here we go so you guys all have sheets on your desk what I want you to do first you're just going to do individually so take five five minutes that's not the differential thing we did the quiz i was like whoa this is wrong i'm I'm a mess today no we're good we did the quiz we're going to do differential diagnosis practice similar to two weeks ago and then we're going to talk about one more topic in the knee so this will be a little lecture part about PFPS and then we'll finish up with our choose your own adventure eval again so here we go differential diagnosis so there's three you guys can go through all of them and then we'll talk about them all together so first take like five minutes or so to just do it on your own and then let's go into a group so at like 9 8:45 or so a little after 8:45 we'll go into a group so just again the big differentials here so don't say uh knee pain that's not going to you know be very helpful in this situation um they'll say this is probably going to happen to an athlete like all those things are you know pretty straightforward but what's really going to differentiate and set these two things apart to make it unique because the reason why I picked all these issues is because for you know to a certain degree they're going to be harder things to differentiate because they're either close in location close in MOI close in somehow way shape or form to where a lot of times when you're doing an eval if it's not super clear maybe you have it down to like these two things or these two things or these two things that's going to be pretty common at times so then it's like cool how are we going to actually set those two things apart so just going through that process mentally um so four or five things for each injury that like really makes it unique cool so go ahead and go through there take five minutes and then we'll talk about it in our groups this is for points two differential diagnosis so we'll do individual first just writing down what makes them unique all three yeah all of them yep like the whole slack that's fair with these guys you can put some subjective info on there but I just want you to focus on the objective for just for the sake of this didn't have like Okay let's start this thing off huh so let's start at the top of the list mcl miniscus um let's switch papers so send it to another group make sure you just don't have your own that's the only thing and then when you're looking at the other group of paper just like circle if they have what we're talking about on there circle it they have an extra thing that's not minus points and then we'll just tally up the circles at the end i don't have a key to this so we're just going to do it as we go for what is our non-negotiables we have to have it on here vgus at Thank you sir why is that important here because zero is nothing zero is actually more yeah so if you didn't put at 30 then sir no you sure want you to remember this moment when you say I didn't get no points and then the next value set you do you think did I do it at zero or 30 because there's a difference there's a big difference so if you put zero for meniscus I'll give it to you at zero because that wouldn't theoretically you know there's better meniscus test but that would be more applicable for meniscus than for MCL so we'll just put it here but you don't have to have that there obviously it's not the main one but back back to MCL is there really any other major special tests that we would use for MCL stress test yeah at 30 specifically any other major special tests no that's the main one right so that's why we have to do that one really well because we're going to rely on it yeah for meniscus would it not be because you're compressing it like okay I see what you're saying you would potentially have pain with either but this is not really like that gold standard for miniscus at all I just put on there for the sake of conversation but you could yeah if you're doing various and you feel medial side pain that MOI then you're thinking okay cool but you should still do your meniscus tests like normal it's just like a nice piece of code u before we go to meniscus what else here since we only really have one special test this is not your eval so what else are we looking for here yep so we went over that last week so you should be able to palpate that precisely yeah top and bottom yeah yeah so any of the Yeah insertion or insertion or or origin of the ligament and the body itself that's good what else for MCL just think about like basic Yes like at the time of injury or after yeah yeah you could have a pop or a snap at the time of injury how about a feeling of instability like that could just be a reported you know I feel unstable apprehensive right so we'll put pop or apprehension that would be two different ones really um how about swelling we talked about swelling last week the extra articular ligaments like MCL meniscus are they going to swell faster or slower than the deeper ones like ACL PCL faster okay whereas ACL is going to be a little bit slower um so that could be something here so swelling um that's maybe not going to be as different from miniscus actually so we don't need to go down that road but still good to consider um what else just think with me flexion extension you're not going to use that to diagnose this but you're going to do it in your eval so that's where in my mind I'm like okay if you're going to do this stuff and it's not going to lead you to the answer but it could like you said I'm like very there's always like a little piece of information that you can get along the way so if you put a person with let's say like a grade two MCL sprain in full flexion would that feel good why why would that maybe not feel good you're stretched yeah it's not like a stretch it's not the same but you are putting it on more stretch what's more stretch in full flexion or full extension well really both of them you're going to have some toughness um question actually anatomy people what is that question more tautness in the MCL with full extension or full flexion i think it's extension extension yeah cool there you go so just consider that with ACL definitely with extension right because it's getting really hot there um but I think that's just a super helpful thing like just with liments in general when you're in when you're standing extension Yeah so you don't have to write this but just think about it right more pain on the medial like on the MCL with extension and flexion just those are just like little things as you go through your Ebound especially if you're thinking right from the get-go this seems like a pretty obvious MCL or happy triad it's good to know just stash that in the back of your mind because a meniscus would that necessarily be pain with extension so if it's an anterior miniscal tear then yeah for sure what if it's a posterior miniscal tear probably pain with flexion yeah which then would be very different