Lower Extremity Conditions

Hip Pain

The specific location of pain can give some insight to what the trouble might be. There are five areas of symptoms that I find are the most common when my patients report they are having hip pain: the sacro-iliac region, the trochanteric region, the groin region, the iliac crest, and the anterior hip.

Sacro-iliac Pain

This is the area of the body in the upper inner buttock that is close to the spine. In the

medical world, this is actually not referred to as the hip, but rather the right or left SI region. Though, it doesn’t matter what we physicians call it, because most patients just complain about the hip and point to this area…which is good enough for me. The SI joint is composed of two big bones. This is the sacrum and the ilium. It is a large fibrous joint that has much less movement than your typical joint, but is very important for posture, gait, and weight bearing. The SI joint rocks forward and up or back and down.

Sometimes tight muscle groups or unlevel pelvis causes this joint to rock out of place one way or another and this causes excessive stress resulting in a deep achy or sometimes sharp pain that can travel up the back or down into the buttock. Correcting the joint position, rebalancing the muscle groups, and leveling the pelvis are the biggest points of care when I am treating an SI joint issue.

Trochanteric Pain

The side of the hip bone right where the femur meets the pelvis is another area of

hip pain. We call this the trochanteric region because the big bony area of the hip joint is called the trochanter. Lots of important structures lie in this area. The two biggest players are the tensor fasciae latae muscle which connects to the iliotibial band, and the trochanteric bursae. By far, these two structures are the most common sources of lateral hip pain. A tight tensor fasciae latae will pull on the iliotibial band causing tightening across the joint that leads to irritation and inflammation of the underlying trochanteric bursae. Typically, both problems occur together. In fact, the insurance companies code these two problems with the same code: Iliotibial band syndrome and trochanteric bursitis.

I find most people with this problem usually have a short leg and an unlevel pelvis. My treatment plan for this problem usually includes ultrasound/electro stimulation, manual release of the tensor fasciae latae and iliotibial band, and adjustments to correct the unlevel pelvis that includes the affected hip joint. There is typically spinal misalignment (normally a lumbar tilt) associated with this type of problem, so I usually end up treating the low back as well. Often the tension in the tensor fasciae latae and iliotibial band runs down the side of the leg and may even affect the outer knee. In this case, I may also need to address the knee joint.

Groin Pain

The inner part of the hip joint is referred to as the groin…not that anybody needed me to explain that. Most all of us have “Pulled our groin” during some activity. This is typically a pulled adductor muscle. The problem affects younger patients who are active in sports, but can occur at any age. There is however another culprit that I see regularly: Osteoarthritis. This is a type of arthritis that is due to the wear and tear of joints and typically affects joints that bear more weight. Osteoarthritis of the hip is almost always described as hip pain that is achy and sharp on the inside of the groin.

Iliac Crest Pain

The region at the top of the hip bone on the side of your body is the iliac crest.

We call it this because it is the upper most portion of the ilium. Just like the crest of a mountain. Attaching to the iliac crest is the quadratus lumborum muscle. If there is a misalignment in the pelvis or spine that causes tilting of the lumbar spine, this muscle becomes over active trying to fight the forces of gravity while in an upright position.

Eventually this can lead to pulling and irritation of the insertion of the quadratus lumborum right on the iliac crest. Typically I find that a patient tends to lean towards one side during lifting activities. This habit can lead to this sort of dysfunction. Stretching this muscle and aligning the spine and pelvis usually do the trick, but I always address proper lifting and bending habits to make sure it doesn’t come back.

Anterior Hip Pain

In medical terminology, anterior simply means front. Below are a few causes of frontal hip pain. By far the most common cause of anterior hip pain that I see is a strain/sprain. Strain means damage to a muscle, and sprain means damage to a ligament. Sprains are far less common than strains, but do occur during an injury when the leg goes back behind the body. Strains in the hip flexor groups are fairly common in sports. Soccer players reaching for balls, runners overexerting themselves, contact sports that require rapid muscle recruitment. In fact, any action that forcibly brings the leg forward against resistance can cause these types of injury. It can happen with one big traumatic movement, or it can be a repetitive trauma, or a little of both.

The hip flexor muscles include parts of the quadruceps (namely the rectus femoris), the iliopsoas complex, and the gracilis. The iliacus muscle sits inside of the iliac bone and attaches to the upper part of the femur. The psoas muscle stretches from the upper part of the femur to the side of the lumbar spine. These two muscle’s fibers blend together and are therefore called the iliopsoas group. The rectus femoris is one of the four branches of the quadruceps muscle. It runs all the way from the base of the knee to the front of the ilium. It is the only part of the quadruceps to cross the hip joint. The graciliis is a small thin muscle that wraps around the leg starting from the front of the iliac bone down to the inside of the knee. Tears in any of these muscles can create anterior hip pain. Strains and sprains are addressed with P.R.I.C.E (protection, rest, ice, compression, elevation-when relevant) acutely within the first few days. Ultrasound helps to speed up healing. Rehab of the affected tissues is also important to regain functionality of the muscle/ligaments that have been damaged.

Feel free to give us a call if you have questions or make an appointment on our webpage.

