History and Presenting Symptoms
The patient is a 22-year-old recent college graduate, who reports a history of participation in many team sports in school, including field hockey, soccer, and softball. She admits that she has always had occasional knee problems, especially on the left side. She is now running regularly for fitness, and her left knee is noticeably sore and aching. More recently, she has developed stiffness and pain in her lower back, which is most noticeable after longer runs. She denies any specific injury to her knees or back, and reports that over-the-counter medications provide temporary relief.
Exam Findings
Vitals. This fit young woman weighs 126 lbs which, at 5’5’’, results in a BMI of 21—she is not overweight. She has never smoked tobacco, and her blood pressure and pulse rate are both at the lower end of normal range.
Posture and gait. Standing postural evaluation finds generally good alignment throughout her pelvis and spine. She has a mild bilateral knee valgus and moderate calcaneal eversion, with hyperpronation on the left side. Measurement finds a standing Q-angle of 27° on the left and 24° on the right (20° is normal for women). Evaluation of running gait identifies a tendency to hyperpronate, especially on the left.
Chiropractic evaluation. Motion palpation identifies a limitation in lumbosacral motion, with loss of endrange mobility to the left at L5/S1. Compensatory subluxations are noted at T10/T11 and T7/T8. Neurologic testing is negative.
Primary complaint. Clinical examination of the left knee finds no evidence of ligament instability, meniscal damage, or patellar tracking problems. All knee ranges of motion are full and pain-free, bilaterally. Manual muscle testing finds no evidence of specific muscle weakness or regional neurological dysfunction.
Imaging
No X-rays or other forms of musculoskeletal imaging were considered clinically necessary.
Clinical Impression
Excessive Q-angle on the left, associated with calcaneal eversion and hyperpronation. This is accompanied by lumbosacral and lower thoracic joint motion restrictions and compensatory subluxation.
Treatment Plan
Adjustments. Specific, corrective adjustments for the lumbosacral joint and the lower thoracic region were provided as needed. Manipulation of the left knee into external rotation was performed to decrease the internal rotation associated with her elevated Q-angle and hyperpronation. Both feet were adjusted as needed, especially the navicular bones.
Support. Custom-made, flexible stabilizing orthotics were provided to support all three arches and decrease the Q-angles. These included bilateral pronation corrections at the heel. As is necessary for most physically active patients, two pairs of stabilizing orthotics were ordered —one designed specifically for her running shoes and the other for her dress shoes at work.
Rehabilitation. Due to her active lifestyle, no specific rehab exercises were required. She was encouraged to perform a comprehensive stretching program after each run.
Response to Care
She reported a rapid response to the spinal and knee adjustments. After she began wearing her orthotics regularly during her runs, she reported a definite reduction in knee soreness, as well as a smoother stride and gait. Within three weeks of receiving her orthotics, she related that she had successfully increased her mileage in preparation for an upcoming 10K run, with no knee pain or back problems. She was released to a self-directed maintenance program after a total of ten treatment sessions over two months.
Discussion
The Q-angle is formed by the quadriceps muscle (primarily the rectus femoris) and the patellar tendon. This measurement quantifies the quadriceps muscle’s pull from the pelvis to the patella, and the patellar tendon’s pull from the tibia. Since large forces are transmitted through the patella during knee movement, any increase in the angle can result in a variety of symptoms, as well as problems in the pelvis or lumbar regions.
Because of their wider pelvic anatomy, women naturally have higher angles at their knees. The standing Q-angle is an objective method of measurement that includes the valgus stresses on the knee and internal rotation forces due to excessive foot pronation. Since we are most concerned with understanding how the knee functions during daily and sports activities, it makes more sense to obtain this important measurement while in a weight-bearing position.
Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program and lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System. He can be reached by e-mail at [email protected].