than this so those do those things it's not like the gold stand it's not the criteria that you're going to put all of your your brain power on but those little things do help along the way and so that's where it's like don't be surprised by this stuff like oh just think okay well in the knee of the m happy triad i know ACL MCL they get a little bit more taut with extension depending on where the meniscus tear is that could actually get more compressed with flexion so if they have more pain flexion than extension then you're thinking maybe actually maybe more meniscus whispers just little things you still do the rest of your eval but that kind of helps funnel along the way rather than otherwise we're just taking range of motion just to take it which is then why I feel like some people stop taking range of motion but then you're losing little clues that you could have otherwise um MMTs that's not going to help you diagnose this at all right because it's not a muscle injury but would we assume if it's non Contact though what would we assume would be pretty weak for either of these same quads groin body okay so it will I guess like isometrically like through like a pez answering kind of like control that like a little hammock but which hip muscle is going to control dynamic valus the most what do you see everybody doing with those bands like after clamshells bandwalk side steps i know that's more like their we'll get there but man oh man it's glute day every day right and like most like lower body rehab so just remember that's why eccentrically those abductors external rotators butt that's going to control the adduction aduction and internal rotation of non-cont bgus right if it's contactus injury that's just uh sorry not t but if it's non-cont and there's you know dynamic vgus happening then a lot of times that poster lateral hip muscle so your glute actually wouldn't need glutman too but that one doesn't get as much so again not going to differentiate here but just good to know you would probably expect maybe that side to be a little bit weaker and if you did let's say a single leg squat assessment with this person would you expect to see some VGUS probably right especially if you did like a hop test or something like that what if this was before the Let's say you do that test day before the injury just for fun and you're just doing like let's just see how you look would you expect to see some VGUS if they're doing a non-cont VGUS the next day like injury with it probably most likely um cool anything that we're missing on MCL i don't think so all right let's go to miniscus what's our biggies here gotta do it yes we do joint line that was one of our five criteria from the uh the cluster last week and then do you guys remember what were the other ones um you joint line McMurray thank you i'm just gonna put T and M apples you could do duckw walk sure duckw walk especially for anterior posterior tears posterior yeah because you're putting all your weight on posterior aspect nice there we go that was one of the criteria in the cluster well that's one point total so yeah joint line tenderness McMurray's catching locking inability to fully extend okay so lacking TKE so terminal knee extension pain yeah you would definitely have pain with bearing here um yeah okay anything else that we're missing say that's pretty good so if this person has all of those things they have a what absolutely could they have both that that's why we have to check right because most non-cont valgus injuries you're going to be checking both of these like there's I don't know why you wouldn't check both right if you have a non-cont valgus your differentials automatically as MCL medial meniscus maybe even lateral meniscus right and lateral meniscus is actually more likely than medial meniscus in our younger athletes so the unhappy triad is actually less common than the atypical triad if you think about it that way you know what I mean so that's kind of funny u okay moving on count up your circles for that one add them up so we don't have to do as much after the end and then we're going to talk about PFPS so patellophoral pain syndrome versus it band syndrome so for PFPS what are the big things that's going to make that unique what do we have oh grind test yeah grind test anterior knee pain yes because this would be more This wouldn't be as anterior knee pain potentially be more what lateral typically yep and IT band could be hip or knee right so that's another big too if you have pain in the hip then guess what it's not patella from pain syndrome so I would even say if you have hip pain this then there you go that's a good differentiator for sure otherwise lateral knee would be a good place to start versus this would be anterior or anterior lateral knee and then we have grime test aka Clark's test right same thing uh any other special tests for PFPS that's the main one is there anything else grind grind test yeah we got that appreh oh to like pull it out okay sure because I guess like a subcategory of this would be like teller sublexations or instability so you can say apprehension and usually which direction would they be apprehensive of like laterally i've never seen any other direction thank you bless you superior inferior is that really a word because it should be moving superior inferior anyways right so it's really just medial lateral usually okay what else overus yeah they're both going to be overused unless it's an acute subluxation pain with prolong sitting pain with prolonged sitting for which one yep absolutely sitting um how about noises right we talked about like catching and locking with the miniscus could you have that here because it's a cartilage rubbing right if you have maltracking or something that's the cartilagynous surfaces so you could potentially have some grinding or some crepitus here which is different crepitus and grinding is different than the snapping that you would potentially have at the IT band right so one's a lot more like a guitar string getting plucked and the other one's just a lot more like sandpaper right so that's where again subjective questioning gets really important if they just say like "Oh yeah it kind of feels weird in there." You got to dig because these two injuries are closely related and they're close together vgus is going to contribute to these as well so you got to like get a little bit deeper so this one if you said snapping that'll do this one if you say grinding or any sort of like crepitus terms that's also good usually not going to walk we can't bucket handle tear that um what else anything how about special test for I yeah absolutely no what's the other one over yeah do you guys know the specificity sensitivity on those just generally is it good bad which one's the best which one's the worst over is not great is not reliable gren is the standing it's basically the same as Nobles but this is standing and this is non Rene's I trust me I tried