Sunday, November 29, 2020

Arch Supports And Iliotibial Band (ITB) Pain


A patient came in this week after being diagnosed with Iliotibial band (ITB) syndrome. The outer part of his right knee would hurt badly after running about 1.5 km. After stopping to walk, he would be able to run for a few minutes before having to stop again. 

He had been running 4-5x each week, clocking about 50 km weekly. He had just seen a sports doctor who first referred him to a podiatrist to get orthotics as he 'pronated' badly.

After getting his orthotics, he 'pronated' less according to the prodiatrist who filmed him while running on a treadmill. But, alas, his ITB/ knee pain didn't change. Since I'd treated a fellow runner he knew, he came to see me, hoping I could help him run pain free.

The ITB starts from the TFL
I've written previously about the ITB and you can read more about it here (anatomy) and here. If you look at the picture above, you can see it starts from Tensor Fascia Lata (TFL) muscle and runs down the outer thigh before finishing just at the outer part of the knee (picture below). This is usually where runners experience a sharp pain.

Also know as iliotibial tract (bottom R of pic)

Studies show that when the hip rotates medially or drop inwards, a strain is placed on the ITB . This also causes the tibia (or shin bone) to rotate inwards causing the foot to pronate (or ankle eversion). 

Researchers have attempted to correct this by changing ankle pronation to see if this might relieve the strain on the ITB.

In this published paper, 30 runners (15 males, 15 females) with no ITB insertion pain were prescribed orthotic wedges to put into their own running shoes. The wedges were 7 degrees lateral, 3 degrees lateral, no wedges, 7 degrees medial and 3 degrees medial. A total of five running trials were done.

The runners were analyzed by video motion analysis while running at their self selected running pace to calculate motion forces and ITB strain.

The orthotic wedges significantly changed ankle eversion (or pronation) angles compared to no wedges. However, the strain rates did not differ between conditions. There was no change in knee joint angles and tibial rotation under all orthotic wedge conditions. 

The researchers concluded that orthotic wedges may not change forces acting on the ITB, even though they altered foot pronation while female runners had greater strain forces acting on their ITB's potentially due to increased internal hip rotation.

It is interesting to note that the female runners demonstrated significantly greater peak ITB strain and strain rates compared to the male runners, potentially due to increased hip internal rotation (because of wider hips and pelvises for child bearing purposes). I have written at length before that for female runners, their knee pain is coming from their hips. Always treat the cause of the problem. Do not treat the pain alone.

Take home message is that even though orthotic wedges can correct your foot's pronation, it may not alter forces acting on your ITB. This means that your knee pain may not get better using orthotic wedges.

Of course any one reading this may say that these off the shelf orthotic wedges are not customized and that the subjects were all wearing different running shoes. Personally I feel that the different shoes are not an issue as these orthotic wedges used in the study did significantly change ankle pronation so they did what they were supposed to do. 

Would this then be fair to say that using orthotics to change ankle pronation or eversion angles does not seem to benefit those with ITB pain at the knee? Perhaps any podiatrists reading this would like to comment.


Reference

Day EM and Gillette JC (2019). Acute Effects Of Wedge Orthoses And Sex On Illotibial Band Strain During Overground Running In Nonfatiguing Conditions. JOSPT. 49(10): 743-750/ DOI: 10.2519/jospt.2019.8837

Saturday, November 21, 2020

Abnormal Knee MRI, But No Pain

Knee MRI by Becky Stern from Flickr


Here's a piece of surprising news for everyone. In this recently published paper I read, nearly all patients who had abnormalities on their knee MRI were asymptomatic, meaning no pain despite having an "abnormal" MRI.

The main inclusion criteria for this study were sedentary adults. They did not do at least 30 minutes of moderate intensity physical activity 5 days a week or 20 minutes of more intense activities 3 days a week. They did not have any knee pain, no current or previous history of knee injury and surgery.

