Tracy (not real name) is a lady I first met while she was waiting to get knee surgery (meniscus repair). We began working together to help her build strength and prepare her body for the procedure.
https://www.youtube.com/watch?v=jpems5aWrt0
That was NOT the kind of surgery Tracy got… I just like/am traumatized by that video.
I am writing this piece about Tracy because it is a lovely case-study of a few things:
a) How someone who is relatively unfit can see a surgery as an impetus to get in shape, address movement mechanics, and go on to hike in the mountains pain free 6 months later.
b) How surgery can sometimes be a very good idea, not only because it can reduce pain symptoms, but that is can sometimes reveal the true underlying cause of WHY there was an issue in the first place.
c) How learning to pronate the foot, and removing an arch supporting orthotic can be a major piece of the knee-pain puzzle.
d) How focusing on symptoms prevented me from seeing the root cause of the issue as quickly.
PRE-SURGERY TRACY
At first, it was Tracy’s left knee that bothered her (primarily with flexion), and she was scheduled to get surgery in a few months.
In an assessment, her center of mass was shifted to the right, and she found it very difficult to shift her pelvis to the left, which, made perfect sense at the time, her left knee being in pain, wouldn’t you want to shift away from it?
As part of our process pre-surgery, my goals for her were to see if we could help left knee flexion feel a bit safer by exploring the mechanics of weight bearing on her left leg (learn to pronate and supinate the entire foot, hip, knee- lots of suspension/transition). Her goals were also to build full-body strength, to be in better condition going in to the procedure.
Two of our outcome measures were kneeling on her left knee, and a quadruped rockback (putting it into deep knee flexion).
Week by week as we plugged away, she noticed some good changes in how much range of motion she could access pain-free, and felt stronger over-all going into the surgery (that was April 2016).
I had my doubts about surgery. I always do, as it is a last case scenario- Avoid unless absolutely necessary. However, in Tracy’s case, the surgery was a very, very, good decision.
As it turns out, her left knee wasn’t the issue. It was just making the most noise. The squeaky wheel gets the grease, as they say.
What should have tipped me off from the beginning was that in our initial assessment I was drawn to give her the AiM right “strike” exercise (replicate the phase of gait at which the right heel first hits the ground), which significantly improved how her left knee felt in both outcome measures. Not perfect, but not bad for a few minutes of work.
Why did an exercise for her right hamstring help her left knee? In Tracy’s gait, a stand out feature was that she did a massive side bend to the right but never left, which seemed to be a counterbalance help her to get her center of mass left but not right. So to me it seemed logical to get her to do the opposite and see what would happen: Left side bend, right heel strike, effectively shifting her mass off of her left leg, getting it onto the right.
(To be honest, I can’t quite explain why I was drawn to right strike… There was more information at play than just the ride lateral flexion, but right strike seemed like the shape her body was craving).
In hindsight, I probably should have followed that thought process further, earlier on, rather than spend so much time working on the left knee mechanics.
WHY exactly did right strike seem to help her?
What in particular about that movement was so useful?
But I got sucked into the symptoms. That, and I had just learned a bunch of cool stuff about knee mechanics and wanted to explore that. Very selfish of me.
That said, the work on left knee mechanics did come in handy as she rehabbed her knee, so, I suppose it’s impossible to say that I “should” have done anything differently.
So, Tracy’s surgery was successful, but, it became very clear what the root of the left knee issue was after the procedure.
POST-SURGERY TRACY
After the surgery, her left knee felt great. Rehab went smooth, and by June I began working with her again to continue strength training. It was at this point that her right knee started bothering her. The left knee felt better than ever- she could kneel on it, do a deep knee bend without pain. So why the issues on the “good” side?
From the start, there were hints that Tracy had trouble weight bearing on the right (right strike being helpful), but these were drowned out by the noise from her left knee. Now, however, it was clear to see that she could not shift her center of mass to the right.
To me this was strange. Generally, after an invasive procedure, people will have issues weight bearing on the side that was operated on. But Tracy had no problem with that.
Was the reason her left knee got beat up because of a long standing inability to weight bear on her right leg? And why was she having trouble getting her weight to the right?
Here’s what we found…
Tracy’s right knee was not externally rotating with flexion. A go-to to check in with when there is knee pain- Is the knee rotating is is flexes and extends? As the knee flexes, the tibia and femur should both rotate internally, but the femur should rotate farther, creating tibial external rotation under the femur (knee ER). Tracy’s femur and tibia stayed stuck together, the femur never quite getting internal of the tibia, flexing with an internally rotated knee. It was likely that the two bones sticking together, not gliding smoothly, was what was causing her knee discomfort. That would certainly create a strategy to avoid weight bearing on the right.
