Question - Lateral Tilt (knee pain with marathon runner)

by A.V.
(NY, NY)

On an x-ray of my knees in the sitting position, I have lateral tilt on both knees. I am a marathon runner (formerly at the moment) and never suffered from any knee pain until I pulled a hamstring on my right side last year. Though I didn't run on it for long, my knees started hurting and despite PT and a home exercise program I can't seem to run more than 6 miles before the pain setting in. It seems strange that I can even run this distance pain free, but I really desire to run more and I also don't want to further injure my knee.

I don't feel any pain at other times of the day. My right knee tracks incorrectly, but my left one does not, but I feel more pain when running on the left, but pain while sitting on the right.

I have been doing VMO strengthening exercises and the physio who assessed me said my hip strength is good. What am I to do at this point? Do you have any experience with biofeedback which I have read a lot about?

Thank you,
A.V.

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Question - Lateral Tilt (knee pain with marathon runner)

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Aug 18, 2008
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Hip strength...
by: Bart - SII

While your therapist feels your hip strength is good, I would add one caution - if it was measured with you laying or sitting on the table and then resisting against them, that only indicates gross isolated muscle strength - this is very different from multi muscle multi joint function like you undergo when performing activities.

You may have good isolated hip strength, but you may have poor muscle control and abnormal firing patterns that limit the amount of work your hip muscles can do during activities.

The other things to look at are your feet mechanics - do you over pronate? Are your shoes providing adequate support for your foot type?

Do you have any mobility restrictions in your upper or lower back? Have your therapist check your lateral lumbar flexion, thoracic extension, and thoracic rotation - all of these things can contribute to knee pain.

If everything checks out, and you truly do have good functional hip strength, then the lateral tilt is the true cause of your problems and a lateral release may be the next option.

Hope this helps - comment back with other questions.

Bart

Aug 19, 2008
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Lateral Tilt Question
by: A.V.

Thank you so much for your quick response. I do have a few further questions: when sitting with my legs outstretched and relaxed, my knee cap is clearly tilted (it does not have to be flexed to do this). However, I can easily move it back into position with tape, it is not excessively tight. Would you mind commenting on what this means?

Also, you spoke about the lower back. What exactly do I want to acheive as far as my lower back? Are there exercises I can do? I find that I often know more than the PT or Doctor and have had trouble finding someone to properly treat this. I greatly appreciate your time.

A. V

Aug 19, 2008
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Lateral Tilt
by: Bart - SII

Most likely it means that you have some laxity in your patella femoral joint - good mobility of the patella is something that is important, but many people will have problems, especially if the patella is tilted. Because it isn't excessively tight, and you can move your patella medially, you most likely would not get a lot of benefit from a lateral release procedure. That is good, and bad. Good because you most likely can treat this without surgery, bad because it means that you have to treat this conservatively, which can be complicated and time consuming.

Your lower back plays a big role in how your knee absorbs stress placed on it. Everything is connected, so if you have mobility restrictions in your lower back, then your hips are not able to adjust correctly. When the hips don't adjust and move, that means that the femur must adjust and move, and that usually leads to an increased valgus angle at the knee, pronation at the knee and ankle, and increased stress on the patella femoral joint.

I have found with my patients that restrictions in lateral lumbar flexion (bending straight over to the side) is often restricted, leading to hip restrictions.

You can test your lateral lumbar flexion by standing against a wall with your rear, shoulder blades, and head against the wall (feet about 4-6 inches away from the wall), place your hands overhead and flat on the wall (tops of hands), and then try to bend as far to one side as you can, keeping everything flat against the wall. You will feel a stretch in your lower back/hips/outside abs. This should be equal on both sides, and you should be able to bend over to about 45 degrees or more on the wall. This is an exercise I give my patients to work on this.

Hope this helps,

Bart

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Aug 19, 2008
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Submitted by: Bart - SII

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Most likely it means that you have some laxity in your patella femoral joint - good mobility of the patella is something that is important, but many people will have problems, especially if the patella is tilted. Because it isn't excessively tight, and you can move your patella medially, you most likely would not get a lot of benefit from a lateral release procedure. That is good, and bad. Good because you most likely can treat this without surgery, bad because it means that you have to treat this conservatively, which can be complicated and time consuming. Your lower back plays a big role in how your knee absorbs stress placed on it. Everything is connected, so if you have mobility restrictions in your lower back, then your hips are not able to adjust correctly. When the hips don't adjust and move, that means that the femur must adjust and move, and that usually leads to an increased valgus angle at the knee, pronation at the knee and ankle, and increased stress on the patella femoral joint. I have found with my patients that restrictions in lateral lumbar flexion (bending straight over to the side) is often restricted, leading to hip restrictions. You can test your lateral lumbar flexion by standing against a wall with your rear, shoulder blades, and head against the wall (feet about 4-6 inches away from the wall), place your hands overhead and flat on the wall (tops of hands), and then try to bend as far to one side as you can, keeping everything flat against the wall. You will feel a stretch in your lower back/hips/outside abs. This should be equal on both sides, and you should be able to bend over to about 45 degrees or more on the wall. <a href="http://www.sports-injury-info.com/patella-femoral-syndrome-rehab-mobility.html" target="_blank">This is an exercise I give my patients</a> to work on this. Hope this helps, Bart

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