minimal pain, and stiffness. The patient was satisfied with progress and the podiatrist informed him that he could carry out physical activity at a level that he was comfortable with. He was advised to return for orthotic reassessment once every two years, but to return to the sports podiatrist at Sydney podiatrist clinic, Martin Place if his symptoms returned.

Please be aware that the information contained in this case study is specific to one particular patient at the Sydney podiatrist clinic. If you have foot pain or any other type of biomechanical problem including foot pain, then you should seek the advice of a suitably qualified sports podiatrist.

Case study by Karl Lockett, sports podiatrist, Sydney, Martin Place.