COHF 010: Pain in both knees

COHF 010: 38­-year­-old female patient who’s a triathlete experiencing pain in both knees, both on the bike and running while training for her first Ironman.

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Today, on Episode 10, we have a 38-­year-­old female patient who’s a triathlete experiencing pain in both knees, both on the bike and running while training for her first Ironman. A little bit about her history, she has neck and shoulder pain, left backof the knee, also foot numbing more on the right, and then the left knee was scoped six months ago.

Evaluation Parameters

On examination, we had bilateral hip weakness more on the left, hamstring tightness, hip flexors loose, hip extensor stretch was okay and adequate, and then we had neutral foot mechanics.

Let’s Hear From The Council!

Dr. Emily Splichal

So anytime you’re dealing with an endurance athlete, you know that they’re going to be doing heavy, heavy training. And oftentimes, just from my experience of working with them, is they focus much less on the recovery component because their time spent training is so extensive that there’s only so much time in a day. So often, they have many of the muscle imbalances and compensations that we see of these specific repetitive movement patterns. So in the case here, how she’s having the hip weakness and right foot numbness, I always start everything from the ground up, so I’d be looking at her foot type first. We were told that she has a neutral foot. I don’t know if that is in double­leg stance, single­leg stance, squatting, et cetera, so I would actually wanna move her through a full series of foot assessments and then do the foot typing through that, making sure that she has sufficient ankle joint mobility.

Stephen King

Often, we can find that 40% of injuries can be explained by that sort of sudden increase in training load, as well as a change in surfaces they’ve been running and changing footwear and things like that. So any changes that may have occurred in the period leading up to this pain or discomfort coming on. Also, I wanna know what the pain’s like later that night and the next day ’cause that’ll give us again a bit more information of their level of activity that their body can tolerate at the minute, as well as what other exercise they’re doing. Are they doing any sort of flexibility training? Are they doing any weight training in particular? For these individuals, it can bea big area that is sometimes missed and sometimes leads to some injury.

David Fleming

So the listeners are gonna notice a real pattern to how I tend to deal with pain. So stay true to form, I’m gonna assess analgesic pathways within the brain, top­down reflexive control of the motor system, looking at the brainstem, the cortex, and the vestibular influences as well as the cerebellum in the mid brain, and as well as checking muscle facilitation and inhibition at the level of the spinal cord. With that information, I can direct the treatment and stimulations to balance how the body’s controlled reflexively, as well as providing takeaway drills to maintain the muscle recruitment that might have been lacking in between sessions and as general homework for the client. As part of the process, I always do tend to include assessment of: What’s the relevance? Is there any toxicity? Is there any gastrointestinal dysfunction? Is there any immune function or dysfunction that’s relative to the muscle recruitment? Homoeostatic physiological systems, organs, and muscles are linked in many, many ways. And muscular inhibition may not clear up with proprioceptive or mechanical stimulation alone, if there is something the brain considers more pertinent in a hierarchical sense. With regards to movement, I’m always keen to get endurance athletes to move outside of their incredibly repetitive and usually linear patterns.

Jessica Sears

There’s kind of a lot of things that are happening with this client, she… First Ironman. Depending on how active she was before, sometimes this is completely new to the body, so the body’s completely out of whack. And knowing that she’s had to have a knee surgery, that’s another component that we’re adding onto there. So if the body was a little out of whack before just wanting to do the Ironman, getting the knee surgery to blend into there, the body’s kind of wondering what she’s doing to herself, especially looking at having the left knee scoped and she’s feeling the numbness on the right side. So you can kinda see that there’s compensation that’s been either there before or it’s just coming to play since the knee surgery had to be done.

Jeff Frame

So my first thought, getting into the pain here, is we’re gonna focus on the neck and shoulder. Alright, so with the neck and shoulder, is this on the bike or is this swimming too? So that’s gonna be my first question. If it is on the bike, then the things I wanna look for is look at their posture. Triathletes have horrible posture because again if you’re swimming, swimming is in a non­weight­bearing environment. If you’re not doing any weight­bearing strength training, then your running posture probably doesn’t look real well. If you’re on the bike and you’re bent over, and triathletes are always so focused on aerodynamics, and I can tell you this from experience, power overrides aerodynamics in about 90% of the population. They always wanna get really slammed down, so they got their seats real high and their handlebars really low. Well, what do you think that’s gonna do to your neck and shoulders while you’re trying to see what you’re doing going down the road? You have to go into that training posture. In reading this individual or this case study, the fist thought I had was, “Okay, bike fit and cleat placement,” okay? But the individual also states thatthis occurs during running as well, so now we gotta look at the chicken or the egg.

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Council On Human Function

Dr. Mark Wade: Council President, Posture Expert, & Global Health Leader, bringing insight together with the council on health, wellness, physical rehabilitation, neurology and exercise fitness strategies for health care professionals.

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