to find the stats on these they basically don't exist so not to be totally trusted so I would just do all three because if we don't really know how good are these tests and you don't want to just do one and take those results as gold right so I would do all three especially because this one should tell you about their flexibility which is nice whereas these just tell you pain um but Rene's is the most functional of them so that kind of helps cool so those are the three there sweet anything else that we're missing what about board tracking for BFPS yes how would you what would you see in your eval yeah so you can see the J J sign or Jstro basically J sign or you can say like a lateral if you literally see it going shifting laterally that that would work too anything else that would be that one [Music] oh I'm just trying to make sure on the lateral patella usually it's usually retro patellar so they can't locate behind or it's perellar so lateral surface so minimal really would you because this would be they would both work with flexion right this one it's compressive and flexion and then if you were to resist extension again you're compressing a joint Whereas this one you're getting that snap every time you cross that 30° plane so if you go past that deflection pass that into extension you could potentially get that little slide um so you could write that but it's not going to tell you as much it's not going to differentiate how about I tend palpation yeah that would work yeah so tender palpation here we didn't talk about that so Gertiey's tubrical why is that important insertion insert yeah distal insertion so that whole IT band comes down to that one little point where else would be pretty tender to palpate at at the Yeah greater choke potentially about at the knee not just gerties but where does it actually snap over lateral condile so that one should be pretty tender not just the IT band but also the epicondile right there too thomas yeah I like it like with the abduction and thumbs sure that would make sense so that reported tightness yeah that's what pull it out we'll just say TFL test sure sweet okay last one tenopathy versus stress fracture so location of pain that's going to be one of the biggest things here right they're both going to be usually chronic location of pain with patellar tendonopathy is gonna be on the patellar tendon the stress factor is going to be on the bone itself right so that's a biggie um yes so specifically then then you're kind of getting into another injury right if you're more tender actually on the tibial tuberosity then we're talking about oscular slot which is very closely related one can usually just progress into the next usually if your tenonopathies serious enough and long enough then it's just going to keep pulling on the bone they go through those growth spurts and then they're going to have aitis on the bone so that's how it would happen on the inferior pole you'd have um osgood slaughters if you guys have ever had that before it sucks and then if it happen on the superior aspect of the patella tendon so on the patella what would we call that popitis of the inferior patella jump jumpers need to um but sending lar so that's different that's not that's like literal apopitis so that is like the bone you know inflammation and pain of the bony insertion point so it's just good things to look if you're this is a pretty easy eval like oh I have anterior knee pain I jump a lot it's the preseason it's right here I have weak quads okay great you have to tenopathy so you might as well palpate these two points to make sure it has like where are we at in the spectrum has it progressed to the point where your bony insertion points their their hypothesis is inflamed or are we just dealing with a tenopathy injury you know and then if it's just tenopathy is tenosinivitis tenonitis tendinosis cool we'll talk about that a little bit more next week about details to differentiate the spectrum of tenopathies because we'll talk about hamstrings a lot so we'll save that um but any special tests for this that we could do say it ellie ellies oh yeah yeah sorry i always call it El it's funny so it's like a prone um quad flexibility right yeah so that would probably be tight so same with Thomas test you're assuming the quad would be tight so it doesn't tell you it's patellar tenonopathy but it's good information that you would find along the way that might not be the case here right so in Thomas cool um probably chronic yeah almost always but so is this so yeah anything that we're missing for tenopathy yeah weak weakness but that would be the same here how about stress fracture Night pain there we go night pain how about tuning for tap test sure stress fracture probably not but if it's an acute fracture it's definitely um if would this be a case for the auto knee rules maybe because they're tender over it but that is mostly pertaining to acute or chronic injuries acute injuries yep yep same with auto ankle rolls too so if it's if it's been going on a long time then that's probably not the time to apply that still get palpate the bones check them out see where they're at um other thing with this let's say they just came to you first time they this pain's been going on for like a week now patellar tenopathy has progressed into this patellar pain say "Okay go get an X-ray." X-ray comes back clean are you stressed spent one week of this patellar pain why not they have pain on the bone you're thinking stress fracture they have night pain tuning fork there we go how long does that usually take to show up in the X-ray yeah at least two to three weeks but maybe four to six because what what do you see in the X-ray stress factor is too small it's a hairline so unless you have a CT scan or something of higher visibility it's going to be invisible but what you'll see is the healing of it so you'll see the bony callus and like the scaffolding of the body rebuilding over it and so you're not going to see it when it just forms you're going to see the healing a couple weeks down the road so you can send them for an X-ray to rule out you know a bigger fracture but just know if it sees if they see nothing that that this is not over you should send them back in a week or two to get another one because you're actually more likely to see something if it's been a couple weeks already you know what I mean yeah swelling or deformity deformity probably not with a chronic one if it's an acute fracture then probably because that patellar has a tendency to just shatter into pieces especially when people like fall on their knee i got treated a snowboarder once that landed funny on a jump he landed on his knees and there was a rock underneath the snow and so he it shattered into three or four pieces it was like a jigsaw puzzle and the surgeon said like literally in the surgery they were like like a puzzle where does this one like how are these like trying to like Yeah yeah man oh