Daughter gymnast (12 yrs) with patellar compression syndrome...how can we help her?

[campbells7]

Hi all

My dd is 12 years old, a talented acrobatic gymnast, and has just had a diagnosis of patellar compression syndrome with chondromalacea (sp?).

She's due to start physio next week, - the orthopedic consultant says she should have physio for 3 to 6 months and reduce her training to 80 percent. What does this mean in terms of what exercises she should avoid, what she shouldn't avoid? Will she be able to compete again? How do I know if the physiotherapist she gets really understands the problem? How do we help her to understand the injury, so she can help herself as much as possible?

She is convinced at the moment that her knee will never be good again and is very sad, so I would really appreciate any help you guys/gals could give.

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[uglyfatboy]

Despite a poor understanding of the word evidence again, i agree 100% with ginger. Having undertaken most of my study in switzerland prior to a 30yr career in uk athletics and gynastics including 5 olymipics games I have seen great variation in the education of english undergrads. Fortunately there seems to be vast increase in the use of evidence based practice in europe which appears, based on the previous posts to now superseed that of some antipodeans.
Hopefully your daughter's therapist will be using the clinical reasonong and evidence based practice expected. it sounds like he is!

[campbells7]

Hi, Ugly, and everyone.

It has been pointed out on this thread that any attempts at guidance are purely general. I do understand that, and I think I have said so. Whilst I know is impossible for anyone to diagnose/ treat over the internet, I came on here just to see what other information was around.

All the responses have been positive and supportive, even if the technical stuff (which has irritated Ugly so much!) has pretty much gone over my head. I much appreciate everyone's interest though I know it's here in real life that is the important bit.

I will do anything to help resolve my daughter's knee problem and, whilst I have the greatest respect for the health professionals I am trying to be sure we are doing the right thing for her. I didn't say that her physio was "spotty" but that he was young and uncommunicative.

The latest news, if anyone is still interested - DD's knee has taken a turn for the worse. In fact both knees are now hurting. What the heck does this mean?

Two days ago we went back to the Medical director of the Rehab clinic where she's had around 6 weeks (five nights a week) of physio. He says she still has water on the knee and claims that while the rehab physio is working well on the muscles it is not having any effect on the movement of the Patella. He has written to the Orthopedic Consultant to that effect and wants us to get an appointment there asap. He feels that is a waste of time continuing physio - I'm not sure the Orthopedic guy will agree as he wanted her to do 3 to 6 months of physio! Who is right? What is the best thing to do? Those are rhetorical questions!

Meanwhile, dd refuses to give up training - but she does no landings, backflips, running etc, She says she hates to see the others doing what she's not allowed. All she's waiting for is the day she can start training for competition again. And I'm wondering if that will ever happen.

[ginger]

Unfortunately, the young physio has been treating the symptoms without consideration of , or undertanding of the cause of the knee problem. In the meantime the lumbar spine has continued to expresss it's own protective behaviour, leading to more of the same, now involving the other side to a similar degree. As would be expected..

[estherderu]

dear Campbells and DD,

I am so sorry to hear this.
What can I say? we cannot do much more than empathize and try and give you as much relevant information as possible.
Not one knee is the same and as I have said before, assessing and understanding the background(reason) for the symptoms is of eminent importance.

I was educated to assess, give a few sessions and reassess, especially if the results were not positive. In the case of treating sport(wo)men, I find have always found it important to see the person move/ see them training as well.

Physiotherapy is not exactly the same profession in every country. There are differences in cultural and this implies that the Health insurances are not the same as well. In Holland they pay for a standard 9 times a year. If you need more, the therapists have to specify why.

I wish you both lots of good luck with the recovery.
And of course a good Christmas and a happy New Year

Esther

[revitol]

Hi everyone!

Firstly, let me stress the importance of ginger's last sentence that he offers general guidance. Campbells7, it is obvious that we are trying to guess what could help your daughter and that we are only making assumptions of what could be the cause/causes of the problem. I'm sure that everybody agrees and maybe I shouldn't point that out.

Moreover, I would like to add some things to what has already been mentioned. Both ginger and physiobob focused on intrinsic (anatomical) factors acting on the knee joint and specifically on the patella. Although weakness of vastus medialis (VM) has been involved greatly in patellofemoral pain, a therapist should always remember that it is not only VM that attaches to the patella. It is also the rest of the quadriceps bands, the iliotibial band (ITB), the retinaculum and the patellar tendon that act directly on the patella and, therefore, affect its function. Any malfunctioning of these structures (e.g. a tight ITB or a weak quadriceps) could also lead to patellofemoral pain. It is obvious that numerous structures around the knee should be clinically assessed.

