Dr. Gangemi: Hey this is Dr. Gangemi and welcome to the newest Sock Doc
video. Today I'm going to be talking about the knee and common complaints
and injuries, performance problems that people have with the knee. Who
better to help out today than G. A. Long mid-fielder for UNC Soccer. They
won the National Championship last year, ACC Championship and ACC Tourney.
G.A. Long: Sure.
Dr. Gangemi: Well done. The trifecta. Thanks for helping out. So, I've
talked a little bit about the knee in one of my past video is on
iliotibial band syndrome, ITBS which a lot of athletes have especially
runners which is pain on the outside of the knee. We're not going to go too
much into that, but I'm going to start there. We're going to work our way
around the knee and talk about common complaints and ailments that people
get which are much more common than the typical meniscus tears and
cartilage debridements that people need and knee clean ups and all these
things that might send someone off to surgeon. Not that those aren't
necessary, but a lot of people have knee problems and knee pain and they
think they've torn something or injured something that needs surgery and
often they don't.
We don't want to disregard that because obviously if you're checking
out your own knee or if you're trying to do some of these self therapies
make sure that you understand that if you're not getting better then you
can have a problem. Don't let it go too long and be smart about it. Real
quick. One point I want to make is on trigger points that I show a lot on
my videos. The reason I do that is because they're very effective, they're
easy to treat. Sometimes it's not easy to find on yourself and you might
need some assistance from another physician or therapist, but when you're
treating the trigger points it help realign the muscle . . . be aware that
a lot of times those trigger points are there from the local injury in the
muscle but they could also be there for another reason. From another injury
somewhere else that you had. From improper footwear from training too hard.
From some nervous system, health problem, nervous system imbalance or
something like that.
If you're always having to work on a trigger point make sure you
don't keep on doing it over and over again. Now, there's a new article up
on the Sock Doc site that explains that too. So, let's quickly get right to
the knee here. If you can stand up G.A. and turn a little bit this way.
That's perfect.
Real quick, on the lateral side of the knee here we talked about the
iliotibial band and it's insertion where people get a lot of pain. There's
iliotibial band syndrome here which is often from the tensor fascia latae, and turn this way
a little bit, the glute max. Those muscles coming together and creating the
iliotibial band and inserting on the lateral side of the knee here.
Remember almost always staying off the fascial connections and where
the injury is felt, but looking for trigger points in the muscle, in the
deep glute max here which extends all the way down well over half. Some say
as far as two-thirds through the femur, through the upper leg and even some
of the connective tissue is intertwined with the hamstrings as well as the
tensor fascia latae.
These come down and then make up your iliotibial band and cause a lot
of lateral knee pain, but what I'm going to add to today is the lower part
of the leg here which is the peroneus muscles and especially two muscles
here, the peroneus longus and the peroneus brevis. We're not going to talk
as much about the peroneus tertius, but the peroneus longus and the brevis
because they're actually just more commonly found than the tertius.
If you can put your knee up here, I'll show this. The peroeus longus
comes down the outside of the leg here and it's going to insert on really
the base of the toe, the first metatarsal and what's called your medial
cuneiform which is right around the arch of your foot. So, I want you to
look for a trigger point right around here coming right off the big toe
where a lot of it stops bending there. The flexibility of your toe. Look in
here for a trigger point is a tendon of that peroneus longus comes here and
the tendon of the peroneus brevis ends right here and also comes up. You
can sit back down.
The reason we're talking about these peroneus muscles which are also
called the fibularis muscles is because those peroneus muscles are very
much associated with proper supination which is how you walk, how you run
and they help with pronation, balance of pronation- supination with your
gait to absorb shock. If you're not absorbing shock properly from proper
gait mechanics then you end up absorbing shock in your knee and that's what
we're talking about. Knee problems. That can also transverse up to the hip.
If you want to be a specialist of an area and really understand the
area you got to look beyond it too. With the knee in this example we're
going to look towards the foot, we're going to look towards the hip and as
I've discussed in videos and other articles you also are going to look at
gain imbalances. In this case, knee problems can sometimes come from an
opposite shoulder problem, if he had an old injury or an elbow problem even
and his gait mechanics are off. Going back to the peroneus real quick, here
these muscles originate on the upper part of the fibula which is that
little bone sticking on the outside of your leg here and then come right
down. As we showed when he turned over and the peroneus longus wraps underneath the
foot and inserts at the base of the big toe. Okay? So, you might find some
trigger points up here in the belly of those peroneus muscles and then
underneath the fifth ray right here which you can see that nice anatomical
landmark on his toe, on his foot as well as underneath that big toe. So,
look for those and it might help your knee pain out a lot. All right.
