Monthly Archives: December 2014

The Importance of Ankle Range of Motion for Knee Pain

25 Thursday Dec 2014

Posted by in Ankle, Patellofemoral Pain, Uncategorized

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Knee Mechanics

It is important to assess multiple areas of the body when treating knee pain and more specifically patellofemoral pain (PFP).  One major contributor to knee pain is hip strength.  Good hip strength is important to aid in appropriate knee alignment and mechanics.  Another important contributor is foot alignment.  Many individuals with PFP exhibit over pronation of the midfoot/flatfoot.  This will cause the lower leg to turn in and place more stress of the patella on the femur.

But one aspect that I believe needs more consideration is ankle range of motion; specifically ankle dorsiflexion range of motion.

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A study by Rabin et al. found that individuals with PFP had less than optimal movement during a lateral step down test and exhibited significantly less ankle dorsiflexion range of motion (4.7° in weight bearing and 5.3° in non-weight bearing) than individuals with optimal movement and without pain.  More specifically, they found that men had a significant difference of 8.5° with non-weight bearing measurements.

Could this limitation in ankle dorsiflexion range of motion be a precursor for maladaptive behavior found at the foot, knee, and hip?  The researchers proposed that the limitation in ankle dorsiflexion will cause less forward movement of the tibia when walking, running, and going up and down stairs.  This may cause excessive compensatory movement of the midfoot, such as over pronation, in order to get the needed range to complete those tasks.  This will also cause the knee to turn and place more force of the patella on the femur.

A recommendation to improve ankle dorsiflexion for people with PFP is to complete a stretch against the wall or counter holding for 30 seconds and completing 2 times.  Use this stretch (presented in the video below) until knee discomfort subsides and a lunge position with the knee on the floor can be tolerated.

A more dynamic lunge stretch (shown in the video below) can be completed to further improve ankle dorsiflexion range of motion.  Hold this position for 5 seconds and complete 20 times.  These motions should be completed on both sides even of you do not have discomfort at both legs.

 

Limitations of the study:

  1. It was not possible to determine whether limited ankle dorsiflexion range of motion is the cause of abnormal lower quality of movement or a consequence.
  2. The findings are limited to visual assessment of the quality of movement during the lateral step down test.
  3. The subgroup analysis was not preplanned and they completed the analysis only after observing abnormal tendencies in the subjects.
  4. The examiners were not completely blinded to the quality of movement assessment.
  5. The sample of subjects were younger than other populations of people with patellofemoral pain so results should not be generalized to all individuals.

Reference: Rabin A, Kozol Z, Moran U, Efergan A, Geffen Y, Finestone AS. Factors associated with visually assessed quality of movement during a lateral step-down test among individuals with patellofemoral pain. J Orthop Sports Phys Ther. 2014; 44(12): 937-946.

Adhesive Capsulitis: It’s Not So Black and White…Or Can It Be?

11 Thursday Dec 2014

Posted by in Adhesive Capsulitis

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adhesive capsulitis

Adhesive capsulitis tends to have a long and painful rehabilitation process.  There is a straightforward progression through the healing process but the time in which to make it through is variable (up to 2 years to recover).

Etiology

The synovial membrane will develop increased vascularity (known as angiogenesis) and hypertrophy leading to adherence to the inferior axillary fold.  The increased vascularity is accompanied by increased nerve growth which is a cause of abnormally high pain at the shoulder.  This will eventually lead to contractures of the rotator cuff (primarily the subscapularis muscle) and further inflammation will cause contractures of the capsule and the coracohumeral ligaments.  This will often tighten the posterior aspect of the shoulder and cause the head of the humerus to translate anteriorly; also known as the “capsular constraint mechanism.”¹

Usually we think of adhesive capsulitis having 3 stages but Kelley et al. described a 4 stage clinical course:

  • Stage 1 – may last up to 3 months and the individual will feel sharp pain at end ranges of motion, achy pain at rest, and sleep disturbance.  At this time there is no growth of adhesions or contractures.
  • Stage 2 – “The Freezing Stage” – may last from 3 to 9 months and is a gradual loss of motion in all directions due to pain.  There is vascular and nerve growth around the capsule.
  • Stage 3 – “The Frozen Stage” – may last from 9 to 15 months and is characterized by a lessening of inflammation but the growth of fibrous tissue.
  • Stage 4 – “The Thawing Stage” – may last from 15 to 24 months and will show a decrease in pain but fibrous tissue may persist.

