Anterior Knee Pain: Upgrade Your Eval & Treatment
In this episode of the Unreal Results Podcast, I tackle one of the biggest questions that I get from healthcare providers and athletes and that is how to deal with anterior knee pain. I of course talk about using the LTAP (Locator Test Assessment Protocol) to help pinpoint the root cause of anterior knee pain. I also talk about evaluating knee biomechanics and the interconnectedness of body parts such as the kidneys and lungs that could also be contributing to anterior knee pain. I also go over some practical treatment techniques & tips including the importance of the flexor hallucis longus muscle and the infrapatellar nerve, to help with resolving these knee issues. This is a great episode to help you level up your evaluation and treatment for anterior knee pain!
Resources Mentioned In This Episode:
Episode 61: The Lung Connection To Foot Pain You Didn't Know About
Episode 45: The Kidneys - Visceral Connections To Movement
Episode 26: Sartorius B.I.G.
Episode 25: The Peripheral Heart
Episode 21: Easily Restore Knee Extension After Injury Or Surgery
Episode 8: Unlocking The Fibula
Self-Massage For Knee Pain - YouTube Video
Toe Flexor Stretch For Ankle Mobility - YouTube Video
Common Peroneal Nerve Glide - YouTube Video
Deep Peroneal Skin Lift - YouTube Video
Example of Aberrant IR - IG Post
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello. Hello. Welcome to another episode of the unreal results podcast. Uh, I am coming on to do a quick episode on a really common thing that comes up in, um, my athletes as well as questions from other practitioners that I have is, um, Sort of troubleshooting patella femoral pain Specifically like patella tendonitis and I put that in quotes if Well, if you're listening, you didn't see my air quotes, but I put it in quotes because it's one of those like junk terms and Junk terms meaning it's a label that people get a lot of the times for anterior knee pain anterior knee pain that happens to be around the patella tendon without necessarily actually being a inflammatory response or a teninopathy type pathology going on.
However, this information will be helpful even if it is a tendinopathy or a tendinitis type of pathology going on. And we're going to talk through the reasons why coming up. So, um, this is not my first episode on the knee. I've done a few different episodes on the knee, so I will make sure that Joe links those in the show notes.
So, um, you know, there's been an episode on like restoring, knee extension post surgery. There's been an episode on, um, The knee and the relationship to the kidneys. So a whole episode on the kidneys, which is a common visceral referral to the knee. There's been an episode on the fibula and unlocking the fibula and how that relates to the knee.
So yeah, lots on the knee and also the Sartorius episode I did a while back that's going to relate to this episode quite a bit too. So lots to dive into around the knee in general, but, um, hopefully this can provide a little bit more like specificity towards this one common thing. So, um, when it comes to, well, any injury, of course, like, I mean, Let me back it up.
When it comes to anything, whether it is knee pain, ankle pain, hip pain, back pain, shoulder pain, or dysfunction, or post surgical scenario, I am always starting in the same spot. And what I mean by that is I am always starting with an evaluation that is going to help me determine where the body wants me to start and help me determine what else is going on that could be either driving biomechanical dysfunction, driving this pain, or driving this inability for the body to heal itself.
That is where the LTAP comes in. So the LTAP, it's acronym for the Locator Test Assessment Protocol. That is the assessment that I've put together to help you arrive at that location. And it is, um, it is, you know, an accumulation of sort of Me blending in the osteopathic type of general and local listening techniques that I learned to evaluate using the Receptors in my hand and it's a way to give them a more sort of orthopedic or like solid objective um information.
And so I'm always going to start with the LTAP. So if someone comes in with knee pain around their patella tendon, I I'm going to be like, okay, interested in, I might. have already even done the LTAP first because oftentimes I do it first because I don't want to be biased by what's going on. And you know, I want a very clear message from the body versus the story they're telling me.
But even if I know when, what they're coming in for, I'm still going to start with the LTAP because it literally could be from every anywhere. Even though I said the common visceral referrals for the knee is going to be kidney. It can, It can be anything from anywhere. And that's a concept that I talked about, talked through a lot in the episode from a few weeks ago, um, talking about, I shared a case, um, I shared a case of someone with foot pain, but it's coming from a visceral referral in their lungs, right?
