So if I have a tibia that's going ER and if you ever see this going IR, you've got a patella that's going to get pulled laterally. Good morning. Happy Monday. I have neuro coffee in hand and it is perfect. All right. Digging into a new week. Quick note of housekeeping. For fast view members, the Q&A from last week is posted and ready for your viewing pleasure. So take advantage of that. Digging into today's Q&A, this is with Kade. Kade is working with a very high level basketball player that has a history of some tendon related issues in the knee, had a little bit of recurrence of knee pain. He's managing it actually quite well. But we did talk about probably what you're going to find most often in these situations is you're going to have a mechanical issue with the knee. One of the most common findings you're going to have is you're going to see this tibiofemoral ER represented at the knee. One of the easiest ways to check this is via your heel to butt knee flexion measure. So when we have a limitation in knee flexion, we oftentimes have that mechanical issue where you have tibiofemoral ER, which would be promoting the screw home representation, which would be an extended representation of the knee and therefore knee flexion becomes limited. So using that as a test may be helpful for you. But we discussed a number of things in regards to the mechanical orientation, how to address some of the tendonopathy related symptoms as far as loading the tendon, how we're going to go about that. So again, probably going to be useful for a lot of people. So thank you, Cade. If you'd like to participate in a 15-minute consultation, please go to askbillhartman at gmail.com. Put 15-minute consultation in the subject line so I don't delete it. We'll arrange that at our mutual convenience. Everyone have an outstanding Monday, and I will see you later.

Okay, Bill. So my main question is regarding an athlete that had to place basketball. He's been playing basketball for quite a while. Definitely has some changes to tendons, particularly at his knees. He has some different movement characteristics that I want to take into consideration. And so the main question is, knowing what I know about the way that he moves, what can I do to make sure that we're loading right and left knees appropriately from a tendon health standpoint?

Well, good luck with appropriate, right? When you're talking about high performers.

For sure.

So they're always going to use compensatory strategies because they have to produce high levels of force very frequently and much higher levels of force than the average person. So you can't treat them like average ever. So I think you've had experience with this person over time. Am I correct? Okay. That's the best way to determine what the best course of action is, is to collect the data over time as you intervene and then see what happens. It's my understanding that you were doing really, really well and then you had a recurrence. Is that correct?

Very, very mild. I wouldn't necessarily call it a recurrence, but it was a signal like, hey, it's something's going on. Okay, let's start. We also had a UTC scan done.