There are 2 main categories of adhesive capsulitis³:

  1. Primary/Idiopathic Adhesive Capsulitis – this type is not associated with a systemic condition or a history of an injury.  There is no known cause or predisposing factor.
  2. Secondary Adhesive Capsulitis – this type is due to a mechanism of injury or precipitating event and can be broken down into 3 subcategories.
    1. Systemic Secondary Adhesive Capsulitis – having a history of diabetes or thyroid disease.
    2. Extrinsic Secondary Adhesive Capsulitis – the pathology is not directly related to the shoulder but results in a painful and stiff shoulder such as a cerebral vascular accident, myocardial infarction, COPD, chronic liver disease, cervical disc disease, or distal extremity fracture.
    3. Intrinsic Secondary Adhesive Capsulitis – due to a known injury to the glenohumeral joint soft tissues and structures.

∗ A loss of shoulder ROM and pain that is associated with postoperative stiffness should not be considered adhesive capsulitis ∗

Treatment

Before treating adhesive capsulitis you should differentiate a capsular restriction impairment from a muscle flexibility impairment.  A capsular restriction will present with limited shoulder external rotation range of motion that worsens with shoulder abduction and can be treated with joint mobilizations.  A muscular restriction will present with limited shoulder external rotation range of motion that improves with shoulder abduction and should be treated with stretching and soft tissue massage.

Joint mobilizations can be completed in different directions.  Inferior glides have shown to improve shoulder flexion and abduction ranges (the glenohumeral head slides 3mm superiorly for the first 60° of abduction¹) while anterior and posterior glides have shown to improve shoulder internal and external range of motions.  An important question is what will improve shoulder internal and external range of motions the most; anterior or posterior glides?

There are 2 principles that can be followed in using joint mobilizations; the “concave-convex rule” or the “capsular constraint mechanism” (mentioned above).

Johnson et al. states that it is important to follow the capsular constraint mechanism and use posterior glides to the glenohumeral head to stretch the posterior aspect of the capsule.  But in order to optimize your joint mobilizations you should incorporate irritability level.

High irritability individuals will present with pain levels ≥7/10, consistent night or resting pain, pain before end range of active or passive movements, and active motion is significantly less than passive motion due to pain.  Clinicians should use low-intensity joint mobilizations in pain-free ranges and positions.

Moderate irritability individuals will present with pain between 4-6/10, intermittent night or resting pain, pain occurring at end ranges of active and passive motion, and active range of motion similar to passive range.  Clinicians should use moderate-intensity joint mobilizations and progressing amplitude and duration into tissue resistance without producing tissue inflammation.

Low irritability individuals will present with pain ≤3/10, no night or resting pain, pain with overpressures into end range of passive motion, and active motion same as passive motion.  Clinicians should use end-range joint mobilizations with high amplitude and long duration into tissue resistance.

References 

  1. Roudal PJ, Dobritt D, Placzek JD. Glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis. J Orthop Sports Phys Ther. 1996; 24(2):66-77.
  2. Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The effects of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis. J Orthop Sports Phys Ther. 2007; 37(3):88-99.
  3. Kelley MJ, Shaffer MA, Kuhn JE, Michener LA, Seitz AL, Uhl TL, Godges JJ, McClure PW. Shoulder pain and mobility deficits: adhesive capsulitis. J Orthop Sports Phys Ther. 2013; 43(5):1-31.