Case Study: Treating Chronic Pain In A Middle-Aged Distance Runner

Bruce Williams, DPM

This author discusses the treatment of a 53-year-old runner who presents with a range of podiatric problems as well as right knee pain and chronic low back pain.

   Knee pain and knee injuries in the general population are among the most common musculoskeletal presentations to physicians’ offices each year. About 50 percent of those who regularly exercise will deal with some form of knee pain each year as well.1 Furthermore, as the United States population continues to age, knee arthroscopy and unilateral knee replacements will continue to become more commonplace. Research is beginning to confirm gait and unilateral force aberrations in patients following knee surgery.2-4

   Due to these factors, it is likely that more and more of these patients will seek some sort of non-operative treatment for knee and foot pain, which may spontaneously occur after knee surgery.

   Physical therapy is of great benefit to the pre- and post-surgical patient population. Often when therapy has run its course, patients will continue to suffer. This case study will focus on the use of video and in-shoe pressure gait analysis, along with custom foot orthosis therapy, to assist a middle-aged patient who wished to return to running and regular exercise.

   A 53-year-old Caucasian male presents complaining of right knee pain and chronic low back pain. The patient states that he had an anterior cruciate ligament repair 13 years ago on his right knee. Prior to his chronic knee pain, he was an active runner. The patient is a schoolteacher and is on his feet a lot during the day. He experiences back pain with physical labor so he really decreases the amount of labor he performs. Any increases in walking and running bother him as well so he now uses an elliptical trainer for exercise.

   The patient also complains of some chronic flexion of his right knee. He had seen his orthopedic surgeon recently and received some exercises for his back and to stretch out his knee. Unfortunately, they had no significant benefit. Coincidentally, the patient's son is a runner and was very pleased with the elimination of his knee pain after receiving custom foot orthotics from our office.

Examining The Patient And Making An Assessment

The patient denies any pertinent medical history in the past or present. The musculoskeletal exam reveals that he has an obvious knee flexion on the right with significant knee varus when he walks. He also has a slight early heel lift on the right with maximal pronation at the rearfoot with this early heel lift. The patient exhibits signs of functional hallux limitus and hypermobility, or decreased dorsiflexion stiffness, in the first ray. There is 0 to 5 degrees of dorsiflexion range of motion in both ankle(s). There is no apparent limb length difference on stance even though he has a knee flexion on the right side. This tells me he is probably short 1/8 inch on the left side. The patient does have some quadriceps weakness on the right side. This usually occurs in patients with chronic knee flexion.

   The patient has chronic right knee flexion and genu varum. He also has bilateral functional hallux limitus, bilateral hypermobility of the first ray and bilateral ankle joint equinus. While the patient has no apparent limb length difference, he does have a gait abnormality. The patient also suffers chronic low back pain.

   I explained that the chronic knee flexion is going to cause a problem for him with more pronation in that right foot. His gait is definitely off and this is likely the cause of the chronic low back pain. I suggested that we tape and accommodate him. I gave him information regarding custom orthotics and gait analysis. The patient did well with the taping and on the second visit to the office, we cast him for temporary orthoses and set up a date for his in-office gait analysis.


I often make orthotics for patients with knee pain.

I explain to them the closed kinetic chain such that pronation causes abnormal forces at the knee and more proximal joints. I explain the compensation of the proximal joint biomechanics due to foot pain and problems. I also explain the cushioning effect to reduce forces at the proximal joints.

I am often surprised how well patients with knee pain do with orthotics. My results truly exceed my expectations. With that said, I usually set their expectations low. I tell them that orthotics are only one part of the multispecialty treatment for knee pain. I describe how their medical treatment along with physical therapy and orthotics all work together.

Most of these patients are referred to me from orthopedic surgeons and physical therapists. I make an effort to reach out to orthopedists and PTs in my neighborhood to tell them how orthotics can help their patients. I offered them a free pair for themselves and their staff to try them out.

This turned out to be excellent marketing.

I hope this helps you as well.

Lawrence Silverberg, DPM

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