Which is not a common visceral referral for foot pain, but it does. When, whenever we can have a change in biomechanics because everything is attached in the body, it can affect somewhere else. And so that's why we started with LTAP. We can't just assume that we have, like, it's a kidney issue because it might not be for someone.
Um, knowing that the kidneys are a visceral referral for the knee though, is like a little bit at least of, like, the low hanging fruit. If you don't know the LTAP, like it's a good spot to start from a visceral standpoint. Um, so I'm always going to start with the LTAP. So once we, once we determine where the body wants to stop, start treatment, right?
Where the body is directing me, I'm going to pause before I do treatment. Then I'm going to look at a bunch of orthopedic things around the knee. itself. So I want to get an idea of like what biomechanically might be driving these issues, driving the, this pain and any like dysfunction or, um, performance issues somebody's may, may have.
So the things I'm looking at afterwards is going to be hip flexion. I want to see how Well, can their femur move in their hip socket without their pelvis starting to move? How well does the femur sink in the hip socket? This is important because if the femur If, if femur can't sink in the hip socket, like we can't sit on our hips, we're going to have a more tendency to load the anterior knee, which is going to have more pressure on that.
And like just set us up for potential for more issues around the anterior knee. So hip flexion is something I look at hip internal rotation, hip external rotation. I kind of just look at them all at once. Um, then I'm looking at passive ankle dorsiflexion. I like to look at that with the leg straight. So the patient is in the supine position and I'm passively dorsiflexing the ankle.
And what I'm paying attention to is not only in the range of motion, but what's going on with the rest of the leg. So, This is, this can be very valuable when it comes to the relationship between, um, the ankle and the knee and just like even understanding in weight bearing what's happening to the leg and what's, what stresses may be coming across the knee joint.
And so, as I passively dorsiflex their foot, I want to see, can that happen without the rest of the bones? doing something. And a common compensation I see is when I passively dorsiflex them, their entire leg moving into internal rotation. This is a fault. This is, and what this is, whenever we see an aberrant motion outside of the body, meaning, well, like in the body still, but like when we can see it, it's an aberrant motion that shouldn't be occurring, right?
This an indication that we're lacking that same motion arthrokinematically somwhere else
So if I passively dorsiflex their ankle and I see internal rotation happening, that means that there might be limited in internal rotation at the ankle itself, at the knee joint or at the hip. And so it's a, it's, it's a check in that I do before and after treatment to see like, how are things changing?
And it is counterintuitive because The aberrant motion that comes out is the motion that they're actually lacking. And so it's the body trying to make up for a lack of internal rotation arthrokinematically, so it tries to gain it osteokinematically. So that's a big one that I look at. The other thing that I look at, I might, is like prone, um, passive dorsiflexion, just to see when I take, you know, when I, when I take the knee joint out of it, like does their dorsiflexion change at all?
Again, same kind of concept of looking at hip flexion when we can't access all of our dorsiflexion Then we put more strain or stress on the front of the knee in terms of controlling our mass With movement patterns when we can't When we can't access dorsiflexion in our ankle, that means that our soleus cannot help with the control of anterior translation, so it puts it all back on to the quadriceps and the hamstrings and just can, can cause a lot of issues.
Um, On that note too, since I just said that, you know, another podcast that I'll have Joe link is the peripheral heart episode. That's all on the soleus because it's important to know about the soleus and how it does relate to the knee, um, from a mechanical standpoint, quite a bit too. So the other thing that I look at is.
I look at, um, I take a non consistent, a non normative measurement, but I'm looking at it for their specific body, of, real scientific, I take my thumb and put it on the inferior pole of their patella, and then my other thumb on the patella tuberosity, and I want to see you. Basically, I'm looking at how much torsion that there is in the lower extremity.
And here's the thing, why it's not normative, is there's not like a normal degree of torsion that I'm looking for. It's going to be relative to what their other side is, assuming that their other side is feeling good and functioning well. But also, and in, you know, sometimes we don't know until we're in it with people.