Knee Pain

Meniscus Pathology

The menisci (plural of meniscus) are two cartilaginous pads in the inside and outside of the knee joint. Their purpose is to protect the joint, help to make motion more fluid, and act as a shock absorber. We name these two pads by their position: the medial (inside) and the lateral (outside). Menisci can become injured during activity or simply wear out if the dynamics in the joint become altered. This usually leads to tearing and the pain is felt as a sharp or lancing sensation deep inside the joint. Altered positions of the joint are important considerations when evaluating the knee. People who are valgus (knock-kneed) tend to wear on the lateral meniscus, while people who are varus (bow-legged) tend to wear out the medial meniscus. Chiropractors can help by repositioning the joint and retraining the knee to function correctly again.

Medial and Lateral Collateral Ligaments

There are two collateral ligaments in the knee and they are named just like the menisci. The inside of the knee has a medial collateral ligament and the outside has a lateral collateral ligament. The purpose of ligaments is to provide stability in the joint and keep the joint from falling out of place during movements. The MCL and LCL mostly help to keep side-to-side movement in check, but also help to prevent rotation of the knee. A valgus position of the knee stresses the medial collateral ligament while a varus position stresses the lateral collateral ligament. Damage to this structure is felt more superficially as a sharp achy soreness on the inside or outside of the knee and usually causes the knee to be tender on the inside or outside aspect.

Anterior and Posterior Collateral Ligaments

Just like the ligaments above help to keep side-to-side motion in check, the anterior collateral ligament (ACL) and the posterior collateral ligament (PCL) help to keep front-to-back motion in check and also contributes to keeping rotation in check. The more common injury is to the ACL which usually happens in sports when abruptly changing the direction of motion as when breaking and cutting a run during football or soccer. This situation usually results in immediate collapse of the individual and most of the time requires surgery. The PCL is less commonly injured because it is a bit beefier than the A CL, but injury still occurs. The mechanism of injury of the PCL is typically during a tackle where a substantial amount of force is applied to the front of the lower leg while the knee is bent.

Hyperextension-type injuries can also lead to PCL damage. Just like its cousin the ACL, the PCL typically requires surgery. The balance of the quadriceps and hamstring have more to do with protecting the ACL and PCL, so there is definitely training that can be done to give these structures some extra defense against injury. But… in many situations, the trauma is so great that no amount of training would have prevented the injury. Luckily a good surgeon can repair and re-pin the torn ligament the majority of the time. However, after the surgery, a good rehab program is essential for regaining functionality.

Chondromalacia Patella & Patellar Tracking Disorders

You may not know this, but your knee cap is not really a normal bone… It is a sesamoid bone (No, not the seeds that come on hamburger buns). A Sesamoid is a bone that develops inside of a tendon (the part of a muscle where it attaches to the bone) that helps to guide the motion of the joint and protect the tendon as the tendon glides over a groove in a bone or surface that creates a lot of stress or friction. Sesamoid bones occur in several places in the body, but the knee cap is the biggest. Without the knee cap, your tendon would fray and become damaged when you move your knee. The knee cap is shaped to fit and slide across the front of the knee joint. When you contract your quadriceps muscle, the knee straightens and the knee cap helps to guide the motion keeping the tendon centered across the front of the knee. People who have varus or valgus positions of the knee can cause scraping of the knee cap across the inside or outside of the groove. The underside of the knee cap is made of a slick cartilaginous substance that helps to reduce friction. When the knee cap tracks to the inside or outside of this joint, it can wear on that surface creating micro damage that accumulates over time and the once slick surface now becomes rough and cannot do its job of reducing friction. Over time, the damage gets bad enough that the surface is significantly changed and pain and inflammation quickly follow. The pain is felt under the knee cap and occurs especially when the knee is flexed under a load as when walking up and down stairs. Chondromalacia patella is the name we use to describe the damage under the knee cap, while patellar tracking refers to the movement of the knee cap across the front of the knee. You can now see how these two things are related.

Osteoarthritis

Also known as degenerative joint disease and nicknamed the “wear and tear” arthritis, OA is the most common type of arthritis. OA can occur in any joint in the body, but is much more common in the weight bearing joints of the body. The knee is definitely one of these joints. Osteoarthritis is AL WAYS secondary to some other process. Most of ten that process is a joint mis alignment and muscle imbalance. Just like the nickname implies, wear and tear that occurs over time is the underlying reason for all kinds of osteoarthritis. Any of the above problems if left unchecked will eventually lead to arthritis. That old trick knee or sports injury can cause enough repetitive damage in the joint that the cartilage will be lost and joint will begin to calcify and change shape. Please don’t ever tell yourself that your arthritis is just due to old age. This is not true, and usually leads to a person thinking that there is nothing that can be done, so they don’t. This is false.

Maybe the joint can’t be 100%, but there is sure a lot we can do to improve the dynamics of the joint and at least stop it from getting worse. You will note one reoccurring theme throughout this article: Knee problems are almost always due to a dysfunction in the alignment and movement pattern of the joint. Even if the injury requires surgery, rehabilitation of the knee is still necessary to address the underlying altered joint dynamics. It is much more preferable to address these joint dynamics before injury occurs rather than after.

Please, if you have knee pain then make an appointment today. Let’s get to the bottom of it before the problem becomes any worse. If you have questions, I would be happy to sit down with you and talk before your examination at no cost to you.

Your health and livelihood is my primary concern.