Practitioners: Be a Detective!

Be a Detective

“Yes, the body can change dramatically. In one session.”

Your client Melissa has been back 3 times, with little change in her knee pain. She has pain in just one knee, primarily on the lateral aspect of the meeting place of the femur and tibia – the knee joint. You’ve done everything you can think of to alleviate the pain.

Last week you noticed the knee in question appeared to be quite a bit larger than the other knee. You asked your client and she said that it has been swollen that way for over a year. This interested you, so you continued the questioning. “When does your knee hurt the most?”

She answered very concisely: “after walking the mall for several hours. I try to get out shopping at least once a week if not twice. I walk the grocery store or in and out of stores in the mall. I used to walk the length of the mall from one end to the other but now it hurts too much by the time I get to the end. You know, it’s all concrete! I can’t get back to my car. So now I just drive from one end to the other. “

This should tell you quite a bit. Her knee doesn’t ache at night or while she sits, or when she bends it. She told you all this by way of not mentioning any of that. It hurts when she uses it on a hard surface. Probe a little further about this pain.

“Does it hurt at home?”

“No. We have carpeting at home, so I never hear from it except when I’ve been standing in the kitchen for hours on end” She replies.

So now you know the knee is sensitive to pressure and hard surfaces. Pressure because standing will activate it.

knee anatomyWhy would a knee respond to walking on hard surfaces? Think about it carefully. Knee joints are made to work hard. They have few actual parts (unlike the shoulder joint), are designed to be very stable when walking, assuming that there are no injuries such as to the meniscus or any of the ligaments. So why would Melissa continue having knee pain?

It’s time to ask Melissa to stand up for observation. Have her roll her pant legs up (or if she doesn’t mind, stand in her underwear or a pair of shorts) so that you can see her knees and legs. Have her stand there for several minutes, relaxed, with arms hanging loosely at her sides and her feet placed comfortably. As she stands, her body will slowly relax into her usual patterns, allowing you to see what is going on.

At this point, you can identify the alignment issues that most often cause joint pain. Having your client in front of you where you can see them from every angle, is incredibly important. We will delve deeply into the outcomes of postural alignment and mis-alignment in this blog. But for now, let’s return to our detective work.

varus knees mild

Direct your eyes to her kneecaps. Do they both face forward? Completely forward? Or do they turn out to the sides (lateral rotation)? Do they tend to point at each other (medial rotation)? Is one more medially rotated than the other or more laterally rotated?

Are her knees directly over her ankles or are the ankles closer together than her knees? Further apart? Do her feet turn out? Turn in?

If she puts her feet next to each other, do her knees touch before her feet can touch? Is there a long space between her legs including at the knees? If she has a space between her legs that includes space between the knees, she has varus legs. The other configuration – her knees come together before her feet – would be valgus knees.

Each of these forms of hip and leg alignment have a direct impact on how Melissa’s knees are functioning, especially over a period of time. When the bones that comprise the knee joint are not aligned as they were originally designed, the joint will report back with painful symptoms, sometimes with permanent damage to the joint. Your mission, if you should choose it, is to spot the misalignment and begin facilitating change into the body, that will result in alleviating her knee pain.

There are many kinds of knee pain and many reasons for them. In this article we are going to focus on varus knees, with the intention of learning how to facilitate change in the alignment of the leg and hip, hopefully eliminating the pain.

The knee is comprised of the condyles of the femur, the condyles of the tibia, two oval shaped cartilaginous menisci, two internal ligaments (anterior and posterior cruciate ligaments) , two external collateral ligaments – medial and lateral and the patella or knee cap. Various other ligaments hold the knee together but for our purposes here, we have our parts list. The only moving parts are the bones. If the bones are misaligned in any way, they can create havoc where they meet.

varus knee xrayVarus knees are commonly called bowed or bandy legs. They occur when the muscles of the medial upper leg (adductors) are too tight. If you think of an archer’s bow, the bone and outer leg comprise the bow itself. The adductors, medial fascial compartment, medial collateral ligaments and inside line of the lower leg comprise the bowstring. If you tighten the bowstring, the bow becomes more curved, forcing the knees laterally, away from each other. The tighter the bowstring, the more tension on the bow – and the more compression on the inside aspect of the knee where the bones are being compressed together, and the more tension on the lateral collateral ligament.

Consider the vectors applying pressure on the knee joint in the case of varus knee stress. The lateral side of the knee joint is being pulled apart while the medial aspect of the joint is being compressed. Over years of varus mis-alignment, the medial aspect of the knee joint can become very painful, especially with prolonged exposure to walking on hard surfaces. In many cases the lateral aspect will become painful too as the ligaments and fascial components of the lateral knee have been overstretched for years, yet still required to function properly.

In some cases, by the time your client has chosen to receive care for their painful knees, they have damaged the cartilage on the surface of the joint, causing a portion of the cartilage between those pressure points on the bones to wear away. The result is bone against bone during movement. This can be excruciatingly painful. Frequently people suffering from this condition are given knee replacement surgery as an only option for managing their pain. In truth, this is far from the only option. In most cases, with biomechanical intervention using bodywork and corrective exercises, this condition can be symptomatically if not completely reversed.

In other cases of varus stress, the lateral collateral ligament can be stretched to the point of extreme pain. This is also generally correctable via bodywork and corrective exercises. Occasionally the lateral collateral ligament can become severely damaged from varus stress and must be surgically repaired.

The LCL is usually injured as a result of varus force across the knee, which is a force pushing the knee from the medial (inner) side of the joint, causing stress on the outside. An example of this would be a direct blow to the inside of the knee. The LCL can also be injured by a noncontact injury, such as a hyperextension stress, again causing varus force across the knee. (Ho, MD, Sherwin SW. “Lateral Collateral Knee Ligament Injury”.)

Working with varus knees requires lengthening of the medial line of the leg, (for descriptions of the Anatomical Lines of the body, refer the Tom Meyers’ Anatomy Trains), addressing the attachments of the adductors and fascial planes at the pelvis, lengthening the psoas and deep core, ensuring that the bones of the pelvis are balanced with each other, easing the lumbar curvature, attending to any torsion that might be present in the lower legs, assisting the feet in aligning with the ankles and raising the arches of each foot. No easy task!

And yet, once all of these structures begin to work with, instead of against each other, the legs lengthen and align, creating longer gait, fluid movement  in hips and back, comfort in the knees, hips and ankles and resilient, responsive feet.

Yes, the body can change dramatically. In only one session. Imagine what many sessions can do. Imagine how your clients will feel about your work when they can feel, see and use such dramatic change. Imagine how you will feel about your work when you enjoy the pleasure of facilitating such change.
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Lauren Bailey, ©2014