Joint pain – knee, hip, shoulder, ankle
Most people are aware that a joint can become arthritic and cause pain from rheumatoid or osteoarthritis. Arthritis can also be degenerative from a previous major fracture or trauma. However the bulk of joint pain syndromes can be directly related to biomechanics of the extremities but also the spine.For example if a person has severe flat feet the calf and leg muscles will ultimately shorten and become unbalanced. Abnormal movement will cause a change in alignment of the joint and it will no longer function efficiently.Joints are also affected by unequal leg length, rotated ribs, or a twisted pelvis from a motor vehicle accident or ski injury. Treatment should be focused on correction of biomechanics. It is critical to understand what the underlying cause of joint dysfunction.
If any major muscles in the thigh or leg that move the knee joint (flexion-extension) become shortened from direct trauma causing myofascial trigger points there will be a change in the position of the patella (knee cap) and normal glide of the knee. Contracted calf muscles cause tibia-fibular joint rotation as well as decreased ankle dorsiflexion, again affecting the mechanics of the knee.A shortened medial hamstring will prevent complete extension of the joint but also cause rotation of the femur putting additional strain on the knee joint.Chronically shortened calf muscles can rotate the tibular-fibular joint again affecting efficiency of movement
- Tear of the Anterior Cruciate Ligament
- Arthritis of the Knee
- Meniscal Cartilage Tear
- Various Runners’ Conditions Affecting the Knee
- Limited Cartilage Defects of the Knee
Case Study – Knee Pain
A 33-year-old male patient entered the clinic with a history of intractable bilateral knee pain. The patient’s pain was so severe he could not walk upstairs, play with his children, or power walk with his wife. The patient was formerly in excellent physical condition: during his twenties, he served in the military, and prior to his knee pain, he played competitive volleyball. However, the patient gradually became sedentary, and began to feel he was losing touch with both his family and social life. The patient consulted two orthopedic surgeons and a family physician, all of whom declared he would eventually need bilateral knee replacement, but could pursue physical therapy for partial relief. In physical therapy, the patient was provided with knee stretches and ultrasound treatments, both of which failed to relieve his pain. The patient was subsequently examined; shows his weightbearing spine films. Note the subtle curvature in both the thoracic and lumbar spine. The physical examination indicated the likelihood of a short right leg, and a leg length x-ray confirmed a discrepancy of 1.1 centimeters. This discrepancy resulted in a significant valgus (bowing) of the right knee, with an extensive muscular imbalance between the two legs. His calf muscles were restricted, and he had poor ankle dorsiflexion. The patient’s gait was distorted, not only because he had developed a limp to unload the right knee, but also because the shortened calf muscles prevented his heel from striking the ground evenly. The tibial-fibular joint of the right knee was rotated and fixated by significant myofascial trigger points in the right hamstring, posterior tibialis, gastrocnemius, and soleus muscles. All of these muscles were exceptionally tender during palpation, and thereby triggering referred pain to the knee. The right adductor magnus and pectineus muscles were very short, and also referred pain to the knee. Treatment commenced with block and left sacroiliac joint injection, and the discrepancy was completely corrected with a 1.1 centimeter lift. In the following four weeks, the patient received trigger point injections of the leg muscles and extensive myofascial release. Manual physical therapy to both feet, with mobilization of the tibial-fibular joint, and cross-friction to the Achilles tendon also occurred. Eventually, and in addition to his lift, the patient was fit with a rigid orthotic that provided substantial arch support. The patient was very diligent with his aggressive leg stretching exercise program and thoracic bolster program for the spine. After completing the third week of treatment, the patient was able to power walk in the park, and after eight weeks, he was able to jog three miles and resume intramural volleyball.
Though some shoulder injuries require surgery such as a complete or partial rupture of the rotator cuff to reconnect muscle and tendon attachments in order to preserve motion, many shoulder pain syndromes do not require surgery. Those suffering from shoulder pain after surgery may need detailed rehabilitation to increase length of shortened muscles such as the pectoralis major and minor, serratus, levator scapulae, since they also affect shoulder joint motion.The practitioner must know how to think outside the box. A short leg can ultimately lead to rotation and poor movement of the upper thoracic spine which is detrimental to normal shoulder movement. Poor weight training leading to overdeveloped trapezius and pectoralis muscles will lead to anterior rotation of the shoulder and ultimately shoulder impingement.