The authors reviewed 230 knees of 115 uninjured inactive adults (51 males and 64 females). Median age was 44 years (range was 25-73 years) and all the subjects had bilateral MRI's (3.0 Tesla, high resolution) done.

Here's what they found. Brace yourself as you read on. MRI showed abnormalities in a whopping 97% of knees. 30% of knees showed tears in the meniscus. Horizontal tears were most common, while bucket handle tears least common.

Articular cartilage (57%) and bone marrow abnormalities (48%) were common in the patellofemoral (knee) joint. Moderate (19%) intensity articular cartilage lesions and severe (31%) were observed.

Grade 4 means bone rubbing on bone

Articular cartilage injuries is my area of interest since I did my postgraduate research in that area. It is interesting to note that a quarter (or 25%) of the subjects had Grade 4 changes (see picture above) visible on MRI but did not complain of pain. Perhaps this is important to remember when imaging the knee since there seems to be more visible findings here compared to the rest of the knee (articular cartilage wise).

Moderate intensity lesions were found in 21% of knee tendons while there were high grade tendonitis found in 6% of knees reviewed. The patella and quadriceps tendons being the most affected.

3% partial ligament ruptures were found, of which 2% were of the Anterior Cruciate Ligament (ACL).

The authors concluded that nearly all knees of asymptomatic adults they studied show abnormalities in at least one knee structure on MRIMeniscal tears, articular cartilage and bone marrow lesions in the patellofemoral joint were the most common pathological findings. 

They also reported finding bucket handle and complex meniscal tears (both of which commonly operated on) in asymptomatic knees. This interesting to note as bucket handle tears (as well as complex tears) would often cause 'locking' in the knee and therefore require surgery.

There you have it, the subjects were sedentary adults who did no exercise so no one can say that it was running or exercise that "wore out" their joints. And some these very same adults had "terrible" or abnormal MRI's, but were asymptomatic or did not have any pain.

So don't fret if your MRI is abnormal. You may not need any surgical intervention, especially if you do not have any pain or if that pain is easily treated.

Maybe these abnormalities should be just described as "wrinkles" on the inside. 


Reference

Horga LM, Hirschman AC, Henckel J et al (2020). Prevalence Of Abnormal Findings In 230 Knees Of Asymptomatic Adults Using 3.0 T MRI. Skele Radiol 49: 1099-1107. DOI: 10.1007/s00256-020-03394-z

Sunday, November 15, 2020

Towel Scrunching Exercises For Your Feet?


Have you ever been asked to do foot strengthening exercises? A patient who saw me this week was asked to do foot strengthening exercises by another health professional who saw him recently. This included some towel scrunching exercises for his "collapsed arches" so as to strengthen the muscles supporting his arches

My patient was quickly bored and I told him just walking in minimalist footwear would be just as effective as doing strengthening exercises for the foot.

We know from published evidence that weakness in our intrinsic foot muscles can lead to a variety of load related injuries. And supportive footwear can contribute to intrinsic foot muscle weakness since these muscles tend to switch off (since they aren't absorbing forces and controlling foot movement) while walking and running.

Researches randomly assigned runners into three different groups. One group wore minimialist shoes (Vivo Barefoot), another group did foot strengthening exercises and the third was a control group. All groups maintained their running mileage throughout the study.

The minimialist footwear group increased their walking step count weekly while the foot exercise group did progressive resistance exercises at least 5 days per week.

Foot muscle strength and size were measured via ultrasound at the start of the study, week 4 and at the end of  the study (week 8). Researchers found all foot muscle sizes and strength had increased significantly in both the minimalist footwear and foot strengthening exercise group. There were no changes in the control group.

The researchers concluded that walking in minimialist shoes is just as effective as doing strengthening exercises for your feet. It is definitely way more convenient changing footwear rather than doing specific foot exercises. This may result in better compliance with patients.

