1. What is it?

The knee plica are residual extra folds of synovial tissue. Synovial tissue is the tissue which lines the knee joint. These folds of tissue can become inflamed or scarred if subjected to either repetitive overuse or severe direct trauma. In some cases the plica may even become entrapped in the knee joint itself.

There are 3 plica in the knee, the most significant one being the mediopatellar plica, which is found on the medial side of the knee, somewhat underneath the patella. Of note is that 40% of the population do not have knee plica, as this tissue was completely resorbed during fetal development.

2. What are the causes/predisposing factors of injury?

Repetitive overuse from running, cycling or overstretching can irritate the plica. Direct trauma such as a hard fall on the knee or a dashboard injury where the knee strikes the dash in a car accident can also irritate the plica. Tight hamstrings also seem to be a predisposing factor.

3. What are the symptoms?

Plica syndrome usually presents as knee pain that is worse when sitting with the knee bent, increases as you arise to a standing position then improves as walking continues. The pain is typically felt on the inside aspect of the knee, just above the lower part of the kneecap. Other symptoms such as mild swelling, popping noises, snapping and a catching or locking sensation may occur.

The symptoms of plica syndrome can be quite similar to those of a medial meniscus tear or of chondromalacia. To distinguish these from each other, an arthroscopic examination is recommended.

4. What can be done to prevent or treat this injury?

Prevention would include hamstring flexibility stretches and quadriceps strengthening exercises. However, quadriceps strengthening exercises should be limited to the last 5 to 10 degrees of motion, since compression of the kneecap is greater when the knee is at 90 degrees. Strengthening of the hip adductors is also recommended.

Treatment can be via cross friction massage, ultrasound, ice or laser. I prefer to use ultrasound first, possibly with a topical anti-inflammatory, and then do cross friction massage. The ultrasound makes the tissue more pliable for the cross friction massage and is generally less sore afterwards.

1. What is it?

Tarsal tunnel syndrome refers to a condition where the posterior tibial nerve becomes compressed. The nerve travels past the medial (inside) aspect of the ankle where it goes through a fibrous canal. It supplies the bottom of the foot with sensation and provides nerve input for plantar flexion (toe pointing) and inversion of the foot.

2. What are the causes/predisposing factors of injury?

Anything that can compress the nerve along its path can create this condition. Overpronation of the ankle can cause the condition, as well as inflammation of any tendons or blood vessels in the area. Inflammatory arthritis may also be a cause.

3. What are the symptoms?

Usually symptoms are a burning or tingling sensation in and around the ankle, which can also be felt on the sole of the foot up to the toes. There may also be difficulty with standing or walking or with various types of shoes. Symptoms tend to be worse with activity and better with rest.

4. What can be done to prevent or treat this injury?

Prevention is focused on proper biomechanics and muscle balance. If there are biomechanical issues such as abnormal foot movement, then proper footwear and/or orthotics may be indicated. If there is excessive tightness or weakness of any of the muscle groups in the lower leg, this must be addressed.

Treatment is generally conservative. Relative rest, anti inflammatories, orthotics, soft tissue work, physical therapy modalities and joint mobilization can be used. If the condition is non responsive to conservative care, surgery is an option.

1. What is it?

The knee joint has 2 menisci, one on the lateral side that is somewhat circular in shape, and a medial one that is ‘C’ shaped. These sit on top of the tibia (shinbone), and help to connect the tibia with the femur (thighbone).

The menisci are made up of fibro-cartilage and serve a number of purposes including: stabilization of the knee joint, load distribution, and shock absorption.

2. What are the causes/predisposing factors of injury?

There are generally two types of meniscus injuries: traumatic or degenerative.

Traumatic meniscus injuries usually involve people that are younger and involved in contact sports. The common mechanism of injury is a twisting or rotation of the upper leg while the foot remains planted and stationary. This causes tearing of the meniscus.

Degenerative injuries are due to wear and tear of the meniscus or repetitive trauma. This creates defects in the structure, which over time may progress to tears or breakdown of the meniscus.
Most meniscus injuries involve the medial side due to its unique anatomy (it is very securely attached to the tibia), and can also involve the anterior cruciate ligament.

3. What are the symptoms?

Usually joint pain and the inability to straighten the knee are classic symptoms of a meniscus injury. Swelling and a painful click when the knee is bent back and forth may also occur. Severe pain may persist if a piece of the meniscus displaces and becomes trapped between the femur and tibia.

4. What can be done to prevent or treat this injury?

Prevention is difficult for both types of injuries. Avoidance of contact spots or sports such as downhill skiing can reduce the risk of traumatic meniscus injuries, but are not a guarantee, since these injuries can occur suddenly without warning during many types of activities. Degenerative injuries occur over long periods of time and are generally not noticeable until a significant amount of damage has already occurred.

