Lateral Knee Pain

Problems with gait

 

Gait and knee

 

Chi Running's Danny Dreyer discusses the right and wrong ways for successful running in relation to heel strike, and has produced an instructional video on 'How to Avoid Heel Strike' shown at: 

https://www.youtube.com/watch?v=rkUqkdPQHis&feature=share

 

It seems to me that this is more than likely what caused my problems in that it affects the hip, knee and foot... the whole leg!

 

 

http://www.sportsinjurybulletin.com/archive/posterolateral-corner-knee-damage#

 

A PLC injury can cause considerable disability. The opposing convex articulating surfaces of the lateral femur and tibia can cause the lateral side of the joint to open when the heel strikes the ground, which produces a distinctive ‘varus thrust gait’. Patients often prefer to keep their knee bent to prevent this.

 

 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724686/  (See PDF)

 

Various static and dynamic functions have been attributed to the popliteus, including “unlocking” of the knee joint,10 initiation and maintenance of internal rotation of the tibia on the femur,1 2 6 9 and preventing forward dislocation of the femur on the tibia during initial flexion.2 It is the only muscle that has sufficient mechanical advantage to produce internal rotation of the tibia on the femur during gait.11

 

 

http://www.healio.com/orthopedics/journals/ortho/2008-5-31-5/%7B91821d01-6dec-4790-87f5-140159a4f3d2%7D/acute-and-chronic-management-of-posterolateral-corner-injuries-of-the-knee

 

On physical examination, patients with acute PLC injuries typically note diffuse tenderness to palpation over the posterolateral joint region. Tenderness over the fibular head should also raise concern for PLC injury. Gait abnormalities may be present, particularly in chronic injuries, such as standing varus alignment of the knee and/or varus thrust or hyperextension varus thrust during the stance phase of gait. 27 Patients may attempt to walk with the knee slightly flexed or use shoe lifts or high-heeled shoes to prevent knee hyperextension and its associated symptoms of pain and instability.

 

At the acute stage of my injury, I felt like '... my knee wanted to bend backwards, like an elbow...', which I now think to be hyperextention. And I was told that I walk around with my knee slightly bent. I have no information about gait, apart from tripping over my toes, as with drop foot.

 

At the chronic stage now, I feel that my muscles are too weak to make an observation. I thought that I was overpronating, however the wear on my new...ish shoes shows far more wear on the lateral edge of the sole, more akin to supination / underpronation. And this is confirmed by the Pronation diagrams in Fig xxxx.

 

But there again, is it likely due to weak muscles...? Or is this evidence that there is a problem with the PLC of my knee...??? 

 

 

http://www.drsarahsimison.com/biomechanics-blog/normal-gait-function

 

Normal gait

Your tibia rotates on top of the talus bone as your foot moves through the gait cycle.  The following movements occur with each step in the foot:

• Talus adduction causes internal rotation of the tibia.

• Talus abduction causes external rotation of the tibia.

• Three degrees of foot pronation causes the tibia to be five degrees internally rotated.

• Two degrees of foot supination causes the tibia to be 10 degrees externally rotated.

• This all adds up to a normal gait producing 15 degrees of rotation through the tibia.

 

 

http://www.drsarahsimison.com/biomechanics-blog/abnormal-gait-can-lead-to-injury

 

Abnormal gait

When abnormal pronation causes the femur and tibia to rotate against each other, there is increased tension applied through the muscles of the calf.  The gastrocnemius muscle attatches to both the achilles tendon as well as to the femur at its proximal end.  The soleus attaches only to the tibia and the achilles insertion.  The abnormal rotation causes increased stress in the achilles tendon, and most importantly twists the tendon at its weakest area - where the tendon attaches to the muscle.  Achilles tendinopathy can become chronic.

 

 

The lateral structures of the knee are stretched during stance phase of gait as discussed by:

http://www.acr.org/Education/Education-Center/Course-Materials/~/media/3FFC290B932E4F9E9767B58A279C7BDC.pdf

 

Injuries of the lateral compartment of the knee are less common than injuries of the medial compartment. However, injuries of the lateral structures may be more disabling because these structures are subjected to greater force during gait (8,16,28).The physiologic varus angulation of the limb axis increases and reaches maximum with full extension of the knee during the stance phase of the gait cycle, in which the lateral structures are stretched.