Coming up to the top of the knee more flexion-extension which is
as you know - that way. Right? Like you're kicking. Like kicking a soccer
ball, a short kick. A lot of people think quad problems although you can
definitely have quad problems clearly or patella tendon problems when you
have a knee issue and they're not uncommon. More often than not you're
going to see anterior front of knee pain or even top of knee pain be more
associated with glute max problems which are obviously related to iliotibial
band problems and lateral stability of the knee which we started with and
talked about in the ITB video.
If you're having problems when you're squatting, sitting, getting up,
standing that sort of thing, basically this motion and you have knee
pain. Climbing stairs. Think more the glute max. Think more of that big
powerful muscle on the back side of your body more so than your actual
quads, however, the quads can be important especially in a flexion
extension type movement then you should look for points in here. One little
muscle I want to talk about because most people don't talk about it too
much is the little muscle in here called your articularis genu.
It sits right on top of the femur. You wanna stand up there G.A.
right quick. It's about right there. Come about an inch up from your
patella. Right about in there. It's going to be deep in there. It sits
right on top of your femur deep underneath your vastus intermedius
which is your quad muscle. It helps the friction of your bursa slide easily
which is one of your little fat pads. You got to go deep in there and look
for that trigger point. It's probably a tender area anyway. It is in most
people, but a lot of people can have a tender kneecap, interior knee pain.
Their patella tendon not tracking properly because that articularis genu is
injured or inflamed.
You go deep in there and hold that trigger point kind of like that
with both thumbs like you're grabbing your leg. Okay? Have a seat. Let's
move to the inside of the knee. We're going to go right to which is a very
common problem. People get pain on the inside of their knee. Even though it
might be on the inside of their knee where their meniscus is here, but
there's three important muscles that stabilize and support the inside of
your knee. They all come together and it's called the pes anserine area. It
stands for a goose's foot.
So, you've got three muscles coming in here. One is called the
sartorius. It starts from the front of the hip, comes over your quad and
inserts right into that inside of your tibia, your lower right bone and
does in this motion. Okay? Then you've got your groin muscle coming from
way up in your groin, the inside of your inner thigh. It also inserts into
there. That's the second one.
Then the third muscle's one of your hamstring muscles that starts on
your sit bone and also inserts into there and comes around and wraps
underneath and inserts to the inside of your knee. Those three muscles are
powerful and really the main stabilizers of the inside of your knee. Why do
people think they might have a meniscus tear or a medial collateral
ligament problem? In reality, they have pes anserine problem, an insertion
of one of the three muscles, the sartorius, the gracilis, semitendinosus
hamstring muscle.
You can look for trigger points right in the insertion there and see
if there's any problem with those or you can trace the muscle up. He had a
knee problem actually the other day from . . . you got kneed in your quad,
right?
G.A. Long: That's right.
Dr. Gangemi: Okay. So, he had a knee problem and his gracilis wasn't
functioning properly, but the way I corrected that or one of the muscles
that I had to correct was actually that gracilis muscle. I had to go way up
in the groin. Check this on yourself or obviously if you're checking it on
somebody else make sure they know where you're going because you've got to
get way up in the groin right where that inserts in the pubic bone. It's in
an uncomfortable area anyway. It's always tender, but it's especially more
tender if it's an active trigger point. Feel around in there. If you feel
any deep nodules especially if it's referring pain down the adductor
and especially obviously if it relieves the pain in the medial part of the
knee, you know you're on the right spot.
The sartorius could be anywhere over since it's actually termed the
tailor's muscle because people will tailor a pair of pants over their leg
like that. It comes over like this and it wraps on the inside of the knee.
Longest muscle in your body actually. So, you can look for a trigger point
anywhere along that sartorius. Honestly, I don't think I have found maybe
more than one or two of them. Very uncommon to have a trigger point in the
sartorius. Usually it might be up on the front of the hip bone which you
can feel right. It's the bone sticking out of the front of your hip or on
the insertion there or the gracilis could be anywhere on the inside of the
leg.