And those are handy. But again, they're certainly not a measurement of symptoms, right? So we always have to take that into consideration as well. So let's think about what you've got going on here. You've got a guy that's got to produce a lot of force. So he's going to live near or in internal rotation all the time. The question is, how does he produce that? Chances are, the higher the force production, the less relative motion you're actually going to utilize. And so that would be normal under his circumstances. So you should expect to see anti-rotation in the pelvis. You should expect to see changes at the ankle and foot. You should expect to see concentric orientation of musculature that produces internal rotation, especially at the knee. Vastus lateralis is going to be concentrically oriented. Short head of biceps femoris is going to be concentrically oriented. What you want to make sure though is that you've got enough, and again, enough is the question mark when you're looking at performance, that you've got enough of the external rotation to capture positions and enough of the internal rotation to reduce force, and that becomes the question mark. So when you start looking at the knee itself, how close to a heel-to-butt measurement do you have? So that's going to give you an idea of how much tibiofemoral internal rotation you have. So you have normal knee bending. So if you have a situation where say you have a femur that is internally rotating to produce force into the ground and you've got a tibia that is remaining in external rotation, you have a mechanical disconnect, so to speak, as far as where you want those knee mechanics to be to produce force. So if I have a tibia that's going external rotation and a femur going internal rotation, you've got a patella that's going to get pulled laterally, which it loves to do, because that's where it came from. So if you have those circumstances, you have a mechanical circumstance that can produce aberrant mechanics during force production. Whether it becomes symptomatic or not, that is duration of symptoms, how severe are the pressures and tensions that are related, and then what is the perception. So again, those are all in play. But from a mechanical standpoint, you want to make sure that you've captured enough of the tibiofemoral internal rotation so that when it does come time to put force into the ground, he's doing it with, I don't want to say balance of forces because balance is variable, but sufficient downward force through the joint versus say a situation where you've got more load on the medial aspect of the femur. And you've got again the concentric orientation of say vastus lateralis that's pulling patella off center. And again, you're going to have a situation where you're going to increase the compressive load of the patella against the femur. Under normal circumstances, there is a higher pressure of the patella against the femur. The question is, is it distributed enough that that's no longer symptomatic? So if you look at the patellofemoral pain research and they always talk about how, oh, the pressure of the patella increases as you go into a deep squat. It's like, well, yeah, it's supposed to, but it's usually very well distributed. But if you have a situation where you've got this rotation across the knee, now you have a focal load that number one, if you think about this, squeeze the blood out of a patella, it hurts. You get an ischemic response in the patella itself. So people come in, they say, oh, my knee feels cold. Or they feel, again, the focal loading strategy. If you've got any imaging, you'll see histories where the cartilage will start to thin in certain areas on the posterior patella. But the thing that I would encourage you to do is to try to give him enough relative motion so he can capture these positions and learn how to distribute load versus making it focal with the understanding that it's probably not going to be a normal situation. Right, and again when you're working with superheroes, it's not normal. Right, you don't want normal because normal people don't run fast and jump high, right? And so you get to know this person over time by collecting data, you intervene to the best of your abilities, and then you monitor these things. But I would say that typically you're looking at some mechanical issues that may predispose some of this load to become more focal. And if you can distribute those, then that's great. You sent me some pictures of the hip internal rotation measures. So be aware as to where those measurements are taking place, okay? So if you do a prone hip internal rotation measurement, what is the position of the hip under those circumstances? So if you've got a pelvis that is anteriorly tilted on the table, I can guarantee you that you've got an orientation into external rotation as you're taking that measurement. So it would be much like watching someone squat and having to move their knees apart and toe out. Okay, so they're capturing a position of external rotation space so they can move into that. And then they produce internal rotation from there. So if you're measuring under a similar circumstance, take that into consideration as to where you are capturing that internal rotation measure. Because if it's not in line with the axial skeleton as would be a standard measure, then you need to be as consistent as possible with how you're measuring. So you know when you're making a favorable or an unfavorable change.

Where again you're going to have a situation where you're going to increase the compressive strategy of the patella against the femur. Under normal circumstances there is a higher pressure of the patella against the femur. The question is whether it's distributed enough that it's no longer symptomatic. So if you look at the patellofemoral pain research, they always talk about how, oh, the pressure of the patella increases as you go into a deep squat. It's like, well, yeah, it's supposed to, but it's usually very well distributed. But if you have a situation where you've got this rotation across the knee, now you have a focal load. That, number one, so to think about this, if you squeeze the blood out of a patella, it hurts. You get an ischemic response in the patella itself. So people come in, they say, oh, my knee feels cold. Or they feel, again, the focal loading strategy. If you've got any imaging, you'll see histories where the cartilage will start to thin in certain areas on the posterior patella. But the thing that I would encourage you to do is to try to give him enough relative motion so he can capture these positions and learn how to distribute load versus making it focal with the understanding that it's probably not going to be a normal situation. And again, when you're working with superheroes, it's not normal. You don't want normal because normal people don't run fast and jump high. And so you get to know this person over time by collecting data, you intervene to the best of your abilities, and then you monitor these things. But I would say that typically you're looking at some mechanical issues that may predispose some of this load to become more focal. And if you can distribute those, then that's great. You sent me some pictures of the hip internal rotation measures. So be aware as to where those measurements are taking place, okay? So if you do a prone hip internal rotation measurement, what is the position of the hip under those circumstances? So if you've got a pelvis that is anteriorly oriented on the table, I can guarantee you that you've got an orientation into external rotation as you're taking that measurement. It would be much like watching someone squat and having to move their knees apart and toe out. Okay, so they're capturing a position of external rotation space so they can move into that. And then they produce internal rotation from there. So if you're measuring under a similar circumstance, take that into consideration as to where you are capturing that internal rotation measure. Because if it's not in line with the axial skeleton as would be a standard measure, then you need to be as consistent as possible with how you're measuring so you know when you're making a favorable or an unfavorable change.