So definitely don't throw away your Vibrams or barefoot styleminimialist type shoes. They are definitely still useful. Vibram ended up with a bad reputation after they were sued. 

However, I feel minimalist type shoes were unfairly criticized as the evidence for barefoot or minimalist type shoes are actually sound provided your running technique is correct. 

*Much less impact if technique is correct-see below

If you walk with barefoot style/ minimalist type shoes instead or running (to strengthen your intrinsic foot muscles) there will be a much lower risk of injury.

Definitely still useful. And much less boring than doing towel scrunches.


Reference

Ridge S, Olsen M et al (2019). Walking In Minimalist Shoes Is Effective For Strengthening Foot Muscles. 51(1): 104-113. DOI: 10.1249/MSS.0000000000001751.

Liberman DE, Venkadesan M et al (2010). Foot Strike Patterns And Collision Forces In Habitually Barefoot Versus Shod Runners. Nature. Jan 463(7280): 531-535.

*Using results of Daniel Liberman's study, runners who land correctly in their running technique will have benefits as impact is a LOT less (even less than heel striking with cushioned running shoes). If you land wrongly (with barefoot style shoes), the impact is 7 times greater thus greatly increasing the chance of injury. See picture above.

Monday, November 9, 2020

Thera Gun Caused Rhabdomyolysis In A Cyclist

Picture by LLL@ Zouk

I've written in August about the effects of thera/ massage and vibration guns and whether they really work. I've also written about the scary effects of rhabdomyolysis before. 

Guess what? There has just been a published case report of a cyclist being administered thera/ massage gun treatment by her coach for recovery and ended up with rhabdomyolysis.

This 25 year old female cyclist rode in a gym for two consecutive days for only about 30 minutes each day. Her coach used a thera/ massage gun immediately over both her thighs for about ten minutes to help with her recovery. The coach did not check the medical history of the cyclist nor did he check with qualified health professionals about using the thera/ massage gun on her.

The cyclist subsequently developed significant pain/ tenderness in both thighs on that same evening and multiple hematomas (or bruises) were present. She also had urine discoloration (tea colored). She went to the hospital and her serum creatine kinase levels (> 30,000 U/L) were through the roof. This is an indication of severe muscle damage.

Normal values are usually 24-195 U/L. Not saying this with pride, but when I had hyponatremia back in 2000, my creatine kinase levels were 240,000 U/L. But that's another post.

Patients with rhabdomyolysis commonly present with muscle pain. weakness, aches and bruising. It is rare, can be life threatening and is often caused by extreme exercise. It occurs when muscles that have been overworked, dies and leak their content to the bloodstream. This ends up straining the kidneys and can cause severe pain.

Anyway, back to this cyclist. She has a medical history of mild iron deficiency which had been untreated and it's potential association to rhabdomyolysis must surely be considered. 

Her coach was unaware of her mild anemia. Cycling for two days in a row would not be considered as extreme exercise since she had previously cycled two days in a row and not developed rhabdomyolysis.

In her case, it is probably the repeated use of the thera/ massage gun after cycling that damaged her muscle fibers leading to rhabdomyolysis. The coach may also have used the thera/ massage gun incorrectly. She was in hospital for 2 weeks and thankfully recovered well.

A published study found 29 cases of exercise induced rhabdomyolysis admitted to the emergency department of a hospital between 2010-2014. The most common cause was indoor cycling classes.

A few of my patients have had rhabdomyolysis. All were active in sports and definitely not couch potatoes. They all felt that the exercise that they participated in (indoor cycling) did not seem strenuous at that time. 

Remember this when you try a new exercise. Start moderately first and and don't be pressured by the coach/ instructor if you're not comfortable.

References

Brogan M, Ledesma R et al (2017). Freebie Rhabdomyolysis. A Public Health Concern, Spin Class-Induced Rhabdomyolysis. AJM. 130(4):

J Chen, F Zhang et al (2020). Rhabdomyolysis After The Use Of Percussion Massage Gun: A Case Report. Phy Therapy. DOI: 10.1093/ptj/pzaa199


Thanks to my patient LLL for both the pictures. Never thought Zouk would end up hosting indoor cycling. Unprecedented times indeed!