man that was a fun one that was a fun one cool so add up those scores circle up everything add them all up once you have that we're going to move on uh and we'll just shout out the scores i'll add them up here and then we'll move on to PFPS and then because we started late we're not gonna have enough time for the choose your own adventure but that's okay we'll get to that either next week or another time or you can do it for homework that's fine too okay probably not awesome you put those up there i was like there's not enough all right who Who's got their scores ready to go out for me 18 for four right all right 18 anybody else 16 16 nice nice yeah come on [Music] America can you read this for me america that was so funny i died i rolled i rolled e also is lol like the most pointless thing do you ever not laugh out loud but then you're not laughing they don't laugh i was not laughing sometimes I can't get satisfaction that should be the same though laughing not out loud should be the real saying that's like not if you're laughing that's obviously out loud what do we got over here 20 20 for Captain America black Widow we got a score and what do we got 18 18 all right not too shabby okay moving on so we talked about ACL and miniscus last week and we are on to PFPS so this is our last leg deep dive for the knee and then next week we're going to go into hip and thigh which there's some crossover because it band hamstring like most of the muscles that cross over the knee also originate or cross over the hip too so there's still a lot in common uh but we're going to talk about runners knee aka pfps so Jason we talked about that already this is going to be a pretty common thing that you can see as we go into extension if it's laterally maltracking you know it's going through the grooves here but once it gets into more terminal knee extension it's going to be up superior to the grooves the tlear groove and because it's not sitting in here anymore it can then start to drift laterally as it exits that channel and there's nothing you know holding it in place so there should be less pain up here as well right so in those terminal knee extension ranges when you're doing rehab with somebody with PFPS this is a safe range to work it to do because a lot of times you can't really work out your quad if you have PFPS because it hurts but if you do things in TKE ranges you're good because this is not in the groove and therefore those irritated surfaces aren't pressing together so you either want to be in full extension or near full extension or you want to be um past like 60 degrees 60 90 flexion because like basically 30 to 90 of flexion is where you're in the groove the most so this is something you might see that J sign if you do see it you'll definitely recognize it you like who it's like literally I can see it basically malttracking so what you guys can do put your hand on your kneecap and just in your chair just straighten out your knee and just see how yours feels some of you guys might actually have a little bit of that but it should just go pretty much straight superior inferior hello early onset arthritis good morning anybody shift laterally or is everybody pretty much a linear line a linear line you know what I mean you know what I mean does anybody shoot out or medial that's kind of cool that's good if you're staying in a straight line that's a good thing uh but just check this is one of the easiest things this will fit into your observation in your eval your your inspection right so don't forget this is something that's going to help you a lot uh but a little background on PFPS before we get into it so what is it calmoral pain syndrome but that's kind of a broad term it just means you have pain at this joint so it's almost like saying like elbow pain syndrome like okay great like tell me more please uh but it's broad for a reason and it's because there's really like two main like subcategories more or less of PFPS so yes there's pain in the joint but it can be due to two different reasons um how you present with it normally your athletes they're sometimes they're not going to be able to point to their pain because their pain is here it's in between the patella and that trolear groove of the femur so it's kind of superficial right it's not like inside the tip fem joint like the ACL so they can kind of get close to palpating it but you cannot get your finger in there right you can't actually pinpoint that a lot of times um so it's going to be difficult for patients to really be able to pinpoint and put a finger on which I think sometimes for our evals it's really frustrating it's like can you please just like point to it for once it's it's not always because the patient doesn't know how sometimes it's because it's in a place that you just can't so just take that with a grain of salt like some if it's a younger high school athlete then who knows they're just maybe like bad historians but just keep this in mind if they have anterior knee pain and they can't palpate it and they're kind of like pointing in and around their patella I was like "This should basically be like top of your list." Patelmoral pain syndrome is just in and around your patella so the pain's here usually because this cartilage it's pretty thick cartilage in between your patella and your femur it's not a miniscus it's articular cartilage so it's just like supposed to be smooth and basically just like almost like a bersa just like lubricate and not have a rough glide there's gonna be a lot of movement here uh but if that is compressed too much which is one thing here so overuse can lead to compression of the joint so if you think about when we go into flex positions when we're running when we're jumping then that patella is going to come down here and the load contraction through the quads and the weight bearing status of that you're going to get a lot of compression in that tlear groove so when you compress things together but you think about a meniscus cartilage does not like too much compression or too much torsion right so eventually when you compress cartilage enough and at a high enough load it can start to be inflamed or even start to chip away fray thin out a little bit that's where you can get maybe your crepitous sensations here in the compressive people right there's maybe not the maltracking that we would see with the maltracking people there's a compression main issue and there's mackracking it could be both but it's just important to to look because not everybody is going to be loose and sliding out laterally some people are just overworked especially early in the season in the preseason think shin splints it's the same idea but it's their quads that are just super tight maybe they're not quite strong enough they're ramping up load and so as a result this starts to get compressed here a little bit too much and then this is where they feel their pain maybe the problem is elsewhere but this is