LCL Sprain Diagnosis and the Functional Approach - WIR 37

In this conversation, Dr. Beau discusses various cases of knee pain, focusing on lateral collateral ligament (LCL) sprains. He presents two case studies: a 58-year-old male skateboarder and a 43-year-old female runner, detailing their injuries, treatment approaches, and rehabilitation strategies. The discussion emphasizes the importance of understanding the underlying causes of pain, the role of strength training in recovery, and the need for a holistic approach to patient care in sports medicine.

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Dr. Beau (00:01)

back so this is I was behind an episode so that was 36 35 and actually we went till May I thought we said April the last season

That's a conspiracy. That's the new conspiracy we just started throwing around. Is it subtract? Updates from last week. My runner I haven't seen. I'm assuming that means he's better. I thought you did. No. I saw him the day after. That's right. He was fine. And then he raced. like, I'm here because it was supposed to be... Yeah. And he raced. One wasn't competitive. If he did get boxed down, it was like tenth or like first half mile or something.

I guess they've had sexual assault since then too, which we also won that race. So, good. I'm seeing them. Hopefully just not grand or invariant by the way. Your runner? Yeah, she's doing great. Her runner. Crossfit. Runner, Crossfit, High Rocks competitor. She's good. She... Hybrid athlete. Hybrid. Anything with high in there? We're just going start putting it. I've only ever seen that High Rocks word like twice. I don't even really know what it is. High Rocks is an endurance-based Crossfit.

It's like you do some, I think it's like a thousand meter row and then you have something to do that's like weight based in the middle. So like, it's like a thousand me. Like one of them that looked up is like, you have a thousand meter row and then you have like burpee broad jumps for like a hundred meters. Then you're back on a rower for like a hundred, like for a thousand meters and you to standardize. Like this is the workout that you're going to compete in or is it change? a, okay. It's that format. so no other updates. She's good.

Yeah, she did some lateral runs, like some shuttle runs, but she was worried about that. Yeah, she has no issues. Are we talking like elementary school PE shuttle run? I don't know. didn't ask what grade level shuttle run she was doing. I'll do that next time.

hearing me or not. I'm a lot of squeaking. For any patients listening, we just changed up the functional health coaching model on here. It's now some monthly based membership. can go to chiropractor.com, Backsplash, whatever. I don't know what it is. Functional health coaching, something like that. Find out more information on that. can sign up in office or online. Also, there's a forum at bottom. I don't know who's got their vibrator on. Somebody. Maybe it's me. No.

It is Alex. Alex is getting his reminder to say it's prostate medicine. Yeah, there's an info form down there if you have any questions because a lot of people just kind of want to know more about it. It's bullet pointed and if you ask more questions, I'm just going to be honest, I'm going to probably tell you bullet points because it's pretty low. So yeah, we'll have to get more people involved in that, but let me know if you have any questions for real. Presenting today sets the lead. So what's the case about? So this one's going to be outer knee pain.

And again, we're being a little more broad. So what would be the, so go real fancy. What would you diagnose as side if you're being a fancy doctor person? LCL sprain. Ooh, that's not that fancy. But trying to be Fibular or lateral collateral ligament. The reason that we're saying lateral knee pain is in our doctor's meeting last Thursday.

case and then what Alex is going to present on. But we started with differential diagnosis and when we come up with like 12 things. yeah, LCL, which this, you know, is a, I would say not a classic mechanism, but a classic presentation of LCL disruption or sprain. But in there we have what? LCL, lateral meniscus, tibial plateau fracture. We put trigger points in the differential diagnosis because they can be

solo pain generators outside of any pathology, lumbar radiculopathy or pseudo radiculopathy. Peroneal nerve. Peroneal nerve. What else we got on there? Cutenius. Yeah, cutaneous nerve. Peripheral sensitization. Meniscus. Meniscus. Our big one was just a list of trigger points I referred there. Yeah, and a lot of people are like, well, it's not really a diagnosis. There's a lot of people running around with, and this is what we know more now is,

You get an image on somebody, everyone knows this, let's say they have tear in their lateral misc, when did that happen? Is that even the pain generator? Then the trigger point could be fin-storing mechanisms creating pain. You get into this whole discussion and I think that should be a primary diagnostic feature. So all that's been said, get after it Seth. Let's do it. All right, so this case, I've got a 58 year old male with left outer. This case. We're losing all West Coast viewership right now.

