From: RusselPolk@aol.com[SMTP:RusselPolk@aol.com] Sent: Tuesday, March 04, 1997 2:56 AM Subject: Sub-Patellar Pain Docs, I have a female, 13 yoa, patient with sub-patellar pain. She is currently taking ballet, tap and jazz dancing, occasionally with 3 classes in the same day. She is having pain under the superior and lateral surfaces of her knees. No perceptible biomechanical problems in knees or hips. I am less versed in feet, but don't see anything there either. Any suggestions? I recognize that she may be overtraining, but she is getting ready for competition, etc. Any particular supports that might be utilized? Knee brace, supplements, etc? Thanks for the help. Russel ****************************** Date: Tue, 04 Mar 1997 09:20:11 -0800 From: "Mark Street, D.C." Subject: Re: Sub-Patellar Pain I have had many years of experience with dancers, Los Angeles Classical Ballet, Long Beach Ballet, Laguna Hills Ballet, Prix de Lausanne International Ballet Competition. Plus my sister is a professional ballet dancer. I would concentrate on quadriceps, specifically a weakness of vastus medialus. You state the pain is under the superior lateral pole of patella. This may indicate lateral tracking of the patella, you may want to concentrate on strength training bilaterally. This can be done by externally rotating the hip and doing quadriceps extensions, have the patient concentrate on contracting the vastus med.. I would start with a towel roll or pillow roll under the knee so there is just a slight bend in the knee and have pt contract into full extension and hold for 5 sec. I would start with 10 reps and increase 10 each week. Perform quadriceps stretches heel to glutes, in three motions hip internal rotation, neutral, and hip external rotation. Be careful with the knee with these stretches do not place undo stress on the knee with the stretch and hip rotation. There are braces you can get that apply medial or lateral pressure to the patella, but I would shy away from these as they do not address the problem. The problem may be overtraining, but it may also be improper technique on the part of the dancer. Go have a look at the way the teacher is teaching and have the teacher evaluate the student in front of you. Get a feel for the mechanics involved in the dancers workout. Most dancers over rotate the knee to get a better "turnout" or external rotation of the hip, knee, foot. Turnout should come from the hip/gluteal area. Most dancers who are not blessed with a good turnout will compensate by turning out the foot and knee, placing undo stress on the knee, and possible injury. Nutrition is whatever you want to make it. Vit. C, glucosamine sulfate, etc. I also recommend a homeopathic preparation called Traumeel, by BHI, active ingredient arnica among others. Of course I can't be sure of my recommendations above since I have not seen or examined the patient. ******************** From: Cates & Jensen Subject: RE: Sub-Patellar Pain Date: Tue, 4 Mar 1997 11:53:20 -0600 Dr. Polk, Just a few thoughs for your patient. ... Prior to any treatment, diagnosis of the source of pain is important ... be "real sure" you aren't dealing with a hip pathology ... (slipped cap fem epiphysis , etc) as hip pathologies often refer to the knee. (AP & frogleg are indicated if hip pathology is suspected) Additional dif dx associated with overtraining might include : -Synovial plicae syndrome, illiotibial band friction syndrome, Sinding - Larsen - Johnsson' syndrome. ( pain at inferior pole of patella) or Osgood - Schlatters (pain at the tibial tuberosity). Rene Cailliet has a great little book (one in a series) on "Knee Pain and Disability" it's easy to read and surprisingly thorough for such a little text. It is published by FA Davis Company. I hope the data is of help to both you and your patient. Best wishes - Jeffrey Cates, DC *************************** Date: Wed, 05 Mar 1997 06:19:32 -0800 From: Dr Warren T Jahn Subject: Re: Sub-Patellar Pain Most importantly please check the hip. Many times in this age group pain is referred to the knee by the hip. Warren T. Jahn, DC, MPS, FACO Roswell, GA ********************************* Date: Wed, 05 Mar 1997 14:49:21 -0600 From: "Noel A. Taylor" Subject: Re: Sub-Patellar Pain Something I neglected to mention in the differential diagnostic frenzy of my first response (GRIN) is that I've seen nearly all such problems resolve when the related sacroiliac joint dysfunction is corrected. --Noel ****************************** Date: Wed, 05 Mar 1997 06:26:35 -0800 From: Dr Warren T Jahn Subject: [Fwd: Re: Sub-Patellar Pain] To: RusselPolk@aol.com Subject: Re: Sub-Patellar Pain There are several things that need to be checked. 1. Has she had a recent growth spurt? When was the onset of menses? 2. What is the measured Q angle? Is it changed by repositioning the ankle mortise when weightbearing? In the acute symptom stage the use of a 13" knee immobilizer is helpful. Try to get her to wear it when she is not practicing her dancing. Since she is an adolescent she may not comply due to peer pressure. Compromise would be wearing it when arriving at home through leaving in the morning. At least have her wear it during sleeping hours. -- Warren T. Jahn, DC, MPS, FACO Roswell, GA *************************************