Semi-tendonosis. We're going to go to the back side of the knee here.
Talk about the hamstrings. So, if you can flip around. Let's show them the
movement that we showed earlier. Let's talk about this real quick. A lot of
people think that they have hamstring problems when in reality more often
they have gastroc or soleus problems. What I'm saying is more people have
calf problems or even glute max problems than they do hamstring problems.
Significantly more. The hamstrings might be tight, but it's because of an
imbalance between them and the calf muscles especially the gastroc which is
the more meatier part of your calf rather than the soleus.
If he's in this motion here, this range. That's lower part of the
soleus. When he comes up about midway here with his foot still pointed
that's more hamstring. Right about when you break 90 degrees here, parallel
to the ground and he flexes his foot and comes all the way up, that's more
gastroc. So do a couple kicks. You can do them each way. If you're feeling
pain like that that's probably going to be your calf. Now point and kick
the same way. If you feel pain like that it's probably going to be your
hamstring. Now bring it all the way down and now kick a little bit. If you
feel pain like that more like a swimming type of flutter kick probably your
soleus achilles type issues like I talk about in the achilles tendonitis
video. Good and then turn this way.
So, hamstring and calf muscles. Back of the knee now where we're
talking about. You do have a muscle called your popliteus muscle which
helps with unlocking of the knee. It's actually big when someone's kicking
a soccer ball and it helps to stabilize internal rotation of your lower
leg, but even though that muscle can be an issue back there and people get
what's called a Baker's Cyst and inflammation of the bursa back here. More
times than not the gastrocs are involved, the calf muscle.
As these fibers come up and cross over the back of the knee crease
here and originate at the top where the hamstring muscles come down and
insert on the bottom. So, you have the calves coming up and the hamstrings
going down and obviously they cross over. A lot of times if the pain appear
it's going to be more of a gastroc problem even though someone perceives it
to be a hamstring problem. Really, the pain down here could be a hamstring
problem, but more often than not it's a gastroc problem. Calves are much
more involved than hamstrings even if you're feeling the hamstring pain.
Now, remember that semitendinosus that I talked about comes down,
starts on the sit bone right there and then comes and wraps down and
inserts to the inside of that lower leg. Let's turn a little bit there to
that pes anserine area along with the sartorius and gracilis. That's where
you can have some medial pain. So, don't forget or don't neglect the fact
that you could have inside of the medial knee pain coming from the
hamstrings back here. Okay?
Another one of your hamstrings goes on that side too. Called your
semimembranosus and then your biceps femoris comes down here on the
back side of your leg and inserts to the back of your fibula. A hamstring
problem here could effect your fibula bone and also cause those peroneus
muscles to be a problem and then effect your supination and go down and
effect that peroneus longus insertion here or wrapping around the bottom
across your arch or your peroneus brevis muscle. So, that's how the foot is
connected to the knee up to the groin from those pes anserine insertion
muscles to your hip. A hip problem can cause a foot problem and vice versa.
They can all be related to one another. Have a seat.They're all going to
influence one another to various degrees.
Remember, if you keep on having to work a trigger point, it's keeps on
coming back or if you're not getting any relief you could be in the wrong
spot. You could just not be addressing where the trigger point's coming
from. It might be a different muscle in a completely different area of the
body. I've had to fix trigger points in his neck from playing soccer that
have correct his . . . where? Everywhere. Right?
G.A. Long: Yeah.
Dr. Gangemi: Your foot? Your knee?
G.A. Long: Groin.
Dr. Gangemi: Yeah, his groin. They're all related somehow or another.
It's hard to sometimes figure these things out on yourself and knee
problems are highly related to over training, poor diet, adrenal gland type
symptoms as I've discussed before. Too much stress. Students have that.
He's playing hard, class schedule, not the best diet in school sometimes.
G.A. Long: Right.
Dr. Gangemi: So, a lot of stress. Athletes tend to get a lot of knee
problems because of the relationship of these muscles especially the
internal ones, the inside ones. The medial insertions of those muscles on
the pes anserine muscles. Those relationships to your adrenal glands as
well as the calf muscles related to your adrenal glands and back of the
knee pain and that should cover it. Thanks for listening. Thanks for
coming.
G.A. Long: Yeah. No problem.