Friday, January 9, 2009

Battle at Wounded Knee

Dear Dr. Bob

I'm hurt. My left knee was bothering me all week, but as soon as I started running it would be fine. The pain would come after a run, and I just put it down to the hard hills of America's Wild West. However, after a particularly grueling uphill run on Saturday, it hurt like crazy all night and the following morning. Sunday I lasted about two strides. Walking down stairs is particularly difficult. I put ice on it last night, and will continue to do this throughout the week. I'm sure I need new shoes but wonder if I have done some lasting damage? With my past experiences, I've lost some trust and faith in doctors and tradition medicine

Kneed Help

Dear Kneedy

It was one of those unceremonious events of "How the West was Won." Broken trust and empty treaties fueled the human darker side and led to a Nazi style genocide on that late December day where men, women, and children lost their lives in a hail of machine gun and rifle fire. Some were pursued as far as two miles then run down in this "police action." One hungry infant was found trying to nurse from her lifeless mother's bloodied breast. The soldiers were given the Congressional Medal of Honor for this embarrassing chapter in our history.

As for needing my help, it sounds like you have patellofemoral syndrome (previously called chrondromalacia or common name, runner's knee). As with all running injuries, it is not the name and location of the injury but identifying the underlying causes and tailoring the treatment to address those causes.

The most common factors contributing to this injury are:

1. Tight muscles (specifically the quads, hamstrings, IT band and the gastrocnemius). Mr. KH, I have seen your quads in person, so I know they are so tight they look like you have been using Viagra ointment instead of Ben Gay. I don't care if they have always been tight. All I know is that your quads are pathologically tight. Maybe they have always been tight but became even tighter repeatedly running the hills of Corbett Canyon.

2. Weak muscles (quads, hams, and IT band). An interesting thing happen when you are forced to rest. Muscles atrophy with disuse. When the quads become shrinking violets, the lever arm of the IT band decreases, making the muscle unit overwork. The end result is IT band tendonitis or patellofemoral syndrome. Either injury will get worse rather than better with rest.

3. Bad biomechanics. For example, if the subtalar joint is too pronated while the foot is on the ground. This causes the talus to go down and in. Since the ankle joint is mostly a one plan hinge joint, the whole leg rotates inwards to compensate. This translates to an improper tracking of the kneecap. This discongruency of the knee is measured as a high Q angle...and no, I did not say you have cute angles.

4. Bad running shoes. This can be poorly designed shoes, defective shoes, worn out shoes or ones that are plain not a match for your foot.

5. Previous damage to knee structures. You are walking in the city and a voice says "stick 'em up!" You know Tae Kwan Do so you deftly swing your elbow back but contact nothing but air. Then a midget blows off your kneecap with a Saturday night Special. All kidding aside, a meniscal tear, a Baker's cyst, genetically inherited ligament laxity and an old untreated ligament sprain are common causes in this category.

I may sound like a parrot here with this repetitious phrase, "awwwwk, Polly want a treatment?" However the best treatment is to focus on alleviating the cause. The treatment may include straps, braces, foot supports, and a multitude of stretching and strengthening exercises. Conservative care is by far the best answer. Surgical shaving of the back of the knee cap has an extremely poor success rate (about as good as outrunning the midget's bullet).

First and foremost, develop a trustful relationship with your health care provider. The practitioner should be worthy of this trust if he/she takes a detailed history of your problem, does a thorough examination focused on the appropriate systems, and informs you of the findings before ever commencing treatment. Sometimes the cause is obvious. Sometimes these factors are more occult and take multiple visits. Work with your doctor. Bring notes. Bring all your shoes and any gadgets you use. A good one will take to the challenge the same way you look at an important road race.

KH, you remind me of a guy I'll call George, who went to church every day and prayed to the Lord to win the lottery. After 6 months of this routine, his faith and trust were ebbing. He prayed again, questioning why if He existed, the Lord of the Universe would not answer his prayer. Then, all of a sudden, there was a brilliant light and a booming deep voice, "George, I hear your prayers, but can you just do me one small favor?""Anything, Lord!" George replied."George, could you at least buy a lottery ticket?"

KH, your lottery ticket is forming a positive relationship with the professional that is trying to help you. Do so before you become a modern day victim of the Massacre at Wounded Knee.

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