 

 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953341/

 

Walking (gait) is a functional movement that requires effective and efficient knee joint stability via both passive and dynamic joint restraints. Injury to any of the static stabilizers of the knee places an increased burden on the remaining ligamentous structures to provide stability during functional activities such as walking. In the case of a multi-ligament knee injury (MLKI), increased joint laxity in the absence of effective static ligamentous restraints can result in excessive demands on the dynamic stabilizers of the knee and lead to excessive or abnormal motion in the knee joint. These altered movement patterns can increase tensile stress on healing tissues and ultimately deter healing in the patient, both post-injury and post-surgically.14 In addition, this altered repetitive abnormal movement may place abnormally high stress on the articular cartilage of the knee, which could result in premature breakdown of the cartilaginous tissues. Hence, the physical therapist's ability to recognize and correct altered gait in a patient following a MLKI is critical to ensure that the knee joint is not subjected to altered movement patterns and abnormally high forces to the joint.

 

 

Ankle and Subtalar Joint in Gait

 

http://www.wheelessonline.com/ortho/role_of_the_ankle_and_subtalar_joint_in_gait

 

Role of the Ankle and Subtalar Joint in Gait

- Ankle Joint: During Gait: 
    - ankle joint has an oblique axis; 
    - in frontal plane, ankle joint is angled 82 deg, directed laterally; 
    - in transverse plane, axis is directly laterally & posteriorly about 20-30 deg; 
    - as a consequence of this oblique ankle axis is that foot  externally rotates when the ankle is in maximal dorsiflexion; 
          - when the foot plantar flexes, it internally rotates; 
    - w/ foot fixed on ground as in stance phase of gait; 
          - forward tibial progression (ankle dorsiflexion) results in tibial internal rotation; 
          - when tibia is behind foot (ankle plantar flexion), it is externally rotated; 

- Subtalar Joint During Gait: 
    - external rotation of leg produces supination of the foot; 
        - during wt bearing, external rotation of limb & subsequent forefoot supination are followed by pronation twist of forefoot to remain plantigrade; 
        - this tends to lock the foot, making it a rigid lever; 
    - internal rotation of the leg produces a pronated foot; 
        - internal rotation of leg & its subsequent pronation are followed by supinatory twist of the forefoot to remain plantigrade; 
        - this mechanism unlocks midtarsal joint & produces mobile midfoot noted at time of heel contact & first 15% of the gait cycle; 
    - inversion of the heel in the normal foot promptly occurs as wt is transferred from heel to forefoot when a person rises on the toes; 
         - such inversion of the heel causes the mid foot to covert from a mobile structure to a rigid lever; 
    - when the heel is elevated during standing or at the time of push off, wt of the body is shared by all the metatarsal heads; 
          - to achieve this fair division of the body wt among the metatarsals, foot must supinate slightly and deviate laterally; 

- Ankle Joint and Subtalar Joint Work Together: 
    - ankle combines dorsiflexion with abduction and plantar flexion w/ adduction, subtalar joint combines dorsiflexion, abduction, & eversion in one direction and plantar flexion, adduction, and inversion in the other direction; 
         - these combined subtalar motions are referred to as pronation & supination; 
    - when the subtalar joint is fused, rotation is increased in the ankle and may cause arthritic change; 
         - when the ankle is fused, greater stresses are placed on the sub-talar and midtarsal joints; 
    - dorsiflexion of the toes tightends the plantar aponeurosis and assists in inversion of the heel; 
         - supinatory twist activates the locking mechanism in foot, thus converting a flexible foot into a rigid lever, an action that is necessary at push off 

 

It seems to me that, if my foot is slapping down on the ground, then it is not going through the more usual procedures such as tranference of weight as with '... from heel to forefoot when a person rises on the toes...'

 

 

Ankle ultrasound images

 

http://www.essr.org/html/img/pool/ankle.pdf

 

Musculoskeletal Ultrasound Technical Guidelines for the ankle... in preparation for an ultrasound investigation into problems within my foot...

 

 

 

 

 

There is overlap here with structures discussed under 'Groin', but then as these structures are all joined together in a kinetic chain, this should not be surprising...