For sure. And I can definitely say that when we put him on his back and measure on the right side, there's a lot of side bending. A lot of it comes from his trunk. His knee is most certainly stuck in extension on that side. He's got a twist. He's got an hip-rotation and then a knee-rotation of the lower leg.

Right.

His knee is most certainly stuck in extension on that side. He's got a twist. He's got an eye-arring and then a knee-arring of the lower leg. The side that I think is probably more likely to become symptomatic over time because it's just based off the way that he moves and some of the other stuff that he has going on. He has changes to his Achilles, very mild plantarious compression on the medial side and then also like his big toes.

Yeah.

The side that I think is probably more likely to become symptomatic over time because it's just based off the way that he moves and some of the other stuff that he has going on. He has changes to his Achilles, very mild plantaris compression on the medial side and then also like his big toes.

So you have a plantarious compression?

According to the UTC.

Okay, now hang on. This is useful. So think about what the knee would have to look like to get a plantaris compression. Yeah, so you've got a fluid shift that is posterior. Like a posterior lateral fluid shift, am I correct?

Yeah, he had like a little pouch on the front of his knee that we were able to it was like it almost looked like his knee was swollen.

Yeah, so that gets confused a lot because it's just the orientation of the knee.

It was weird. I don't think it was synovial fluid.

Yes, absolutely. So as I said, this gets confused with swelling in a lot of cases because what you have is the femoral orientation resting on top of the tibial plateau. And so it creates a shift in the fluid compartment itself. You get a sort of anterior aspect of the knee that shows a little bit of puffiness, and then the posterior aspect looks swollen. Again, it gets misidentified. A lot of times the athlete will complain of posterior pressure at end range knee flexion, and it's often just the fact that they can't reorient the knee to move the fluid out of that area. So you're just compressing on an incompressible fluid, and that's what they end up feeling.

Yeah. His knee flexion and the butt improved tremendously once that started to move back in the correct direction. I guess a quick follow up, because I know you had talked previously about loading Achilles differences like a posterior calf that's compressed. Put them in a seated position, like a seated calf raise, make sure they're in the same position.

Yeah.

Let's just, I guess, as an exercise, if we're checking all those boxes from a movement standpoint, like you just discussed, and we do want to do some direct loading of those tendons, like if you look at the research, most of the research is going to suggest that you put it in the most lengthened position possible. So like old school knee extension, put it all the way at the bottom and then you only apply pressure and hold for an isometric and so on.

Yes, sir. Do I need to? Sorry. That's not the thing. No problem. into consideration when loading. Is it going to be the same thing? Is it going to be creating a situation that I don't want if I do that on both sides? Did I have one side that's like an EQI, like an asymmetric, almost an EQI? Would that be a better fit for one side or the other? I'm just trying to figure out best way to load.

Do I need to? Sorry. That's not the thing. No problem. into consideration when loading. Is it going to be the same thing? Is it going to be creating a situation that I don't want if I do that on both sides? Did I have one side that's like an EQI, like an asymmetric, almost an EQI? Would that be a better fit for one side or the other? I'm just trying to figure out best way to load.

Sorry. That's not the thing. No problem. into consideration when loading. Is it going to be the same thing? Is it going to be creating a situation that I don't want if I do that on both sides? Did I have one side that's like an EQI, like an asymmetric, almost an EQI? Would that be a better fit for one side or the other? I'm just trying to figure out best way to load.

That's not the thing. No problem. into consideration when loading. Is it going to be the same thing? Is it going to be creating a situation that I don't want if I do that on both sides? Did I have one side that's like an EQI, like an asymmetric, almost an EQI? Would that be a better fit for one side or the other? I'm just trying to figure out best way to load.

You're talking about loading the Achilles, right?

Right now, Patella. Patella. Oh, so we're talking about a squat where we're talking about just anything like yeah, I mean any position I'm not married to anything but my question is like you had mentioned there's kind of like a best way to load, like okay, you've got this posterior compression in a right calf. Like he does right straight leg like standing, like loading his Achilles in that position might not be the best. Okay, yeah, well okay, so again, you've got some mechanics to deal with here as to how you're going to load the Achilles.

mechanics to deal with here as to how you're going to load the Achilles. So obviously loading it in a bent knee versus a straight knee orientation is not going to be the same. Is that kind of what we're getting at?