Of course, other structures of neighboring joints should also be examined. Foot pronation was correctly stated that it could fire patellar pain. Subtalar joint pronation could be secondary to a tight gastrocnemius/soleus muscles as well. This pronation could lead to tibial internal rotation; this to femoral internal rotation and this could increase the Q angle (angle between the quadriceps action vector line and the line of the patellar tendon), which could trigger joint pain. Furthermore, structures that have attachments to the ones mentioned above, such as gluteus maximus to the ITB or hip adductors (adductor magnus) to the VM, could also affect the patella indirectly. Hip and pelvic structures might also be responsible, as well as spinal deformities. It is not worthwhile to mention all possibilities but they should be taken into account.

Another important factor is the girl’s age. She is 12 years old, signifying that her skeleton is still growing up and forces acting on it have a high impact on its final formation.

Apart from body biomechanics, external factors could cause this problem too. Shoes, landing surfaces, even the skis that your daughter uses during her free time are factors that could affect her knee.

And of course, acrobatic gymnastics is a very demanding sport. Flexibility/mobility is fundamental in performance and more mobility leads inevitably to less stability. A generalized ligamentous laxity of the knee has been assumed to be associated with chondromalacia patella. Physiobob was successful in his comment about ‘necessary’ pathology on a gymnast’s body in order to perform competitively.

All of the above have one common conclusion; every person should be treated independently. This is where I go back to ginger’s first comments about existence of this kind of pathology and adding that there are no true pathologies but true patients. That is why there are always exceptions. Everybody is unique and that’s how he/she should be treated.

I hope I didn’t confuse anyone and that campbells7’ daughter will be fine and able to do what she loves.

With best wishes

[Lachlan]

Ginger: You were talking about L3 and the femoral nerve affecting VMO and this being the key issue. I am curious as to whether this is your opinion or you have some articles for me to read that i am not aware of?

Whilst everyone has made some excellent suggestions I feel you can do everything right with patellofemoral pain syndrome, but it wont get better unless the correct relative rest is also provided. It sounds like your daughter is still participating in activities which are causing pain. I feel she would get better alot faster if her whole rehabilitation program is pain free. She should be able to do most activities just avoid activities which load the knee in a bent position, with gradual increases as symptoms improve.

Yes there is a large biomechanical component to the condition, i remember reading a recent MRI study on patellofemoral pain in which they found the shape of the patella and the way it loads at 20 degrees flexion could predict who had patellofemoral pain syndome (sorry dont have the link). This study indicated that there are also biomechanical factors that we simply cannot alter through physiotherapy.

[ginger]

Lachlan , the direct answer to your question is ,Yes , this is an opinion I maintain on the basis of the clinical indicators I have seen over the past twenty five years and , none that I am aware of. As a working physio in my own practice I have often heard the call to further substantiate my claims about referred events such as with PFS. At one time I left my practice to pursue research aims after promises of support, which, unfortunately felll short of my needs. having resumed my normal practice I find little time or facilities available to concentrate efforts towards RCT's etc. I have been publishing on various sites , noteably , the Rehabedge site for a number of years. Should you be interested in going over the topic in more detail I would suggest you begin there with a key word search. I also lecture here in Melbourne when these are arranged for me.
Cheers

[campbells7]

Thanks everyone, again.

Thanks Esther and Ginger for your sympathy!

Your comments continue to be helpful in that I am now thinking we should maybe push for a different physio, maybe the sports specialists at the hospital. I hate to think that the treatment at the rehab clinic was so unhelpful and possibly has made things worse?

The thing is, the Orthopeadic consultant, back in October, said the alternative was the lateral release surgery - I've heard people say that surgery should be avoided at her age so we'll obviously be discussing that. I think perhaps I should push for more physical therapy and more examination of whether her hips, feet or ankles are the cause. I don't know whether anyone's ruled those out or not.

Lachlan, yes, I am also afraid that there is something she is doing in training that is causing pain. She says not. She says her knees hurt even over Christmas when she had no training. She knows that she should avoid activities which make her knee/s hurt. Trouble is, she's not really clear on what makes her knee/s hurt! Does anyone know where I can find some clear instructions that a 12 year old could take on board that would tell her what she should or shouldn't do - on a day to day basis as well as in training?

