Case of the Week - Pes Anserine Pain

Even those with some anatomy background might be wondering, Did I miss something? Where is the pes anserine? The name pes anserine means goose foot. We use it to describe three tendons that splay out like the toes of a goose. These tendons, the gracilis, sartorius and semitendonosis, all belong to muscles with different functions. As a unit, however, they often cause pain in the medial knee. Patient with pes anserine pain often complain of ITB syndrome, and vice versa. See last week’s blog for information on ITB syndrome.

Patients with pes anserine pain often complain of pain in their knee, specifically the inner side toward the back. It should be noted that patients with pain within the knee joint itself are usually describing a different condition.

As with ITB Syndrome, pes anserine pain’s root cause is often muscle imbalance. The muscles that control the knee muscle contract with equal force, quality and endurance on all sides of the joint. When one group is weaker, it becomes overworked leading to tendonitis, pain with exercise and eventual pain at rest. Last week we discussed the importance of VMO strength in alleviating ITB syndrome in runners. With pes anserine pain, the strength of the ITB is key. The pes anserine tendons support the knee from the inner side and the ITB supports the joint from the outer side. As the quads and hamstrings flex and extend the knee, the supportive structures on the sides help guide the movement. If the ITB is weak at the knee, the pes anserine tendons must work harder to stabilize the joint. Eventually, this will cause pain and inflammation in the area.

The short-term solution is to alleviate the excess tension. Massage of the pes anserine tendons, including use of the foam roller, will decrease local tension. Patients should also stretch their thigh adductors and hamstrings on a regular basis. Massage of the ITB may also be indicated.

The long-term treatment plan should involve identifying and correcting muscle imbalances in the knee, hip and ankle. In the most common presentation, this involves strengthening the tensor fascia lata and gluteus medius (hip abductors) at the hip and stretching the hip adductors.

For a great article on knee anatomy, visit http://darkwing.uoregon.edu/~athmed/aclrehab/anat.html

Exercise: Adductor and hamstring stretch

Stretching your adductors and hamstrings is something most people have done at some point. The key here is quality. Always lean into a stretch slowly. For these stretches, keeping your spine straight and hinging your movement from the hip will give a better stretch, faster. Breathe into each stretch for 10 seconds and slowly return to center before moving on.


Suggestion of the week: Increase new exercise slowly

Especially with running, but with any sport, increase the intensity slowly to build up muscle and avoid injury. If starting a new running routine, increase by small increments depending on your fitness level. A beginner should start with increases of minutes, instead of distance. An experienced runner can increase at 2-3 mile intervals so long as they provide adequate recuperation time in between runs.

Case of the Week - Iliotibial Band Syndrome

Patient: 27 year old female legal assistant

The patient presents complaining of knee pain. The pain came on without any injury she can remember. It gets worse with jogging; she no longer jogs due to pain. She is a former dancer, now working a desk job. She reports mild numbness across the tops of her feet and some right sided buttock achiness. She has tried to increase her warm-up and cool-down, but this only helps decrease the pain slightly. She is concerned she will not be able to run anymore and wonders what sort of exercise she should be doing instead.

Examination: Significant tension and tenderness in both iliotibial bands from the medial portion, distally to the band’s insertion on the tibia. Pressure applied to the medial portion of the band increases the numbness perceived on the feet. The right piriformis and gluteus medius are also significantly tight and tender. Provocation of the sacroiliac joint was positive for local pain. Patrick’s test was positive for pain on the right hip. Ober’s test for ITB tension was negative bilaterally, but Renne’s test for ITB tension reproduced symptoms on both legs. Nerve and circulatory testing in both lower extremities were within normal limits. Low back orthopedics were negative.

Discussion:

The iliotibial band or ITB is a common source of complaint for many athletes, especially runners and cyclists. The ITB runs from its muscle at the hip, the tensor fascia lata, to past the knee on the outside of the thigh. Because of its location, it works to stabilize the hip and knee, and can even become involved in pelvis and low back problems. In this patient’s case, an increase in running and a decrease in other aerobic activity caused increased stress on her knee stability. The ITB became inflamed as it increased tension in an attempt to improve knee stability. As the tension increased, the symptoms traveled up the leg into the hip. As the ITB got tighter, it began to cause abnormal sensations in the foot. It is important to note that testing proved the patient did not have any actual nerve damage or irritation. The numbness she experienced was a result of deep-referred symptoms.

In this case, the patient was instructed to stop running for two weeks and underwent intensive treatment to reduce the tension on her ITB’s and related musculature. Once the tension was decreased, the patient was able to return slowly to exercise with a new program for warming up and cooling down that included stretching of the ITB’s.