where they feel their pain okay so that's our compression folks are uh malttracking folks it's the same spot where they're going to feel their pain it's right in between there but a lot of times since we were maltracking laterally they're going to feel their pain laterally right so it's less general maybe those people can pinpoint a little better they're going to point right to their lateral patella um and maybe even on like this lateral trope or groove aspect right so they're probably a little less likely to say it's kind of everywhere maybe though right especially if it's really sliding a lot and it's getting a lot of surface uh but they're a little more likely to just point to that lateral aspect okay we do have that patellar um grind test we'll talk about that in a second but patellar tilt test is something that some people do because you can have a lateral tilting patella and you can also have a lateral track patella right if you're tracking laterally that's where you're actually sliding and moving out but if you have a lateral tilting patella then you're just automatically compressing the lateral aspect of that groove right just know that the one special test we have for this it's not very reliable so just know it exists patellar tilt test basically what that is is you get your finger underneath that lateral pull of the patella and you try to lift that can be like symptom re reducing for some patients oh yes that feels so good great then do some moes for that but that does not tell you all the time with great certainty a positive or negative is going to indicate PFPS or no PFPS it's not the great the greatest special test in the world that's C-grade so don't worry about that test this we already talked about um in our subjective they're really going to get their pain around the patella with running squatting stair climbing um especially descending the stairs so ascending yes but descending even more reason being for that is you have a stronger eccentric contraction going downstairs as opposed to going up the stairs so if you're talking to your cross country runners or just runners in general running down the hill is probably going to be more bothersome than going uphill but any of our student athletes probably have stairs in their life somewhere some way at home or at school um so that's a good question to ask and this is more load than compression on the joint a prolonged sitting we talked about that just being in that in your position right now for long periods of time you're right in the middle of that tlear groove and you're you're under a compressive load right now and if you don't move it and circulate joint fluid and just give it a break on that spot like almost think like a pressure ulcer you can just get soreness from just being in that spot too long right it's not a pressure ulcer but same idea okay so best uh functional test so this is different than special test is just having them do the movements that bother them so do a squat do a step down do a single leg squat let me see how your patella moves is it malttracking are you going into VGUS where's your pain coming from just try to recreate their pain in this way because not everybody's going to have a positive here and that grind test they're going to hate you for doing that first of all and not everybody's going to have crepitus with the grind either so it's not always the best special test for this injury so this is how it looks normal tracking is here and then these are the issues so when we just go pure flexion extension this is how it should be moving and grooving train on the train tracks think about that trolear groove is like knuckle and then the patella is just sliding right through the middle that's how it should look um and then this is where so this is the patella reflected off so this is the underside of the patella this is where we're going to get our um the pressure at each degree of flexion okay so this is where we say between like 60 and 90 degrees of flexion is where you get the most pressure forces so think about your squat that's where you're going to be loaded up the most in the depth of your squat or jumping so you want to try to avoid those ranges if you're modifying activities and somebody's recovering from this injury right so that's why I say again work on your TKE because you have a little bit less compression over here or if you go a little bit deeper then your patella is almost out of the groove on this side as well cool there's an example of your lateral tilter so you're just getting more compression on this side that's pretty hard to diagnose without an X-ray and then there here's you're uh now tracking potentially when you have like vary and valgus so there's no patella in these pictures which is a little bit annoying but I like the picture because it's showing you where the tracking line's going to be tt is tibial tuberosity that's marked and then TG is tier groove so this is a neutally aligned knee so if I do a squat with my knee straight this is your tracking line you're always most people are going to track a little bit more laterally than medially because of your Q angle right even a normal Q angle is about 15 degrees of VGUS right even an an antroverted hip is still like 5 to 10 degrees of VGUS so just remember that most people are not truly in true varys they're just in less VGUS so this is neutral this is where you should really be um gliding this is vary then it really just puts you back in the groove because you're getting out of algus when you go into more VGUS your tibial tuberosity is just going further away or lateral to your tlear groove so if you're squatting with VGU running with VGUS jumping with VGUS the patella is going to follow this line right it's going to go in the tunnel and it's going to get pulled to the tibial tuberosity because that's where it attaches to so if this point moves away that's going to pull you can see how that angle is going to pull the patella laterally onto the groove so this is different than what people used to think so this is what we're saying by that is to say that hey VGUS the femur moving medially is actually going to then put the patella laterally the train of thought used to be and this is kind of like the old school is that it's all the patella's fault it's not the train tracks it's the train the train itself they people used to say the patella the train would just slide out laterally because of a tight IT band pulling it laterally or a weak VMO which doesn't doesn't pull it back medially right this has been basically debunked and many many many many many research studies to the point where now it's like even like on the BC like this is not this is not it anymore but maybe some of you guys have some older preceptors that still talk about this so that's why I just want to throw it out there not so that you do this or prescribe to this but you're going to hear it and you just think okay cool that was right good for you