Understanding Common Knee Injuries And Lower Extremity Implications In Runners

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Oftentimes, the performance of a runner is based on foot type. Basically, long distance running requires a neutral foot. Overpronated feet lead to overuse injuries/syndromes.
With distance runners, stress reactions and fractures within the tibia are common. They occur less frequently in the medial tibial plateau than in the diaphysis.
After performing a full lower extremity biomechanical exam, we often perform a video gait analysis in our practice to assess patients’ running mechanics. 
(Photo courtesy of David Levine, DPM, CPed)
By John F. Connors, DPM, and Ana J. Sanz, DPM

How To Recognize Meniscal Injuries
The menisci of the knee are C-shaped cartilaginous wedges covering 30 percent of the medial and 50 percent of the lateral tibial plateau. Menisci are mobile buffers that absorb shock and also help guide knee motion by providing stability. Meniscal injuries can be acute or chronic in nature. The meniscus is composed of fibrocartilage, which has minimal healing potential. The only vascularity is in the peripheral 20 to 30 percent of the meniscus. With time, micro-damage can occur in the meniscus. These microtears can eventually lead to a more complex tear. The patient usually complains of a “catching or locking” feeling in the knee. Diagnostic methods range from McMurry’s test to MRI studies.

The severity of meniscal damage will dictate if conservative treatment or surgical management via arthroscopy will help. While MRI is a very useful test, Jordan Metzl, MD, a sports medicine physician at the Hospital for Special Surgery in New York City, says physicians should be cautious about false positives in runners who have been running for many years.

Case Studies: Treating Three Competitive Runners
Case one involves a 21-year-old female runner who presented to my office complaining of right proximal shin/knee pain. The patient was running many miles with high intensity. There was a history of trauma where the patient fell and hit her knee. She was having difficulty with running. Pain was present with impact and also with knee flexion and extension. The patient was experiencing a “catching” feeling when running.

The clinical examination revealed discomfort around the medial knee. The differential diagnosis was possible stress fracture, pes anserine bursitis, mensical injury and plicae syndrome. The MRI studies revealed a medial tibial stress fracture. There was no mensical damage but a medial plicae did show up on MRI studies.

Treatment consisted of rest with cross training and physical therapy. After receiving two failed cortisone injections from the patient’s sports orthopedic doctor to decrease symptomatic plicae, the patient underwent the surgical removal of symptomatic plicae and is now running pain-free.

The second case involves a 30-year-old elite female runner who presented to our office complaining of left foot and left knee pain. She was having difficulty training and it was limiting her performance.

Upon the clinical examination, it was clear the patient had a neutral foot type on her right side but a slightly overpronated left foot. She had patellofemoral syndrome on her left knee. I diagnosed limb length discrepancy as the patient’s left leg was structurally longer than her right leg. I subsequently performed video gait analysis.

I casted the patient for custom-molded running orthoses and incorporated a lift into the right orthosis. The patient won a medal at the 2000 Summer Olympic Games and also triumphed at the London and New York marathons.

The third case is a 31-year-old elite female runner who presented to my office with plantar fasciitis and medial knee pain. The clinical examination revealed an overpronated foot type, a weak VMO and weak gluteal muscles.

After performing a video gait analysis, we provided custom-molded orthoses and had the patient institute aggressive physical training consisting of VMO and gluteal strengthening. The patient is currently a very highly ranked runner and is able to train pain-free.

In Conclusion
Many runners will consult a sports podiatrist for their lower extremity injuries. It is very important to have an understanding of lower extremity biomechanics and the mechanisms behind running injuries. Our job as sports medicine specialists is injury prevention. The use of video gait analysis has proven to be extremely beneficial to our practice.

Elite runners from all over the world come to our office to have this valuable test performed. Surrounding yourself with other sports medicine specialists, such as orthopedists, physical therapists, massage therapists, chiropractors and nutritionists, is also very important in facilitating appropriate referrals and the best multidisciplinary care.

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