~ Podiatric, Sports, and Dance Medicine ~
A little something extra about knees and orthotics
While we're talking about knees and orthotics, let's mix together several patients I've had over the years, and I'll give you another summary case history.
What about the patient who comes in desperation to my office who's had kneecap region pain for 11 years and has done everything to get them better but they're only getting worse?
I mean, she tried running 11 years ago and developed knee pain. She visited a podiatrist who gave her orthotics and told her to rest from running. She did both, but the knee pain persisted. The he told her to visit an orthopedist who specialized in knees. She did that, he saw she had orthotics for her flat feet, so that was fine, and then he prescribed physical therapy for her knees. She did that, but the knee pain persisted. She began to get walking pain all the time in her knees, despite no more running.
Problems persisted over the years. She'd get new orthotics when the old ones got funky, do her physical therapy exercises, change orthopedists, change podiatrists, change physical therapists, but just get more and more miserable. MRI's showed surprisingly little tissue damage in her knees for all the problems and duration this beast has added to her life.
When the patient came to my office, she expected a new pair of orthotics. She'd heard about me from someone who said I make "good orthotics" (no such thing... the only goodness is matching the patient's circumstances with the appropriate treatment, and sometimes the treatment happens to be orthotics).
She had a bag full of orthotics which cost her say $6,000 and helped zero. My next step after we got to this point in our visit was...
... to check her knee angles, or Q (for "quadriceps")-angles as she stood barefoot, feet relaxed. In this case, her angles were absolutely normal standing relaxed barefoot, and standing relaxed in her running shoes. Then I tested her Q-angles while she was wearing several of the orthotics she brought along, and found that her q-angles measured as abnormally low every time she stood on orthotics.
Me: "Have you ever tried walking around without your orthotics?"
She: "Of course not! My knees are killing me and every orthopedist, podiatrist and physical therapist I've met in the past eleven years had cautioned me to wear the orthotics."
Me: "I know you don't know me and have no reason to believe me because we've just met, but I think wearing orthotics has been the reason your problem has persisted." I'll go over the coincidence of her acquisition of the orthotics before her knees fully calmed down from the initial resting from running; the fact that the pain has persisted for eleven years despite rest, physical therapy and negative MRI.
She: "Well, I must admit no one has ever checked my knees while I was standing in sneakers while wearing my orthotics."
Me: "Right, and guess what? Your knee angles are absolutely normal when you're not using the orthotics, and are in a bad range when you wear any of these orthotics. So my advice to you is to wean out of all orthotics. Don't go crazy with too much exercise or walking, we don't need another variable to throw my plan off. Let your tissues adapt to the change. Do me a favor, call me in three weeks and let me know if you feel a trend going (improvement).
Most often, the call is extremely favorable. This doesn't mean orthotics usually hurt knees, please don't get me wrong. I saved an article from the podiatry journal many years ago which I show patients, which proves statistically that 83% of patellofemoral problems improve with orthotics. This patient happened to fall into the 17% who didn't. The key is being able to tell if you're in the 4 out of 5 who get better, or the 1 out of 5 who does not.
Thomas M. Novella, D.P.M.