Treatment is divided into 2 categories: surgical or non surgical. The type of treatment depends on the severity of the injury which is usually determined by an arthroscopic exam or an MRI.

Conservative treatment is geared towards reducing pain and swelling, and increasing mobility and muscle strength around the knee joint by doing rehabilitative exercises.

Surgical treatment tries to preserve as much of the meniscus as possible to reduce the risk of osteoarthritic changes in the future, but there is sometimes a need to remove broken off fragments or remove sections that may not heal.

Ankylosing spondylitis is a common cause of chronic low back pain in young men. It usually occurs between the ages of 15 to 35, with an average age of 26-27 years old.

The disease involves a process of joint inflammation followed by joint erosion and then finally joint fusion. This series of events can occur over a period of 10 years but only a minority of patients end up with the most severe joint problems.

Approximately 1/3 of patients with this disease also have other systemic changes such as iritis (inflammation of the eye) and, heart, blood vessel, gastrointestinal and genitourinary problems.

2. What are the causes/predisposing factors of injury?

This inflammatory condition appears to be an autoimmune disorder.

3. What are the symptoms?

General symptoms include aching and stiffness felt in the lower back, buttocks and thighs that can change from side to side or be on both. Most of the symptoms are felt predominantly in the morning and evening hours. There may also be periods of complete remission of symptoms. Other locations where stiffness and aching may be found are in the hips, mid-back and shoulders. Chest expansion may be diminished in some instances where fusion of the mid-back joints has occurred. Sciatica may also occur, but does not go below the knee.

What can be done to prevent or treat this injury?

Diagnosis is the key. This condition must be differentiated from other causes of chronic low back pain, so that appropriate management can occur. To achieve this, x-rays and specific blood work (erythrocyte sedimentation rate and HLA-B27) should be performed.

Treatment consists of antiinflammatories, postural training, and therapeutic exercise to maintain joint mobility and proper posture.

1. What is it?

The piriformis muscle is situated deep in the gluteal area and goes from the front edge of the sacrum to the greater trochanter of the femur. This muscle acts to rotate the leg away from the body. Anatomically, the sciatic nerve runs under the piriformis muscle. If the piriformis muscle becomes spastic or tight, the sciatic nerve can be irritated, creating a piriformis syndrome.

2. What are the causes/predisposing factors of injury?

A twisting or pivoting injury on the affected leg can irritate the piriformis muscle. Also, sitting cross-legged, having a functionally short leg from either foot hyperpronation or a posteriorly rotated pelvis can cause a piriformis syndrome. The latter problem is due to the piriformis muscle being overstressed as it tries to stabilize a rotated and tilted sacrum.

3. What are the symptoms?

An intense deep ache may be felt in the buttock and even travel all the way down into the foot. Exquisite tenderness can be experienced when the piriformis muscle is palpated. Resisted external hip rotation (trying to push bent knees apart, feet together) will be weak and painful.

4. What can be done to prevent or treat this injury?

Foremost, make sure if you pronate too much, you have proper footwear and/or orthotics. Also, attend to any dysfunctional lumbar spine and pelvis biomechanics by a combination of spinal manipulation, stabilization and strengthening exercises.

Specific treatment consists of deep soft tissue treatment, manipulative therapy, therapeutic muscle stretches and strengthening of the hip muscles.

Tell Me Where it Hurts

One of the most frustrating issues both the patient and their healthcare provider must deal with is poor communication. On some occasions when I see a patient about an injury, they go on at length providing details that do not relate to the problem. Here, in brief, are the details that you should provide your healthcare provider with to help them solve your injury problems.

We use the letters OPQRST to shape the history taking part of an examination.

O = Onset. This is the what, when, where and how question. Did you have trauma or not? Did this start slowly or suddenly? Is this recent or an ongoing injury. This question relates to the possible mechanism of the injury. Try to be accurate in describing things such as is the injury one week or one year old.

P = Palliative and Provocative. What makes the injury feel better or worse? Be specific with these details.

Q = Quality. What does the injury feel like? (Dull, achy, sharp, tingling, burning or loss of strength) If you have problems relating to these descriptions, try relating it to things you are familiar with.

R = Radiation. Does the pain stay in one place or does it travel around. If the pain travels around, what does this pain feel like?

S = Severity. How much does it hurt? I use a scale of 0 to 10, where 0 is no pain and 10 is the most pain you could possibly feel. Does the pain vary in intensity?

T = Temporal. What is the timing of the pain? Is there a certain time of day or night that the problem seems better or worse? Is there a pattern?

Hopefully, if you can go to your care provider with all these details in hand, a more focused and effective visit will be the result. I have found that it is not the amount of time spent during the visit that matters, it is the quality of information obtained that most determines a successful outcome.