Sunday, November 1, 2020

Dealing With Defensive Medicine During COVID


I had a patient recently who injured his knee while playing badminton. The surgeon sent him for an MRI and wanted to operate after the scan showed that he had tore his lateral meniscus.

He decided to have the operation but the procedure was postponed after he got sick. The good news was that he got so much better after the wait that he decided that surgery was not needed anymore.

This reminded me of an British Medical Journal opinion article I read this morning. The article cited examples as a direct result of the lockdown/ circuit breaker period where patients got better as fear of catching Covid-19 in hospitals prevented them from seeking help.

Of course there were also tragic cases when patients cannot receive essential care and eventually dying as a result. Depression and mental health cases come to mind too.

There was an outcry in Singapore recently when it was announced that Medishield Life plans premiums were going up. Healthcare costs are definitely rising all over the world. Patients are often referred for unnecessary tests and treatment when costs are covered by insurance. Overuse and over-diagnosis consume resources and insurance premiums subsequently increase.

This is in part due to doctors practicing defensive medicine. Previously, I had written that some doctors actually charged more for steroid injections after a court case against an orthopaedic surgeon after his patient complained to the Singapore Medical Council after she developed side effects. 

The article suggested that this may be due to multifaceted reasons with vested interests playing a crucial role. Quoting the article, "medicine is permeated by a bias towards doing something rather than doing nothing, even when it may do more harm than good to our patients. Doctors failing to diagnose are resented and sometimes punished, while doctors who cause suffering through over diagnosis and over-treatment are not".

Practicing defensive medicine may also be due to expectations from patients and a fear of being sued.

While not all my esteemed physiotherapists may not agree with me, I would suggest that physiotherapy probably has the same problem. We are often quick to diagnose a 'syndrome', 'an inflammation' or a 'knot'. Perhaps it should be "I don't know for sure" now, but I can do my best to come up with a plan to treat this. If it still doesn't settle, we will definitely investigate further.

Covid-19 has definitely made us more aware of our priorities and actions. Let us use this opportunity to understand and contribute to shift away from defensive medicine and physiotherapy.

You can read the article by Minna Johansson and Iona Heath here.


Picture above taken from Joee Denis.

Sunday, October 25, 2020

Still Using Kinesio Tapes Even If Research Paper Says They Aren't Useful?

I saw two patients with badly sprained ankles this past week. The first patient was hobbling while shuffling on one foot. The second patient was an 18 year old, former national sailor. She sprained her ankle 10 days ago and still couldn't bear weight. She was only putting her toes of her left foot on the ground while walking when not using crutches. Her comment was, "Oh! I can't believe this! My ankle is normal again! I should have listened to my dad and seen you earlier!"

I definitely made both of them better. And I used Kinesio tape as part of my treatment to help with the swelling. So I was very surprised when a systematic review and meta-analysis found that Kinesio taping did not improve ankle function or performance in people with ankle injuries.

A systematic review meta analysis is a search aided by computer looking for all randomized and clinically controlled studies while meta analysis means using statistics to combine the data derived from a systematic review. So the published review is not an article to scoff at.

However, I looked through the supplementary material, and the tapes used were of course of different brands, different taping techniques were used, and it included different types of ankle injuries. Some of the taping were done on the calf muscles, some around the ankle joint, while others taped the Achilles tendon. In my opinion, that would not be fair as different brands of tape would have been compared, there were different conditions, and different techniques were implemented. Not to mention that not everyone would have learnt how to tape appropriately since there are different brands of tape. It would be similar to comparing apples to oranges.

Some of the studies

Note to self. Even if it's a systematic review or meta analysis, make sure you read everything and not just the title and the conclusion. 