but like we're a little bit more with it um so again it's not the VMO's fault and if you think about why not well one the same nerve is controlling the VL and the [ __ ] so you can't have more activation from one than the other thought used to be like this one was inhibited or it was a delayed onset of activation and so it was pulled laterally because this one wasn't doing its job you can ask Dr scher Dr balta it's the same nerve controlling both muscles so one can't be shooting later or earlier than the other because they're it's the same trigger for both guns basically yeah and then the other thing is this angle of pull is mostly superior not medial like it's a little bit of medial pull but really its job is to extend the knee not medially track the patella it's a knee extensor that's what the quad does so it's not the train's fault it's the track's fault usually when this is happening typically so if you go into VGUS and the the train track just moves underneath the train yeah the train is out or it's maltt tracking and it looks like that's the problem because that's what we see visually see that J sign see that patellar being subluxed but that's not to say that it's the train's fault reason why this is important not so much for diagnosis but for treatment completely changes how we treat right instead of doing it band stretching and VMO strengthening we are going to control the femur with glute work balance work propreception antibalgus work completely different ball game cool so here we go this is um there's a not position statement I didn't have you guys read this one because you already read CBG last week but they have a position statement that is basically just on the FDS like Nana has one thing on the knee and it's this they said this is important and I think part of the reason for that they do have one on ACL per so I shouldn't say there's two but you're going to see this probably more than your ACL and meniscus just because it's it's not as serious it's a little bit more common so between this and IT band syndrome this will be way more of your knee injuries really than your like big scary surgery ones um so what do they find the biggest risk factors here um basically so quad weakness quad tightness that is going to be a risk factor so part part of the reason there quad tightness we talked about the compressive PFTS if it's tight it's going to compress it that makes sense weakness usually comes with tightness chicken or the egg right if someone has weak hamstrings they go sprint all day long are they going to be tight the next day absolutely so it's hard to separate the two but also if you have weak quads then the joints around it are going to take more of the shock absorption forces so those are going to go together um and then we also have some other ones over here so this is just looking at risk factors at the knee we talked also about the hip where that's over here so at the knee the biggest risk factor predictors are quad weakness and quad tightness so it has nothing to do with VMO versus VL and has nothing to do with quad tightness versus IT man tightness like the old school way this is just saying hey the clot as a whole we can tell not good for the knee which which makes sense the things that are not associated with it so C-grade level of evidence saying that delayed [ __ ] activation is going to is going to basically cause this risk factor which basically means it's a flip of the coin c-grade means there's some evidence for some evidence against there's no real definitive statement one way or the other so you can basically flip a coin and say this person has delayed [ __ ] activation does this affect their PFPS who knows which that's pretty bad odds if we're going to do that uh the other things that don't affect it at all is Q angle foot posture index and other static structural predator so that's an interesting one excessive Q angle so if I have a lot of structural VGUS it does not actually increase my likelihood to have PFPS but we just said it's the train track's fault to go into VGUS so why do you guys think static VGUS is not a predictor it's kind of similar I guess to two weeks ago when we said static foot posture is not a predictor of plan fi dynamic foot posture is the predictor but static foot posture does not always correlate to dynamic what it's doing with motion right so it's kind of the same idea just because someone has a little bit of VGUS at rest which we all do does not mean that they're going to move into dynamic excessive VGUS when they run jump squat and do the things that do some people can control their VGUS pretty good other people have a normal Q angle but they're diving away into VGUS so this is not a predictor so it's helpful to like you know observe people standing but if we're not watching them move then we're not actually we shouldn't even do the observation at all right so what does predict it other than quad tightness and weakness is other kinetic chain things at the hip so dynamic hip a deduction and IR that's dynamic VGUS predicts it not static which makes sense if you see them moving into VGUS every step every jump they take then there you go now I can guess okay the train tracks are moving immediately the train is just kind of stuck where it's going to be because it can't really control itself and now you're going to be at a higher risk for this injury u dynamic debogus same thing otherwise this is an interesting one too not a predictor reduce strength of hip extensors a vector external rotators so there's a lot of like back and forths here so static VGUS not a predictor dynamic vgus is so then you would think oh cool so if they have weak glutes then they're probably prone to this right but then this says weak is not correlated what the hell says isometric that's part of Yeah yeah isometric strength is not the same as dynamic strength but that's how we MMT people so that's just the limitation of our exam I think in a big way but also is this assessing propriception and joint control right can someone have strong glutes and still have a lot of dynamic Valgus yeah because strength and prop reception are two different things and you know someone can be good at both or not so just because someone has strong glutes does not mean that they will never go into VGUS we that's again why we have to watch our patients move like a movement analysis especially with knees you have to watch and see with your singling spot show me a jump show me how you do a layup i just let me go out to the track let me just watch you take off from the sprint blocks like do you go into VGUS because your exam can tell you this this and this but two out of those three things don't matter so we actually have to then go watch them this is going to be the biggest thing outside of the quad time to actually see what's going on cool so fix the tracks not the train right so that is by fixing the VGUS if they have dynamic VGUS the only thing we can really