Tracy also has a bunion formation on her right foot. I hadn’t been able to see this before because I was too focused on her left side. Doh. Note to self: Don’t chase symptoms. Bunions can be seen as a functional adaptation, for example, to stop pronation. Pronation and knee flexion/ER happen at the same time in gait, and so the bunion could have formed to stop the knee from bending and externally rotating by blocking the foot from pronating.
Tracy had also been given an orthotic years ago to support the arch of her right foot to block pronation and keep the pressure off the tender bunion, which, in my opinion, seemed to be compounding the issue, not solving it.
In summary:
Right knee not externally rotating= painful knee
Pelvis shifts left, but not right = not able to get mass onto right leg because of right knee feeling unsafe to flex
Right bunion= blocking pronation and knee flexion
It’s nice when the information lines up like this.
THE NEXT STEPS
In the words of Gary Ward, we proceeded to “pronate the shit out of” her right foot.
The next paragraph is for the dedicated AiMers.
The method we chose was a modified suspension in which we could simultaneously:
- decompress her bunion
- pronate her foot
- flex the knee and externally rotate her knee
At first, I simply got her to bend her knee as I guided her tibia inwards and pulled on her first met. This decompressed the bunion, opening up the medial side of her foot, and encourage some dorsiflexion and abduction of the forefoot, allowing her foot to pronate. We also needed to wedge the lateral edge of her foot to close the space between her lateral arch and floor, helping her to feel her full foot in contact with the floor, and to experience a real pronation, not eversion.
Then, to encourage more knee external rotation, I got Tracy to rotate her pelvis as far to the left as she could, to maximally internally rotate her right femur as I blocked her tibia from rotating further medial than her big toe, helping her to get her femur to internally rotate beyond her tibia, and creating knee external rotation.
Then, I stopped pulling on her toe to see if she could pronate without my manhandling, and we used a medial forefoot wedge to help her foot get frontal plane opposition.
There was no knee discomfort during this process even though she was bending her knee farther than what would normally reproduce pain.
Tracy is a woman of very few words and, when I asked her how it felt, she told me it felt “good”.
After this, we got her to try some step-ups, something that was bugging her knee to do, and there was no discomfort. Yay!
DITCH THE ORTHOTICS?
It was clear how pronation was a nourishing experience for her right leg, yet she was wearing an orthotic daily that prevented her from accessing it. I am often tentative to ask people to try removing their orthotics. Many people feel unsafe without them, even when they could be keeping them in pain.
Fortunately, Tracy came to this conclusion on her own. “So… Maybe I should take out my orthotic?” she said. I told her, “Yeah, try it. If it feels awful and dangerous and your knee hurts you can always put it back in, but try spending some time without it and see what happens, as an experiment”.
Typical… The solution is often to remove something, not add more, just as there is nothing you can buy to make you better, more complete, but so much to gain in letting go.
The following week I asked how things were feeling without the orthotic. Woman of few words says, “Fine”. Any knee discomfort? I ask. “Nope”.
Wonderful.
Tracy is a rare kind of person to work with.
Laughing as she moves into spaces where her body feels off balance and falls over.
Determined to try everything I ask her to do, completely trusting the process.
Smart enough to suggest taking out her orthotic before me trying to persuade her to even consider it.
For every woman like Tracy, there is a client who refuses to face their issues head on, choosing to move around them, not trusting in themselves or in their guide, opting for passive therapies entirely or simply ignoring the issues as long as they can.
CONCLUSIONS?
Writing out this case study helped to cement a few important lessons for me:
- Remember to ask why is the body doing what it’s doing. Ask, how is this serving the individual? Ask the 6 questions: What is happening? When does that happen? Why is that happening? How is that happening? Where is it happening? and, What if we…?
- Remember not to get sucked into the symptoms. Interview the whole body.
- Surgeries aren’t all bad.
- Change can’t be rushed. People will be ready to take away crutches like orthotics when they are ready, and when they see the value in it.
And lastly, I wanted to write this to remind myself to enjoy every second of working with people like Tracy, because not everyone is as open to trying the weird shit I ask them to do as she was. People like me, who recommend to train your feet to pronate and throw away the arch supports, are the minority.
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