1. Layer your clothes. Try moisture wicking clothing – it really works. The newer technology fabrics allow perspiration to occur without getting trapped next to the body or on the inner lining of your outer shell. For the upper body, I prefer to go with a lighter inner layer, a medium thickness insulating second layer if it is really cold, followed by an outer shell. This gives me the option of unzipping or removing the outer layer if I get too warm. Winter tights, and if necessary an outer pant shell over top, should be adequate protection for the lower body.

2. Get shoes with a good grip. Check the soles of your running shoes: if they are relatively smooth, you will likely have traction issues. Alternatives are trail running shoes or specialized spikes that you can slip onto your shoes. I just use my regular training shoes (Saucony Grid Hurricane VII’s) since they have a pretty aggressive tread pattern.

3. Don’t forget your feet. Socks can be an overlooked item of clothing. There are many high tech socks out there that provide better insulation that may make your run more comfortable. If necessary, you can always wear 2 pairs, just remember to loosen your shoelaces to accommodate them.

4. Mittens are warmer than gloves. On really cold days wear running mittens so your fingers can share their warmth with each other. Gloves are more stylish, but give up more heat.

5. Cover your ears. Make sure that your ears have adequate protection from the cold. I have suffered from frostbite to my ears from winter running- it’s not pretty and very uncomfortable when it thaws out. Be sure that your hat (toque) covers your entire ear and is thick enough to provide adequate insulation. A good option is a balaclava or earmuffs.

6. Ever had your eyes freeze shut? In our winter climate, I’ve had this happen. Any tears produced can freeze, essentially gluing you eyelashes together with ice. The solution- apply petroleum jelly to your eyelashes and eyelid areas. Any tears simply slip away.

7. Finally some training tips. Start your runs into the wind and finish with the wind on your back. Try running at the warmest time of day. Do not run long or hard after fresh snowfall as this will likely lead to overuse injuries of the ankle, knee or hip. Wear reflective clothing if you are running when it is dark. Carry money for a bus or a cab with you. Try running routes where there are facilities available along the way to warm up or use the bathroom.

Have a Merry Christmas and a Happy and Healthy New Year!

In my opinion, the two critical areas of disagreement regarding orthotics are: casting technique and construction.

1. Casting Technique: Weight bearing or non-weight bearing?

Non-weight bearing casting has been popularized by podiatrists and involves placing the foot in a “sub-talar neutral” position, and basing the orthotic prescription on this.

Weight bearing casting places the foot in a deformable material or on a scanning device and taking multiple measurements to calculate the correct prescription.

Which technique is best? Both techniques have limitations. Sub talar neutral is a position that the foot may or may not achieve during normal foot movement; if it does move into this position, it is only for a very limited time during the gait cycle. That is, you are placing the foot into a position that may not represent true function. Weight bearing casting is more functional in that it does show the actual foot position. The corrections however are based on what is assumed to be optimal from the information obtained from the cast or scan. As you can see both methods make some assumptions regarding what is best for your foot.

2. Construction: Rigid or flexible?

To understand this issue, remember that the foot has to have multiple functions. It has to act as a flexible structure to adapt to uneven terrain, a rigid lever able to propel us forward, and a shock absorber that has to deal with impacts of 5G’s while walking and up to 8G’s when running.

My opinion for runners is that flexible is the way to go. It allows for normal foot function and the added capability of enhanced shock absorption if the orthotic has viscoelastic materials built into it. The other and perhaps most important element of a flexible orthotic is that it can stimulate joint receptors which creates a proprioceptive response in the cerebellum. That is, the part of our brain concerned with coordinated movement receives better quality information from the foot, which enhances muscular control and neurological function of the gait cycle. Our gait becomes more efficient.

Rigid orthotics tend to crutch the foot in one position, which denies it the ability to operate in a fully functional manner and reduces its shock absorbing capability. Proprioceptive response is also altered, but in a negative sense since the joint receptors that are normally stimulated with joint movement provide less information for neural processing.

Overall, my preference is for a flexible orthotic that is based on a weight bearing cast or scan. These tend to be a more functional device and result in fewer problems for the athlete as far as joint stress and adaptation time are concerned and offer up enhanced biomechanical efficiency that can and usually does translate into better performances.

Excessive supination is a relatively rare occurrence with approximately 1-2% of runners making up this group. Usually these people have high arches, rigid feet and demonstrate a wear pattern along the outer edge of their shoes from the heel to the forefoot. Because of foot stiffness and lack of shock absorption, this group is at a relatively higher risk for stress fractures and injuries such as ankle sprains and iliotibial band problems. Runners with supination issues should have shoes that are flexible with good cushioning to reduce shock transfer to the rest of the body.

