"Kneecap Training"

[HillSlugger]

Over course of the summer (triathlon training) I developed discomfort in my left knee, above the patella. When I saw a knee specialist he said that I had tendonitis of the quadriceps tendon. When rest and antiinflammatories did not clear it up I went back. This time he told me I had too much knee flexibility and he sent me for PT to strengthen the knee. The diagnosis was "bilateral patellofem pain and quad tendonitis". At my first PT session today the therapist told me that my kneecaps were too loose and that they weren't tracking straight; both are deflected outward and the left one also has a bit of twist to it. So, for treatment she taped my kneecaps into the proper position and then started exercising my quads to this new alignment. We started with 8 minutes on the elliptical, then leg presses, "thigh push-outs", "thigh pull-ins", quad extensions, and electrostimulation. I'm supposed to wear the tape 2 days on, one day off, and do PT twice a week (Tuesdays and Fridays).

Can one or more of our lovely PTs tell me if all this makes sense? How long should I expect it to be before I start noticing definite improvement? Which part of this is making my lower back hurt?

Thanks, Nicole

[Zen]

Which part of this is making my lower back hurt?

Do you mean the exercises are making your back hurt or did you already have back pain accompanied by knee pain?

[HillSlugger]

Do you mean the exercises are making your back hurt or did you already have back pain accompanied by knee pain?

My lower back aches since PT this afternoon (my knees and thighs are quite tired and achy).

[Wahine]

MD - I understand where your PT is going with this but it may not be the right way for you to start. Make sure that when you see the PT you give very clear feedback about how you felt after the session. Eg: my back started to hurt an hour later and didn't stop hurting until I took advil a few hours after that. Be as specific as you can. If you are specific the PT will take this info and use it to mold a program that works for you. If they're any good they will. If you are not specific, it may come across as whining (not that it should but unfortunately sometimes PTs can be presumptuous and I hate to say it but especially if you're a little bigger and they think that you're not used to exercise). I personally prefer to start people on a stretching progam for the hips first and maybe with some strengthening of the inner thigh isometrically before I start in on leg presses, thigh push outs or knee extensions. In fact I never give knee extensions as an exercise for patellofemoral pain. I also like to add some deep tissue massage to release the lateral quad/thigh.

I really like taping techniques for this type of problem.

Here's how I might approach this with your PT. Poke around your quad and outer thigh area and see if you can find some knots. Point these out to your PT and politely ask if they think that deep tissue massage might help that. As for the hip stretches, I would say something like, "My hips seem really tight, could this be contributing to the problem. Would it help for me to stretch them?"

I'm laying this out in this way because some PTs feel threatened when a patient comes in and suggests a different approach. I don't personally think that there is anything wrong with this and I appreciate it when my patients put their thoughts out there, regardless of if it's positive or negative. But I am confident in myself and my work. Someone not as confident will not react well and instead of keeping a nice understanding repore and taking action to adapt a program as needed, they may start to rationalize why the treatment may not be going well by finding blame elsewhere.

Please realize that I'm not saying the treatment they have started with is bad. It may be very appropriate. I just think that you need to give some feedback and ask about some other options. It could be that your PT is planning to add these things in that I have suggested, they just couldn't get to it today.

Finally, your back pain may have something to do with your knee pain and if it persists it should be evaluated by the PT.

Knott will likely add some foot stuff to this.

[KnottedYet]

Knott will likely add some foot stuff to this.

Oh, yeahhhhhhhhh...

It's all because you have compensated hindfoot varus and probably forefoot also, and so over-pronate.
(seriously, ask your PT if insoles like Superfeet would help your knees)

Wahine said it all!

[HillSlugger]

Oh, yeahhhhhhhhh...

It's all because you have compensated hindfoot varus and probably forefoot also, and so over-pronate.
(seriously, ask your PT if insoles like Superfeet would help your knees)

Wahine said it all!

Yes, I overpronate. I have motion control running shoes. Still, I had ankle issues after I started running and now use custom orthotics in my running shoes. I have Superfeet in most of my sneakers and shoes.

Could you please explain "compensated hindfoot varus and probably forefoot also"?

Many thanks!

[KnottedYet]

Yes, I overpronate.

Oooh, wow, did I have a lucky guess or what?

Perhaps ask your PT if you should be wearing your custom orthotics all the time, or ask if the PT can "post" your Superfeet for everyday wear. (Posting is just putting wedges on the underside of your Superfeet so they correct your mechanics like the custom orthotics do. Shouldn't cost you anything other than the PT's time and *maybe* a few bucks for the wedge material.)

"fore- and hind-foot varus" is just the $64-phrase for the structural pattern of your feet at sub-talar neutral, and "compensated" means that your ankle/foot have collapsed during weightbearing to help the sole of your foot reach the ground. (that compensation is overpronation) If you had uncompensated varus, you'd be over-supinating and you'd've talked about a different set of symptoms in your knees and back.

And, everything Wahine said!

Edit: darn, I just did a quick search trying to find this nifty online video of feet and what they do, and I can't find it. Sorry!

