Thursday, May 30, 2013

Knee pain(free)

I am thankful everyday that I am healthy and able to run at all, and every time I run without knee pain I am especially grateful because not long ago, this wasn't so.  This morning I ran 6.2 miles at an 8:06 pace - a good pace, and pain-free.  Felt alright, but not like I did in March when I was really mileaging-up.

At the clinic, I see "knee pain" patients all day long: otherwise healthy soldiers with a generalized, sometimes bilateral knee pain, which they can't pinpoint to a particular trauma or injury, but they know isn't getting any better.  If I had to pick a favorite type of injury, it would be these, because generally speaking, the fix is easy, non-invasive, and really improves the quality of life for people who love to run or otherwise use their lower limbs.

The typical patient usually describes pain medially and inferior to the kneecap - "inside my knee" they often say.  They tell me that the pain is constant but exacerbated with standing from a seated position, running, squats and going up/down stairs.  Sometimes the patient reports some swelling of the knee, sometimes not.
 
Dan's left knee, ouchie zones to scale


It's patellofemoral pain syndrome (PFPS).  Jumper's knee. Runner's knee.  It has a million names.  It's knee pain, it's happened to me, and it stinks.  Luckily it can be fixed!

This PFPS is due to an imbalance in the quadriceps muscle as it yanks on the knee cap when you use your legs.  The quadriceps are 4 separate muscles each pulling like so:
1.  vastus lateralis 2.  rectus femoris 3.  vastus intermedius 4.  vastus medialis
and if they are not fairly well-balanced, the glide of a knee cap along a femur won't be so smooth or even.  Pain factory!  In general (sample population: my patients + some reading) it's the medial quadriceps that's the weakest - the vastus medialis. 

The army isn't as nice to knees as it should be. There is a lot of pressure to keep running and stay off of "profile"...but a patella is also putting a lot of pressure on a femur, which hurts, HURTS!! and can lead to softening of the cartilage on the undersurface of the patella (read: more pain!).
Good lookin' right knee right there!

What do I suggest?  

RICERest (no running for sure! up to 30 days even). Ice.  Compression (eh, not really necessary here).  Elevate (sure).  Eating rice while RICEing - also ok.

Home exercise program for quad strengthening.  Here's a simple truth and a good start: to reduce knee pain, strengthen your quads.  All of them.  Equally.  We need to achieve balance between the vastus medialis and vastus lateralis.  So do those short arc quads, wall squats, leg presses, straight leg raises, seated leg extensions with a tennis ball between your knees, isometrically squeezing the same tennis ball.  I'm not a physical therapist by any means but you get the idea.  Stretch often.  And don't neglect the hammies either while you're at it!

I also like non-steroidal anti-inflammatories (NSAIDs).  These are great drugs with a good anti-inflammatory and analgesic effect.  I don't use them just when the pain is bad, I use and prescribe them for use everyday for a few weeks in order to enable a lasting anti-inflammatory effect.  I personally like ibuprofen.   

As always I recommend getting personal medical opinions from somewhere besides the internet...