But usually, um, we have one side that's different. Or in, in the cases of pain and dysfunction, we might see that they have one side that's different and that's, that's something that's concerning. So some people though are naturally just torsioned and so their fingers are not going to line up. Some people are like half a finger, a whole finger, two fingers, right?
Again, I'm just sort of getting the general idea of what is going on this side because I'm gathering this information because after I treat someone, I want to see if it changes and if it changes, I want to see if that relates. to then their pain provocation or, um, biomechanical issue that I care about.
So that's how I look at torsion. And then I also look at just general joint mobilization or joint mobility of the tibia in internal and external rotation at 90 degrees of rotation. Knee flexion. The last thing I look at is, um, prone knee bend and I'm looking at the prone knee bend in terms of from a neural tension standpoint.
I want to see how far we can passively flex the knee with the body in prone, in the prone position before I see someone's pelvis try to move away from that tensioning of the Um, lumbar plexus or femoral nerve, saphenous nerve on the front of the leg, obturator nerve, all of those anterior nerves. And, um, the, I lied.
There's one more thing that I look at and that is pulse. The pulse, the distal tibialis pulse on that leg, or even on the opposite leg too, because I want to see how the blood flow to the lower extremity is, specifically I wonder about the blood flow to the tendon itself, especially if there is a true tendinopathy going on.
Tendons in general don't have great blood flow already, and then this is actually too why I look at the torsion, because often times if we have a torsion going across the patella tendon there, we're taking that patella tendon and we're wringing it out. And just like a, um, towel that's wet, when we twist it and wring it out, all the fluid goes away, right?
It blanches away from the center of the rotation. and um, dehydrates it. And so if we are thinking about this from a blood flow standpoint, a structure that already has very minimal blood flow, we put it on torsion and we decrease the blood flow even more, it's going to have more of a tendency towards those tendinopathy type responses.
So this is something that I often look at too. And then also, The posterior tibialis pulse can give me a good idea of if there is an entrapment around the infrapatellar nerve. And the infrapatellar nerve is the nerve, a nerve branch from the saphenous nerve that innervates the sensory information around the patella tendon.
So these are the things I look at. Then, Once I have this orthopedic list, you know, I might too, you know, depending on the person and what's going on and what they've told me, I might ask them to do a squat, a single leg squat, single leg balance. I might ask them to do a split squat or a lunge with both the front leg and the back leg forward.
I want to see what their movement patterns like. And I also want to see, um, What provokes their pain? So, sometimes I just ask them, Is there anything that you can demonstrate to me from a movement standpoint that would cause pain to your knee? A lot of the times for this issue, it is that split squat position.
Uh, so, that's usually all the things I'm looking at. I might also look at long axis. internal rotation and long axis hip adduction, but specific to the patella anterior knee pain, patella femoral, like, um, things itself. That's pretty much what I'm looking at. If it, oh, the other thing too, when I'm looking at the measurements around the inferior pole of the patella and the tibial tuberosity, I'm also measuring how many of my fingers between the tibial tuberosity and the inferior pole.
And I'm looking at on that. side to side. And oftentimes what I've seen is people who have patella tendon pain have a tendency towards more space, more length between the tibial tuberosity and the infrared bullet patella on that side. And so I might also look at in general, the patella position and the patella mobility, though I don't put a whole ton of, um, Stock in that and it's not something I'm like gonna necessarily do a ton of joint mobs for is, but again, it's just something I see that if it changes with whatever else I do treatment for.
So then what are we going to do? Well, first I'm going to do treatment wherever the LTAP directed me, right? So if it's the kidneys or if it's some other visceral organ, I'm going to start there. The central nervous system, I'm going to start there, or if there's some sort of peripheral neurovascular treatment somewhere.
I'm starting there too. And then I'm reassessing these things and seeing if I can clean up all of these objective orthopedic measures. From a treatment standpoint, the things that tend to be pretty helpful are cupping or some sort of soft tissue fascial manipulation to the area around the adductor hiatus.
the lower part of the sartorius border where the infrapatellar nerve comes out. That's like a really quick way to make people's patella tendon feel better. Oftentimes that patella tendon pain is not a tendinopathy, it's just pain from a cutaneous nerve entrapment and that is a classic spot for it.