Outcome: The patient has had a complete resolution of the ITB Syndrome in both legs. She uses a foam roller regularly to help maintain healthy tension levels in the ITB’s and related muscles. She receives maintenance chiropractic care approximately one time per month, as needed.

Suggestion of the Week: When you have knee pain, it is important to remember the knee’s muscles must be balanced for the joint to function properly. This means that both the front and back and the inside and outside of the knee must have equal support. One of the most commonly weak knee muscles is the Vastus Medialis Oblique or VMO. If this muscle is weak, the knee cap cannot track properly during knee bending, and this can cause many different problems, including ITB Syndrome. Get your knee evaluated for muscle balance to ensure good joint motion and biomechanics.

Exercise of the Week: Use a foam roller to self-massage difficult areas on your body. You can use the roller on your back muscles, buttock, thighs, calves, shins and shoulders. Make sure you only stay on an area for about 30 seconds, and be careful not to roll over a joint. Daily use of the foam roller on problem areas can help people decrease the frequency of their chiropractic maintenance visits because they are able to provide some maintenance care themselves. Follow this link for more detailed instruction: http://www.performbetter.com/catalog/assets/Exercisesheets/PDF/FoamRoller.pdf. Please be aware that this link also includes instruction for balance training exercises using the foam roller. While this is an excellent use of the product, this is not the intended use in reducing muscle tension.

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

A Departure - The Mind-Body Connection

This week, instead of writing about a case, I want to explore some thoughts on the connection between the mind and the body. As a chiropractor, I mainly treat joints of the body, and the muscles and nerves associated with those joints. But joints are not isolated occurences. A joint has a purpose: it is there to allow movement. Movement allows us to interact with our environment. Interaction with our environment is what we call living life. And that same environment also interacts with us.

During the interactions between our body and the environment surrounding it, stress occurs. It can be your boss yelling at you, breathing the cigarette smoke of the guy next to you, or typing reports for several hours in a row. These are all stressors and they ALL affect the body, usually resulting in joint dysfunction, fatigue, muscle tension and muscle group imbalances. Mental stress causes us to grow physically tense, muscles go into spasm and cause joint dysfunction. If this is serious enough or goes on long enough, it can inhibit nerve function. Environmental toxins likes cigarette smoke are stresors because our body has to put energy into processing these chemicals when it should be using its energy for more important things, like our immune system and brain function. The physical stress of working long hours is the most obvious example because it makes sense that an inherantly physical problem would have a physcial outcome.

Think about this for a moment: Every stressor we encounter MUST be processed by the body in a PHYSICAL way. Even mental and emotional stressors impact our physical body. With this in mind, how can we possibly stay well? We are constantly bombarded with stressors. Even if we saw a chiropractor every day, we couldn't combat the onslaught. Or could we?

What about our most powerful weapon? The MIND! As humans our minds are treasure troves of untapped resources. We have the power to impact our body in a physical way with our mental intention. Stay with me here... By now, thanks to Oprah, everyone with a pulse has heard about The Secret. http://en.wikipedia.org/wiki/The_Secret_(2006_film) This book/movement deals with the power of intention and the law of attraction. Simply stated, we get what we ask for. If we spend all our time worrying about how we are going to get yelled at by the boss, we WILL be yelled at by the boss. Conversely, if we put our intention toward, say, moving out of the apartment and into a house, we will attain that goal. The universe is a generous place and all you have to do is ask for what you want.

So what does this have to do with health? In order to truly have the power to manifest our intentions, we must be fully mentally present within our bodies. When we are fully present in our body, we begin to realize that the body sends us messages about what it needs. This is where I come in. Many times, on the road to a higher level of mental awareness, a patient realizes their body needs help to achieve its highest level of functioning. I help by adjusting joints and re-balancing muscle groups to provide a stable environment for the mind to work in. Once a person's body is functioning at its best, the mind can focus its intentions more acutely and accurately.

I guess my point is that as we try to better ourselves and our lives, often the first step is to start with our body. Once the body is sound, the mind is free to reach its fullest potential. This is why I truly believe everyone needs a chiropractor. If everyone on earth had regular chiropractic check-ups to help combat the constant stressors of living, then everyone would be freer to function on a higher mental plane. And I think we all know that a collective higher consciouness can only mean good things for us as a people and our planet.

I'll get off my soap box, now. Thanks for listening.

Other resources for those who are interested: The Celestine Prophecy by James Redfield, What The Bleep Do We Know? http://www.whatthebleep.com/