Have appointment on 5th Jan with Orthopeadic (sp?) Consultant. Happy New Year to you all.

[ginger]

campbells7, I mentioned earlier, that it is no surprise that efforts to bring control to your daughter's knee pain by exercising the knee muscles was and will be either a complete or at best, a partial failure. If my original assumptions are true, that is , that she has a common condition known as PFS, then her pain may be of two distinct but linked origins. In the first instance , irritations at the L3 nerve root ( caused , as you will recall ,by protective behaviour there) would give rise to pain in or near the innner aspect of the knee, possibly extending towards the area described as under the knee cap.
The same nerve irritation will lead ultimately to a poor recruitment pattern of the muscle that controls the knee cap during bending , VMO, which will see a worsening of this condition , particularly during effort, such as landing , running, and in extreme cases, walking.
The answers lie not in rest, although it may be said , that a period of no training is of benefit. This is because the nature of spinal protective behaviour, is that it is driven by the ongoing losses of movement that are it's own result. In other words the less you move , the more it holds.
'IT', being the natural non pathological tendency a vertebral spine has , as a feature of it's origins, neuromatrix and essential brain functions, to remain in a pattern of holding, until spinal movements return. It is movement then, of the spine , that has the beneficial effects , that lead to an undoing , as it were, of these normal , ubiquitous behaviours .
I will suggest an exercise that has the potential, to release a certain amount of these protective behaviours.
Done with care , the McKenzie lumbar roll exercise , as I will describe for you, will allow a reduction in paravertebral tone at or near L3. This ought to immediatel;y reduce knee pain, provided, that it is done in a relaxed manner, with no added effects and of course provided that all the foregoing , is as I assert.
Have her lay on a firm warm surface, floor is best. On her back, with knees bent to about 45 degrees. Head supported by a small pillow, abdominal muscles relaxed, head and neck relaxed.
Have her perform a side to side movement of both knees together, such that a gentle pendular swing is maintained at about one swing per second, have her keep this movement going, without any added movements of the upper limbs or head, in a relaxed fashion, no stopping or stretching, for FIVE minutes. This is NOT a stretch, or an activity that requires great effort or any kind of exquisite self control.
Have her repeat this ( Rock and Roll exercise ) two or three times a day.
You will notice, or rather , your daughter will probably notice, that she returns to standing and activity after this with an increased sense of freedom, this includes the knees.
Surgery is an option that ought not to be considered.
PM me and I will direct you further on a method you can easily perform yourself which will have more benefit.
Cheers

[campbells7]

Thanks Ginger,

I will get her to try that exercise asap - it will be interesting to see if she feels a difference. I'll let you know.

Thanks for the offer - I will PM you in the next day or so.

[campbells7]

Hi all,

In case anyone's interested. My daughter started physiotherapy again three weeks ago with a new therapist. We are much more optimistic as this therapist seems quite different to the first one. She looked at the Xrays, TAC, and MRI, inspected my dd walking, explained a lot of stuff to my dd, and ten minutes into the session, taped my daughter's knee. I researched a lot on taping methods after some of you mentioned this but none of the physio's or Orthopedic Doc seemed to know much about it. I was wondering if this new physiotherapist would mind if I suggested we try it, when lo and behold, she got out her tape box!



While I know this is no guarantee of anything, her whole attitude is so different to the first guy we can't help but feel like maybe she really does know what she's doing.

Not much else to report - I hope to have more good news soon.

[estherderu]

Hi Campells7

Very glad to hear this.
Hope all goes very well!

kind regards

Esther

[KalleKarlsson]

You can always try Kinesiotape. Kinesiotapeonline.se - Sporttejp Kinesiotejp - Kinesiotape online - kinesiotapeoline.se

[Andreas Karlsen]

Try to talk to a physiotherapist. Or maybe try kinesiotape. Hope you are gonna make it work

[estherderu]

dear Andreas,
It is clear that you have not read or not understood the discussion about this case.
I have the feeling you are promoting a product.
Please refrain from doing so.
Esther

---------- Post added at 04:03 PM ---------- Previous post was at 04:01 PM ----------

dear Kalle,

Please do not promote a product.
If you have any questions regarding the discussion about, feel free but now it looks as if you are promoting tape... this conversation ended more than a year ago