Edit #2: and your PT at some point should assess your posture of your entire body. Especially with the back pain popping up, you might have some underlying posture habits (like locking your knees, or anterior pelvic tilt, or poor transversus abdominus control, or glutes that take a holiday, etc.) that could be playing games with your bod.

[HillSlugger]

MD - I understand where your PT is going with this but it may not be the right way for you to start. Make sure that when you see the PT you give very clear feedback about how you felt after the session. Eg: my back started to hurt an hour later and didn't stop hurting until I took advil a few hours after that. Be as specific as you can. If you are specific the PT will take this info and use it to mold a program that works for you. If they're any good they will. If you are not specific, it may come across as whining (not that it should but unfortunately sometimes PTs can be presumptuous and I hate to say it but especially if you're a little bigger and they think that you're not used to exercise). I personally prefer to start people on a stretching progam for the hips first and maybe with some strengthening of the inner thigh isometrically before I start in on leg presses, thigh push outs or knee extensions. In fact I never give knee extensions as an exercise for patellofemoral pain. I also like to add some deep tissue massage to release the lateral quad/thigh.

I really like taping techniques for this type of problem.

Here's how I might approach this with your PT. Poke around your quad and outer thigh area and see if you can find some knots. Point these out to your PT and politely ask if they think that deep tissue massage might help that. As for the hip stretches, I would say something like, "My hips seem really tight, could this be contributing to the problem. Would it help for me to stretch them?"

I'm laying this out in this way because some PTs feel threatened when a patient comes in and suggests a different approach. I don't personally think that there is anything wrong with this and I appreciate it when my patients put their thoughts out there, regardless of if it's positive or negative. But I am confident in myself and my work. Someone not as confident will not react well and instead of keeping a nice understanding repore and taking action to adapt a program as needed, they may start to rationalize why the treatment may not be going well by finding blame elsewhere.

Please realize that I'm not saying the treatment they have started with is bad. It may be very appropriate. I just think that you need to give some feedback and ask about some other options. It could be that your PT is planning to add these things in that I have suggested, they just couldn't get to it today.

Finally, your back pain may have something to do with your knee pain and if it persists it should be evaluated by the PT.

Knott will likely add some foot stuff to this.

This is my first experience with PT so I don't yet know how it's all supposed to work in regards to the decision making. Thanks for you comments and suggestions.

The PT knows I'm a triathlete (she seemed quite impressed); she even commented on how "cut" I am (maybe she was coming on to me ). Do you think she may have taken this into account when she chose my exercises? I see her again tomorrow, but then switch to early AM sessions next week with someone else. Just wondering if different PT might do things differently and how much control I need to take.

[KnottedYet]

Every PT does things a bit differently. (for example, I *always* fixate on feet and posture first) But, every PT knows their own habits and knows how to branch off from there; and every PT is going to adjust what they have you doing based on how your bod responds.

Lots of feedback to the PT is always good. Lots of questions are good. I love it when my patients come in saying, "Hey, I looked this up on the internet; how does such-and-such apply to me?" "Why am I doing this exercise, and how does it help my problem?"

Here's one of my favorite quotes: (I have it hanging at my desk)
"No physical therapist can possibly match the work of an educated patient."

If you think of your PT as education sessions rather than work-out sessions you will get even more out of the whole process. The more you can learn, the better you will be able to manage your muscles and joints both now and later.

[KSH]

Well, it sounds like you are working on getting better and fixing the problem. That's great.

I can't really address your questions... but I wish you the best in getting yourself all healed up and ready to run again in the future.

[Wahine]

Here's one of my favorite quotes: (I have it hanging at my desk)
"No physical therapist can possibly match the work of an educated patient."

If you think of your PT as education sessions rather than work-out sessions you will get even more out of the whole process. The more you can learn, the better you will be able to manage your muscles and joints both now and later.

I love that. I'm using it.

[HillSlugger]

Is it reasonable to expect that this line of treatment will lead to long term improvement and that I can expect more triathlon in my future?

Is it reasonable to think that I might be able to start some easy spinning in a couple weeks? My doctor has told me that swimming is OK and "biking as tolerated".

[KnottedYet]

I love that. I'm using it.

I miss-quoted it. Instead of "can" put in the word "could". That's from James McGavin PT.

[KnottedYet]

Is it reasonable to expect that this line of treatment will lead to long term improvement and that I can expect more triathlon in my future?

Is it reasonable to think that I might be able to start some easy spinning in a couple weeks? My doctor has told me that swimming is OK and "biking as tolerated".

That's the main goal. The more you can learn, the more you can improve, and take it from there!

[Wahine]

Is it reasonable to expect that this line of treatment will lead to long term improvement and that I can expect more triathlon in my future?

Is it reasonable to think that I might be able to start some easy spinning in a couple weeks? My doctor has told me that swimming is OK and "biking as tolerated".

Yes and yes. It is very possible to recover from this sort of problem and very possible to return to triathlon. I had a lady with a similar problem last year who was an avid telemark skier and had been competetive in her past. She got better in 6 treatments and was able to go back to hard core skiing with her knees taped soone than that. Tele skiing is much harder on the patellofemoral joints than triathlon.

If you get the right stretches in you should be able to get back to spinning in a couple of weeks.