As clinicians, we would never just use Kinesio tape or any tape alone just to treat a patient. For the two patients mentioned above, we would never get optimal results just using tape on them. We use our hands to assess, mobilize and/ or manipulate their ankles, while others may use needles, ice, tape or even modalities to treat their patients. Others might teach exercises to get their patients better.

Should we stop using Kinesio tapes? Definitely not. If we use them correctly, they definitely work. Have a look at another of my patient after I use the original Kinesio tapes for just five hours. Scroll down to see more evidence.

Surely you can see the outline of the Kinesio tape

Reference

Nunes GS, Feldkircher JM, Tessarin BM et al (2020). Kinesio Taping Does Not Improve Ankle Functional Or Performance In People With Or Without Ankle Injuries: Systematic Review And Meta-analysis. Clinc Rehabil. DOI: 10.1177/0269215520963846

In the picture below is a patient with a hamstring tear.


Here's how his hamstring looked like 3 days later in the picture below. I have lots more photos like these in my phone of my patients. Contact me if you're still skeptical, I'll show you all the photos from my phone if you like to see them. 

3 days later

Sunday, October 18, 2020

Do Patients Present With A Standard Textbook Pattern of Referred Pain While Having A Pinched Nerve?

Dermatomes- look at C4,5 compare below

One of the useful things I learnt while I was still in physiotherapy school, that I am still using daily, are dermatomes. A dermatome is the area of skin that sends signals to the brain through our spinal nerves. These signals help us sense temperature, pressure and pain. 

When a patient comes in to our clinic with radiculopathy, which means a range of symptoms caused by the irritation of a nerve root, we can gauge what levels of the spine are affected, knowing the dermatomes chart. 

These symptoms can include pain, numbness, tingling sensations, sensory changes, loss of strength and even a change in reflexes. These can occur in the cervical (neck), thoracic (upper back) and lumbar (low back) regions. It is often known as a 'pinched nerve'.

C4,5 check with earlier picture
For example, if a patient comes in complaining of pain in the shoulder it may mean that C4,5 may be implicated. This is especially so if treating the shoulder does not make the patient better.

So I was very interested when I read about the following study, where the researchers studied how often patients who had cervical radiculopathy presented with the standard textbook versus non standard patterns.

Only patients with single level cervical radiculopathy operated by six surgeons were included in this study. Their symptoms of radiculopathy were compared to a standard textbook pattern. 

239 patients' records met the inclusion criteria. Their age, weight, BMI, gender and symptom duration were not different between patients with a standard radicular pattern versus those with a non standard pattern.

Picture of referral pattern from article

Overall, 54% (129 patients) fit the standard textbook pattern while 46% (110 patients) differed from the standard pattern. C5-6 and C6-7 were the two most common levels operated on for radicular pain. Non standard patterns of presentation were found in 50.9% (C5-6) and 44.7% (C6-7) of the cases.

Same sided neck pain (81% of patients) was the most common presenting symptom. Shoulder pain was reported in 142 patients (59.4%). 19.2% of the subjects (46 out of 239) had pain/ symptoms at the neck level with no referred pain down the arm. 

When a non standard pattern was encountered, it differed by 1.68 dermatomal levels, either higher or lower.

The authors concluded that observed patterns of cervical radiculopathy in their study only followed the standard textbook pattern in 54% of patients studied. Non standard referral patterns were more common than thought. 

Now, that's a good reminder to doctors, surgeons and physiotherapists (note to self). Patients suspected of referred pain from the neck and back may not always have symptoms that fit the standard textbook pattern.

We need to do our due diligence to ensure each patient get treated appropriately.


Reference 

McAnany SJ, Rhee JM et al (2019). Observed Patterns Of Cervical Radiculopathy: How Often Do They Differ From A standard, "Netter diagram" distribution? Spine. 19(7): 1137-1142. DOI: 10.1016/j.spinee.2018.08.002.