- Impingement Syndrome
- Rotator Cuff Tear
- Shoulder Separation
- Shoulder Dislocation
Case Study – Shoulder Pain
A 56-year-old man was evaluated for a chief complaint of left shoulder pain. He previously had a right shoulder arthroscopy. The patient was an active farmer and his shoulder pain was of particular concern due to the approaching planting season. He came to the office for a second opinion before returning to the orthopedist. At age 18 both his legs were amputated after a farming accident.Although told he would be completely disabled, the patient ambulates with artificial legs. His physical examination revealed a torqued and rotated spine from throwing his artificial legs to walk. However, his body is balanced for his situation and he has minimal spinal pain. He was treated conservatively for shoulder pain, responding well to trigger point injections, joint mobilization, and mobilization of the cardiothoracic junction. Several years passed before his next visit when he needed a “tune up.” He continues to be a source of inspiration to those who know him.Hip painThe hip is a major weight bearing joint. Some people with chronic destructive illness such as rheumatoid arthritis will have steady destruction of the joint capsular and ultimately need a total hip replacement (artificial hip). Some of these patients’ may have persistent pain after surgery. During repeat visit with the orthopedic surgeon x-rays may confirm excellent placement though the patient still has pain. Restoration to normal hip function will change the alignment of the spine, and the mechanical load in the knee and foot as well. With persistent post operative hip pain lo length x-ray bone scanogram has to evaluate if both legs are the same length as discrepancy can affect mechanics. There may also be residual myofascial trigger points in the buttock muscles that can mimic hip joint pain. This is very treatable.Some surgeons are using the “mini incision” anterior approach instead of the traditional lateral incision. This requires extensive dissection of the hip flexors including the iliopsoas muscle will decrease hip range of motion; forces the patient to walk flexed forward and aggravate low back pain. This can easily be solved with iliopsoas compartment injection with local anesthetic which releases the muscle and improves blood flow.Hip pain can also be mimicked by sacroiliac joint pain. Decreased movement of the sacrum will also cause decreased hip movement. This can be treated with injection and manual mobilization of the sacrum.
- Bursitis of the Hip
- Avascular Necrosis
- Arthritis of the Hip
Case Study -Left Hip Pain
A 56-year-old woman was referred to the office by a respected neurosurgeon. Her chief complaint was a ten year history of pain radiating down her left leg, with occasional numbness in the left foot. The patient was happily married, worked full time, and was very active in spite of her pain. She had been well until a neuroma (nerve cyst) was removed from her left hip. The patient stated since then, she had seen numerous neurosurgeons, family practitioners, chiropractic physicians, and physical therapists. Her pain was worse in the morning and was aggravated by sitting, lifting, lying down, and bending. She felt some relief from wearing a girdle and using a heating pad. She stated her sleep was constantly interrupted and she had given up many recreational activities. The patient had been told that her sacrum was fused to the ilium (the lateral pelvic bone). Physical examination revealed an anxious and tearful woman. She could bend forward and touch the floor, but she had minimal movement of her lower spine. When she walked, she put most of her weight on her right leg because of pain. Palpation revealed distinct tenderness over the left sacroiliac joint (lower back). She had contraction and sensitivity of the major low back muscle (quadratus lumborum) and left buttock muscles. This muscular imbalance pulled the left hip up, twisting the pelvis and making the left leg appear shorter. The patient’s left sacroiliac joint dysfunction most likely developed after her neuroma operation and for the past ten years she favored the left leg. The body then learned not to move this joint, and subsequently the pain syndrome developed. Treatment included two left sacroiliac joint steroid injections performed one week apart. After each injection, the patient was treated with manual decompression techniques, such as hip scouring and extraction. The patient also had three sessions of trigger point injections to the lower left back muscle and gluteal muscles. The combination of trigger point injections and myofascial release corrected the pelvic torsion. At the time of discharge the patient had a normal, balanced pelvis and was pain free.Ankle painOne of the most frequent ankle injuries is the internal rotation. Sometimes the fall is intense enough to fracture the joint requiring stabilization with surgery. After the ankle heals the patient may feel persistent pain particularly in the lateral aspect of the joint. With the initial fall there is a whiplash effect and the peroneal muscles form trigger points that can refer pain to the ankle. The peroneal nerve becomes entrapped by tightened peroneal muscles. Very often the focus is on the fracture and the residual myofascial component from the “snap injury” goes untreated. Treatment involves trigger point injection to the peroneals and then mobilization of the tibular-fibular joint. It is also important to balance pelvic alignment which may have changed 2º due to the fall and wearing a boot or case.
Case Study –Ankle & Foot Pain
A 54-year-old waitress was referred for evaluation and treatment of right foot pain caused by a fall at work. Because of persistent foot and ankle pain, several diagnostic studies were ordered, including two MRIs, an EMG, a bone scan, and x-rays. Although the studies showed no abnormalities, an orthopedic surgeon made an incision on the top of the foot to release an entrapped nerve. The patient continued to have intense foot and ankle pain. Six months later we were asked to re-evaluate the patient. During the interview the patient was extremely agitated. She explained that when she slipped, all her weight had landed on the twisted ankle. The patient stated she was told she might have sympathetically maintained pain. She was taking two antidepressants, two sedatives, one anti-inflammatory, and one muscle relaxant.Physical examination revealed some hypersensitivity to touch. The patient walked favoring her right leg. Because of chronic disuse, the muscles of the right lower extremity were contracted. This trapped the blood and made her foot blue and swollen. The patient had significant palpable trigger bands in several of the lower leg muscles, which referred pain straight to the foot.She was treated for approximately six weeks with four sessions of trigger point injections to the calf muscles and myofascial release physical therapy to decompress the peroneal nerve. During the course of her treatment, the patient was weaned off all medications except one antidepressant. With the physical therapy and medication changes, she became calm, focused, and pain free.At the end of the treatment, she was able to walk normally and had improved mental function.