Prospective orthopedic surgery

This is one of the few prospective orthopedic surgery studies involving arthroscopy in which patients with persistent pain and medial plica and arthroscopy were randomized to either have it resected to simply lavaged. The dark line on top are the folks that were resected and it denoted their likelihood to preserve a good or excellent result. So this in one of the intraarticular processes that one encountered in a person with chronic knee pain, that probably should be treated arthroscopically with resection. However, this was an early case. She wasn’t too far along and she had not had the benefit of a physical therapy evaluation and approach, so that’s what we did with her.

Okay, so she is at physical therapy. We are going to do a biomechanical evaluation here and when we do we find that she has some tight structures, not unusual for a young person, even a runner. Iliotibial band, hamstrings, gastrocnemii soleus tightness. We find relative weakness and some imbalance in her quadriceps and hamstrings. A little bit, about five degrees, of that rear foot valgus we showed you before, and she does seem to have excessive pronation on weight-bearing, particularly when she is running.

Our evaluation of this is that what we are seeing is an athletic or overuse injury due to an increase in training intensity and relative lower extremity deconditioning. So that relatively minor impairments are exacerbated by increased demands. Our goal we developed with her is to reduce impairments, improve the mechanics, do some temporary activity modification to allow time for the tissue to repair and for training adaptations to occur, which will protect her in the future. The first thing we will look at is ankle and foot control and we thought we would try a trial of arch taping or commercial orthoses for arch support and some shock reduction, to see if that would help. We also have encouraged her and told her how to choose running shoes that are designed for stability and pronation control, rather than for flexibility and light weight. This is an example of the kind of patellar taping that can be done in the clinic. It’s nice to do, not just because people with do this regularly, but to do this once and then try weight-bearing and different activities, you can very often get a good idea of whether supporting the medial longitudinal arch is going to be effective or not. In this case, she chose to try some insoles or foot orthotics. You can see her standing here without the orthotics, with a Band-Aid on her knee, and here just standing on the orthotic. You can see the fairly pronounced change in the alignment of her feet just by changing the relationship of her foot to the ground, and therefore her ankle.