do with the train is work on the quad quad cool so this top video is a physician explaining it i just want to this is like two minutes and this is one minute and this is kind of like it's a good explanation but it's kind of like the old school way to think about it whereas this is kind of like the newer school way to think about it so I just want you guys to kind of see the difference the kneecap joint between the kneecap itself and this little groove that it rides in at the end of the thigh bone this is a joint that can give people a lot of problems and there's a lot of ailments that can affect this joint the thing to understand about this is this is a very high stress joint this cartilage coating in this joint is some of the thickest cartilage of any joint com and the reason for that is that this joint has some of the highest stress on it of every joint any joint thigh the quadriceps muscles the muscles in the front of the thigh attached to your quadriceps tendon that goes through your cell or your kneecap and then attaches down onto the the shin bone down in through here those are very strong powerful muscles that exert a lot of force on this area one thing that can happen is those muscles can get very tight over time and what that does is it puts tension in the tendons making them more irritable but also creates a situation where you're essentially taking the patellofhemeral joint and tightening it the kneecap gets bound down in that groove and that can cause a lot of pain some of what we're trying to accomplish with therapy is to help loosen that up both the muscle attachments loosen up the muscle that reduces tension on the tendons and then also loosen up the ligamentous attachments around the kneecap that can get bound down as well a second thing that can occur is that people can actually have looseness around the patella the ligaments that stabilize it uh can be somewhat loose and lax particularly if someone's has generalized uh loose jointedness and this can cause extra motion in that cap joint that can also cause irritation the goal of the strengthening exercises is to help strengthen them and stabilize this kneecap somewhat and help some of the irritation that comes from that extra motion go away okay see what I'm talking about so the first part was talking about the compression like that all tracks no pun intended but the second part he said we're strengthening ligaments first of all pretty sure that was in there and then he said we're just going to strengthen this kneecap to get it to stay put so again that's where some of like the older school approaches is going to differ with what the research is currently saying um this is not the most professional of videos but it's it does the job the new thing is you your knee isn't tracking alignment with your foot when you walk when you launch it looks like this tracking properly is whenever your foot straight or your foot whatever it is and you bend your knee when you walk when you run the kneecap and the foot are pointing in the same direction here's where you um is you get weaker over time your foot starts to flare out when you walk it flares but your knee's still pointing straight it creates a torque and as you walk as you launch as you squat whenever it's not tracking you're creating a torque or twist in the knee over and over and over and you start tearing meniscus and messing with your ACL and your ankle have to learn to start tracking properly look at your damn knee look down at it your kneecap needs to point over your foot at all times when you walk when you lunge when you squat when you live easy enough that is a good way to educate our patients though that's why I put it in there it's like sometimes you know Dr talk only gets you so far in life um but that's that's it right there for the malttracking group of people right so not the compressive people that's it you want the knee to stay over the toes and not go one way or the other if you go one way the other you got various and valus so instead of explaining all these sciency terms like we just did to you but to our patients we're not going to talk like that we say keep things tracking so do the rehab in front of the mirror look at yourself make sure that kneecap faces the mirror faces forward if it starts to wobble go in and out that's not what we want to see right they don't need to know anything else beyond that other than that when it goes the other way it's going to hurt so they'll understand that pretty quick the biggest u Okay so I think two more one more thing so what are we going to do what are we going to do about it this is um a little bit of the preview but there's actually more a lot more gradea recommendations about treatment than there is for diagnosis which is interesting uh but conservative interventions that's us right and then surgical that's not us we're going to refer for that stuff but most of these cases most all of them are going to be handled here very very rarely is this going to be a referral the only way it is is it's going to be someone that's recurrently dislocating their kneecap which is really rare right maybe it happens once and then usually you can rehab it pretty good okay so what are we do first things first activity modifications that's where we're going to be manipulating this right here so dropping the volume or the frequency of activities in order to get load less than their capacity so we're going to get the inflammation down and then when we strengthen them back up that's when we are going to improve the capacity so we're going to fix this model right here okay so that being said how are we going to do this a lot of the uh therapics for this is going to be strength related because especially if someone is going to be a maltracker that's kind of a instability issue with VGUS so you want to stabilize them so we want to do there's a lot of good studies looking at glute and quad strengthening versus just quad and from what we just talked about you could guess the glute and quad approach is going to work a lot better and it does and if you just do one or the other which you never would then glute versus quad is also more effective than just quad uh but really you want to do both because a lot of times that quad weakness will be an issue too so glute and quad so don't throw out the quad but don't just focus on the VMO right so the whole quad the whole glute get everything fix the VGUS and fix the strength at the knee too uh the thing is is a lot of people can't do quad strengthening exercises with PFPS at least right away so the caveat to this is hey in the acute stage when we're still inflamed for the first couple weeks let's just focus on glutes before we start incorporating in the quad strengthening because they just can't do it yet right so glutes first um maybe some stretching of the quads but then we're going to add in the quads once they're able to okay so that's the X101 for this kind of injury um and then