Wednesday, April 20, 2016

Case Study: Chondromalacia Patella (Knee Pain)

April 20, 2016/ by Dr. Jody Gilligan
My left knee was a disaster on the bike. I remember it taking about an hour for it to handle any pressure on the down-stroke. So when a fellow cyclist comes in with this all-too-common complaint, I know I can help. Here’s an example of a case I had the opportunity to follow up on lately:
Case study
33 y/o female
Left knee pain. Most of the pain seems to come from behind the knee cap on the inside of the knee. Diagnosed as Chondromalacia Patella by her orthopedist.
MRI was negative for any major degenerative changes. Minimal changes in the articular cartilage were noted.
The woman was recommended to our office, for a bike fit, by a patient she met while training on her road bike on A1A (on vacation). She stated that she has had this issue since she started training for triathlons 2 years ago. At first it was only an annoyance that would go away after warming up. Over the past year it had started to worsen as her training volume increased. For the past 3 or 4 months the knee hurts when she goes to stand after sitting too long (around 30 mins). It didn’t bother her running but pushing off the wall, in the pool, is painful as well. She also has a history of low back pain and left hip pain, which she was not experiencing at the time of the examination.
Before visiting our office, she had been under the care of her orthopedist. She was prescribed NSAID’s, stretching exercises and leg strengthening exercises (focused on the strength of her VMO) with minimal improvement. It was then recommended that she take 4 weeks off from training, which she does not wish to try (yet). She also has regular (weekly) massages and practices yoga.
What We Did
A very thorough examination of everything pertinent to this bike fit. It would be useful to know if there is some sort of perpetuating-factor or structural-issue before this patient continues with any activity. I start with Structural Radiography of the lumbar spine and pelvis before moving on to neurological, orthopedic and functional testing. Here are some of the findings:
Limited Structural Exam Findings
·         Significant right thoracic shift/translation, right forward/anterior pelvic rotation
·         She displaced more weight on the right leg (+7lbs) when standing
·         Structural Radiography: A congenital Leg Length Discrepancy (LLD), right leg is 7mm shorter than the left leg resulting in a 18mm right thoracic translation/shift. L5 Grade 1 degenerative anterior spondylolisthesis with moderate loss of the L5 disc height. Hyperlordotic lumbar curvature. Bilateral CAM deformity of the femoral heads.

Functional Exam Findings
·         Significant restrictions in bilateral ankle dorsiflexion, loss of hip internal rotation on both sides, restricted posterior glide, hip flexion and external rotation on the right side and extremely restricted knee flexion with hip extension. Her quadriceps musculature would be best described as beef-jerky. There were several other muscle groups with similar characteristics.
·         Video Motion Analysis demonstrated that she was too high and way too far back. Every compensatory movement-pattern you would have expected, based on the LLD, was present.

How Did She Do It?
When you grow up with a significant LLD in our perfectly flat world, you will most likely develop some structural shifts in the spine and a few compensatory movement-patterns. She had just about everything I’d think of if you told me your right leg was shorter than your left. So I was amazed she felt ONLY one significant secondary condition/symptom. This is a great example of how tough our bodies are, until they aren’t…
Having equal leg-lengths on the bike removed a major perpetuator of the compensatory movement-pattern she was displaying. Positioning the saddle in the correct range allowed for an impressive movement-correction as well. You can say it “took pressure” off the knee, but it isn’t that simple. At best this would be a temporary patch until the deeper functional issues “caught up” to her.
These things don’t clear up on their own, overnight, and they can come back if you aren’t paying attention. That’s why the bulk of our time spent together was on teaching her how to take care of herself. The Corrective Bike Fit is a major investment in yourself. You aren’t going to pedal-mindlessly out of here. I expect you to understand that the fit itself, along with the enhancements made to provide structural asymmetry, are just the foundation to better movement.
You can translate that into greater comfort, speed, performance, etc.

So I was reminded of this case because she dropped by to say hi and purchase some foot-correctors while she was on vacation. She reported that her knee felt better right away and had not been an issue since the bike fit. She does her “homework” regularly and feels very empowered with the knowledge she invested in.