Treating Knee Problems can be very simple if you follow some basic rules. Number #1 Orthopedic principles give you Plan A to approach treatment. #2 Understand that the Knee is influenced by 3 areas: the knee itself, the foot, and the hip and for any given individual one area may have the most crucial influence. #3 Start treatment with Plan A, but be willing to use Plans B, C, and even D. #4 Approach the knee from all three areas of influence: hip position, flexibility, and strength, along with knee flexibility and strength, and foot position. #5 Using the help of a physical therapist and orthopedic surgeon/sports medicine doctor is vital in knee injuries or pain syndromes. #6 Whereas most knee problems will be straight forward, do not give up on the recalcitrant cases as you will be able to learn the most from them.
One of the easiest things you can do for knee complaints as a podiatrist is to make their feet more stable. I have talked at length about this. Sometimes simple foot balancing orthoses are all that is necessary. Sometimes you have to put either varus or valgus corrections into the feet to affect the knee. Sometimes it is more the sagittal plane that needs to be corrected with heel lifts, variations in heel heights in shoes, and lifts for short legs (structural or functional). And, sometimes the transverse plane is the most crucial with strengthening of hip external rotators and abductors, and stretching the internal hip rotators and the hip adductors.
Now, let’s talk about genu valgum. It is a frontal plane deformity of the knee joint with its opposite being genu varum. I have dealt with the 2 of the main types, more developmental and more pathological. The image below shows developmental genu valgum with 2 different foot responses. More on this soon. Pathological genu valgum has various rare causes, but several orthopedic causes are quite common that we can treat. These occur due to foot pronation leading to valgus malalignment of the knee or at least holding the knee in valgus (similar to the left of Image #1), or related to anatomical problems with the lateral knee leading to valgus malalignment of the knee. The following article talks about classification based on angles.
Image #1 is normal developmental genu valgum that the growing child never grew out of. Children are normally knock kneed from ages 4 to 8, but then their knees will straighten in 99% of the population. 1% of the US population is 3.4 million people with recalcitrant genu valgum requiring our help to alleviate. Here is an article that summarizes some of the treatments: medicalnewstoday
The following video is excellent in describing how we should be proactive with these children or adults: video link
Some simple and progressive exercises, foot orthoses, a Rx for a nutritionist for weight loss advice, sometimes even a simple knee brace, and from the beginning the patients will feel much better.
I hope you now know a little more about the millions of patients out there with genu valgum. Now I want look closely at Image #1. The patient had a NCSP of 10 everted due to the Genu Valgum. The right foot was actually supinating 3 degrees in stance, and all the way to vertical with many of his shoes. This means that the subtalar joint is functioning supinated or laterally unstable at the foot. The goal of an orthotic device for both feet was to make the patient function near subtalar joint neutral so the heels were set at 10 degrees everted and measured at dispense by the OCSP angle (RCSP while wearing orthotic devices). The left foot, and the main reason for the visit, had lateral knee pain developing quite severely in the last 3 months. The foot was functioning 6 degrees pronated from NCSP, and simple varus positioning of the foot 6 degrees brought the heel back to 10 everted. I used 3 mm Kirby Skive for 1-2 degrees of varus and 3 degrees of extrinsic varus posting (rearfoot and forefoot), and balanced 5 degrees of forefoot varus support (my cast captured 12 degrees inverted forefoot deformity). I hope this makes sense from previous posts. When you balance forefoot varus, you get great arch support but it is unpredictable how many degrees the heel will change. I needed to apply a 6 degree varus force on the heel, and will get 1-2 from my Kirby medial heel skive, and 3 from my varus posting, but I got 1-2 from my balancing of the 12 degrees of forefoot varus (which was most likely part supinatus).
Image #2 shows a similar figure of a patient with genu valgum with the right functioning supinated across the subtalar joint and the left pronated across the subtalar joint. The left may be a precursor for PTTD, or at least some pronatory problems. But why is the right troublesome? The supinated right foot is a rigid non adapting foot prone for joint dysfunction, falls due to its absence of being a mobile adapter, and shock absorption issues as it will not pronate at all.
Image #3 is just a simple summary of what you may observe in the knee. Remember when you schedule gait sessions to have your staff remind patients to bring in their shorts.