Overpronaters tend to make up approximately 80% of runners and can range from mild to severe. This group is characterized by arches that are flatter than normal, hyper mobile feet, and demonstrate an excessive wear pattern on the outer edge of the heel. Because of the lack of stability from overpronation, these runners are more succeptible to soft tissue injuries and medial knee problems. Runners with overpronation problems require shoes that are somewhat rigid with devices to control the speed and/or degree of pronation that reduces stress to the rest of the body. Mild overpronation can typically find a good result with stability shoes while severe overpronators should move up to motion control shoes.

What about the scenario where a runner has one foot that is different from the other foot? For example, one foot supinates and the other pronates. This is where custom-made orthotics are recommended. Here you can get one orthotic designed to reduce the stress of supination and the other for pronation. These are generally used in combination with a neutral shoe.

You may also have a situation where the amount of pronation varies from foot to foot. This, too, is an ideal situation for orthotic use. The type of shoe used in this case is not so clear-cut and may range from a neutral to a motion control shoe depending on the type of orthotics, degree of pronation, and weight of the runner.

As for what type of orthotics are preferable, this is somewhat controversial and will be the topic for next month’s article.

Osteoarthritis describes a condition where the cartilage that covers the surface of our joints begins to deteriorate. This process tends to begin with small defects including cracking, fissuring and thinning and may end up with a bone on bone situation where the cartilage is completely destroyed.

What are the symptoms?

Osteoarthritis tends to involve weight-bearing joints such as the knee, hip and spine. Usually the symptoms consist of morning stiffness that loosens up after 15 to 30 minutes of activity. There may also be grating or crunching noises that come from the affected area. If the condition worsens, activity will aggravate the symptoms. There may also be mild swelling of the joint along with enlargement of the joint.

What are the causes/predisposing factors?

There are a number of theories as far as causation. One theory suggests that biomechanical faults place abnormal stresses on the joint which over time create damage. Another theory argues that chemical changes occur in the joint leading to joint damage. Personally, I feel that it is a combination of biomechanical and biochemical changes that prompt the development of osteoarthritis. Regardless, the net result is the same: the material that makes up the joint cartilage is compromised, which leads to a weakening and eventual breakdown.

What can you do to prevent or treat osteoarthritis?

Here’s where it gets interesting. There are literally hundreds of scientific investigations and about 20 well designed research studies that have demonstrated a substance called glucosamine sulfate can help prevent and treat osteoarthritis.

Glucosamine sulfate is naturally produced by our body, and is used to make a molecule called chondroitin sulfate, which is a component of joint cartilage. It is thought that as we age our body produces less glucosamine sulfate, which leads to a decrease in cartilage production. This is why supplementing with glucosamine sulfate may be a very smart strategy since you are providing the raw materials your body needs to produce cartilage.

Glucosamine sulfate supplementation should be approximately 1500mg per day, preferably divided into 500mg doses 3 times per day. This regimen should help maximize absorption.

Some people may wonder about supplementing with chondroitin sulfate. Unfortunately, chondroitin sulfate is very poorly absorbed (less than 15%) because of the large size of the molecule. Glucosamine sulfate being a much smaller molecule is more readily absorbed by the body (over 90%). So if you are trying to choose between them, glucosamine is the better choice.

The one possible downside of glucosamine sulfate supplementation is the time it takes to notice relief of the symptoms. This is because the supplement first must be taken up by the cartilage producing cells (called chondrocytes), then converted to chondroitin sulfate and then distributed into the joints.

What I recommend to speed up relief is to take some other natural products along with glucosamine sulfate that give it an added “kick”; specifically, MSM (methyl sulfonyl methane), bromelain and quercetin. These ingredients are natural antiinflammatories that provide quick relief of the symptoms of osteoarthritis while the glucosamine sulfate is being processed by the body. If you plan on taking these supplements make sure you are purchasing quality products that guarantee their purity and potency and should state as much on the label. Figure on spending about a dollar a day for a combination glucosamine/MSM/bromelain/quercetin supplement that is of good quality. If you think that is expensive, remember most people pay at least four times that amount per day on their coffee and lattes which may have an anti oxidant benefit, but doesn’t do much good for their joints. So, are you and your joints worth it?

One final word on glucosamine sulfate, if you are pregnant or breastfeeding, you should not take this supplement. The same holds true if you have kidney disease or kidney problems. When in doubt, consult a healthcare professional knowledgeable about nutritional supplements.

Other strategies for osteoarthritis include analgesics for pain (capsaicin cream 0.025% is a good one), non-steroidal antiinflammatories (which have many side effects, can speed up arthritic change if taken long term, and may cause heart problems), joint injections, and ultimately joint replacement.

Active treatment consists of joint mobilization and manipulation to normalize joint mechanics and strengthening and stabilization exercises for affected areas.

Remember, osteoarthritis needs to be actively managed for the best long-term results.