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