this is another interesting one too trunk muscle control and capacity so core core strength so obliques transverse abdominis rectus spine AQLs that is just as effective in a lot of ways as working glutes and quads which is kind of interesting so if we think about VGUS just zoom out from the knee right that's what we're really trying to work on here to fix VGUS is not just a hip issue if you have hip drop which leads to VGUS a lot of that is coming lumbar complex the core as well so when it comes to VGUS injuries like ACL PFPS weak glutes is one of the biggest predictors of of the injury but so is weak trunk as well that's why if you guys look at like the FIFA 11 program for ACL prevention for soccer injuries there's a lot of core there's a lot of hip a lot of prop reception control that's how we got to reduce the VGUS and then throw in the quad too another thing that we can do short term is give them a foot orthotic so a little bit of arch control um because if we think about someone with a hyper dynamic pronating arch then their knee is going to go in too so this is taking a top down approach saying the vgus is probably from the hip but it's also to note that hey vgus could also somewhat come from the feet if you have pretty dynamically flat feet if this person does have dynamic planus then they would do pretty well with a foot orthotic in order to raise that arch and straighten out their knees a little bit but just like any you know arch support any tape that we do this is short-term relief up to six weeks and then you got to cut it because if you keep doing if you keep doing that then they're going to actually just lose arch strength and they're going to rely on it in the long run it's going to be a crutch so this will help get their symptoms down while you work on this stuff and then you should wean off of the arch support so they can actually control it themselves with their own muscles and then lastly uh patellar taping so this would be like not patella tendon taping a little strap around but patellar taping for like the tracking whether it's lucco or um go that one's called you pull it across or k tape but this can be effective you have to test it this is not going to work for everybody but there's some studies showing that hey if you apply the tape and then they're able to exercise painfree then they're a good candidate obviously to have the tape so it's just a little test it's not going to work for everybody um so if it's not going to take away their pain they don't need to take but some people respond really well they'll say "Hey let's try it if it works for you great." Um it's going to help you a lot the thing is with that again this is not going to fix their problems it's just relieving their pain short term this is not going to change the way they track especially once you take the tape off and it's also not really changing the way the muscles work it's just relieving some pain um through some neuroscychological properties braces and sleeves no effect otherwise surgically what are they going to do we're not going to refer these patients for surgery for a long long time like literally the article said exhaustive rehab attempts like until you're blue in the face and they're blew in the face and you've probably fixed it by then first of all uh especially if you're doing this stuff but if not then they may need a surgery there's two things that they can do for surgeries just so you know one is a lateral retinaccular release so if they truly do just have a lot of lateral tension the red knackum and IT band they can just go in there and slice it and loosen it just to relieve some of that tightness and they can also do a pillar joint realignment so they can literally move tibial tuberosity over on the tibia in order to have more linearity of of the joint itself so this is the last thing i'll show you this video and then we'll preview for next week i almost accepted the dark circles sagging skin and fine lines wait for it 15c routine changed everything that's amazing patients may require a lateral release where tight structures on the outer lateral side of the patella are cut this is required in patients who have very tight tissue that pulls the patella outwards it can be done through the same incision as the reconstruction surgery or through a larger incision around the knee lateral release allows the patella to sit more centrally within its groove and move correctly restoring normal alignment there's that small group of patients additional operation required to assist in stabilizing the patella you don't want this is performed to change the insertion point of the patella tendon on the tibia a 6 cm long bony segment of the attachment of the patella ligament is repositioned and held in position with two screws in order for it to heal in this new location this will improve the alignment of the patella in the groove of the feur and eliminate symptoms of instability additionally patients may require a lateral and that's a repeat well cool i think it's helpful well you guys will watch a lot of these videos in theex because if you're treating anybody posttop you better know what they did in the surgery um in order for yourself and for your patient to have confidence and now what are you going to do so that's just kind of good to see what's going on there um otherwise there it is that's PFPS in a nutshell so right so fix the train not the tracks we don't have a lot of special tests to check for this so use the location of pain use the MOI the history and then also just recreate their pain with the movement testing that we just talked about okay so we're done for today i have this but I think maybe we'll just start next week with this if that's cool with you guys unless you want to stay but I doubt it um so we'll do this for the knee next week and then but we're also moving on to hip and thigh so your homework for this week you have less like last week there was a lot of clinical stuff this week for that you just have the regular journal and then we just have our article this is um for the hip but it's looking at hamstring strains specifically so it's a whole article just on hamstring strains like you had no idea that you could get this deep into the weeds and we are um so there's about I think 12 or 13 pages in there I want you guys to go over and then there's like the questions that go along with it so that is open it's up and it's open last last time it wasn't um but so first response is going to be due this Friday second one Monday end of day cool there we go uh yeah that's that's that quote of the day only person who is educated is the one who has learned how to learn and change so it's active we can't just sit here and leave and be like I know everything you have to use it so use the stuff today when you go to clinicals if you have a knee eval think about what we talked about otherwise thank you guys good stuff and I'll see you on Thursday thursday green the pillow