Another big driver of the torsion I see that is going to right. We talked about the torsion being something that decreases the blood flow kind of puts that twist on the, um, on the tendon can also lock up the ankle joint and not allow for internal rotation. So we're going to see that, um, tendency towards, um, the aberrant internal rotation.
motion happening with passive ankle dorsiflexion is a tibia or a lower leg that is sort of locked in external rotation. And a lot of times when we see this, so the tibial torsion piece, we might see the lower thumb being more lateral to the infrapatellar pole thumb. And a lot of times when I see this, not only is that that positional fault, but also went on testing tibial internal rotation, they're going to be limited.
Um, a lot of times when people see this, what gets blamed is the hamstrings, the lateral hamstrings and the, um, TFL IT band. But I found that the main culprit of it most of the time is a tightness of flexor hallucis longus on that side. And that's because flexor hallucis longus. So the long big toe flexor.
Even though the big toe is on the medial side, the muscle goes from the medial side and crosses over, originates on the lateral side, originates on the fibula. And so when it's tight, it sort of locks the whole lower extremity in external rotation. And that makes sense, right? Because what do we see as a pattern of movement when somebody is lacking length in their flexor hallucis longus is a lack of toe extension.
And when we see a lack of toe extension, we tend to see people walk with their feet turned out, right? So this is actually the thing that I see driving this pattern quite a bit. So oftentimes the key to these anterior knee pains is doing a little treatment, deep tissue, dry needling, whatever you would like, even just a stretch of the flexor hallucis longus.
And, um, That usually like clears up a lot of things. This is why too that I was like the unlocking the fibula Podcasts gonna be really helpful as well. But That's it. And then two, you know, making sure that we've restored all those biomechanical things. So, um, oftentimes these common issues, the infrapatellar nerve entrapment and the tight flexor hallucis longus will fix all of these things.
It's, it's surprising, but if we take a step back and let's say like, okay, we did the infrapatellar nerve cupping and they feel a Having issues and maybe we even tried to stretch the flexor hallucis longus and it's not quite unlocking things like we still see a little bit of a torsion and then we're going to take a step back and think about like what nerve innervates the flexor hallucis longus that is what we're one of the peroneal nerves.
I think it's the deep peroneal nerve. And so we're going to work the areas of the deep peroneal nerve, might even go one step further and like, look where that nerve comes from, right? It comes from the common peroneal nerve. Common peroneal nerve comes from the sciatic nerve. So we can like make sure all of those areas are free to move and do their part.
We can do a simple common peroneal nerve glide. We can do a skin stretch at the deep peroneal nerve. We could do a tibial nerve glide and see if that changes things too. And then oftentimes we'll see that reflected in better hips. flexion as well. So that's really what I'm trying to clean up though. Real good hip flexion, no aberrant internal rotation.
So we've got good tibial internal rotation, good, good dorsi flexion, not a ton of torsion and an infrapatellar nerve that's free to do its thing. So, um, I'm going to make sure to linked in the show notes are some of the, um, YouTube videos. I have the treatment. So I have a self massage treatment of the adductor hiatus area for the infrapatellar nerve.
I also have an area. Um, I also have a, um, common peroneal nerve glide, and I have a video about how to properly stretch the flexor hallus as longest and a little bit just about it. Um, so I'll make sure that is all linked. And I also have a Instagram post that I demonstrate this passive ankle dorsiflexion and aberrant internal rotation range of motion.
So you can see what that looks like. See what I'm talking about. But, um, these are really great things to check. Obviously treatment's a little different, you know, because though I gave you some key spots to treat again, it's really going to be driven by where the body is directing us. What sequences the body tell us that
we need to do in order to sort of unlock things and improve blood flow, improve mobility at the hip and at the ankle and at the fibula to decrease the tendency towards this anterior knee pain. And then even, even if it is a tendinopathy type thing, like setting us up for success when we're doing the eccentric or concentric loading to remodel the tendon.
So hopefully that's helpful and uh, we'll see you next time.