Sorry. this… On the prescribed plan I'm looking at, 58 year old male with left outer knee pain, he noticed this about two weeks prior to this first visit. He was skateboarding, stepped off hard into an incline. Mind you, he took like 18 years off of skateboarding and got back into it just because of something he wanted to do, I think, with his son. So he now skateboards.

Yes. Yes. It's it's out there and starts like, Sean. If you want to go kind of body type, I wouldn't say it's like your normal skater, skater look. He's got a, he's done very well. He's lost like a hundred pounds or something like that. I think in the last year, year and a half or something, went through some like traumas past. So now he's kind of getting back into it just with walking.

and then getting into some trail runs, which is actually where I met him was actually at a trail race that we worked. But yeah, so into an incline. So he's trying to do some trick. He said that he's just trying to learn, I guess, like how to get the skateboard up onto the side. I don't know, a little ollie type thing. I don't know. I don't really know super like skateboard fancy terms, but he's trying to go up and he kind of got nervous. he kind of got step stepping off. And so he was like hard planning because he tried to some speed into the ramp.

hard plant to an incline. He noticed he has some radiation with his symptoms up into his lateral thigh and a little behind his knee. He had some swelling that he noticed after this incident about two weeks ago, sorta went down, but hasn't really gone down too much since it happened. He notices that the worst pain is when his dog actually comes up and bumps into the outside of his knee and he gets like a shock. Yeah.

which he gets a reading sometimes up again until the lateral aspect of his thigh.

like Wigman's

see how his referral pattern is like up into.

which initially my first thought was kind of like, we're dealing with a nerve. Cause when I hear like a little shocking symptom, when you get smoked really quick in an area that the nerve is pretty close to the skin, I'm like, okay, we're probably dealing with a nerve. But then when he points to it, I'm like, there's not really a nerve out there until like where it radiates up into. The other thing that he complains about is he does, so he does some like stretching routines when he's in the shower. yeah.

I did not go into detail. I just said, so when does it hurt the most? And he's like, every morning I do some type of stretch routine in the shower. And that's kind of how that came up. So it was a pretty broad question that led to a very specific time of day. So he notices that when he squats down, he does get some pain in the outside of his knee. Outside of that, he has a little bit when he walks, but nothing really except for mostly when he notices that his dog, because I think he has four dogs at home.

So whenever he walks, I'm like, all of them are about like knee height and one like just smokes his knee. Prior to this event, about like a month before he clipped a tree mountain biking, broke his left big toe and fractured a couple of ribs on his right side. Past surgeries, rebuilt collarbone in 2023, gallbladder removed in 2020 and a melanoma removed in 2000 in his mid back.

And his main goal seeing me today was he wants to be able to run the endless mile in three weeks.

And he did the 72 hour one and his goal was 100 miles. Did he do it? He got 100 miles in.

So pretty sweet. So watching him walk, a little bit of, I would say bowing of his legs when he walks on both sides. If you want to say almost like the cowboy walk, where like kind of like a wide based stance, like knees, I don't know, just a various kind of stress to him. No extension of left hip. And then he has a foot flare on his left as well. Top tier dysfunctional non-painful on most things, all cervical and obliquity patterns, multi-segmental flexion, extension.

right rotation and single leg stance on the left.

doing class four speed tuss, Pokemon where it hurts.

In particular, in this case, yeah, there was a trauma, but if you listen to the beginning and you're familiar with like an LCL injury, if you looked at like a football player that's going to have an LCL terror soccer player, you'd usually think like some like inside to outside, like blow on the knee, right? And you're going to think bend the knee to the outside. well in this guy's case, he just like Seth said, he had like a heart plant, which doesn't seem at all like that would be an NR differential diagnosis.

which brings in things like tibial plateau fractures and things like that. I don't know how much you think it weighs on it, but having that various kind of knee formation already, and then you're stressing all the time, if you take hard step, mean, maybe there's more lateral force there. Just general broad-based movements, some of those hurt, some of those don't, and some are dysfunctional. That's kind of what we talked about in our doctor's meeting was actually like how many people are actually walking around with a degenerative?

LCL sprain and based on his age is kind of something that popped into my head of like he could have degeneration here and then now it's just getting ticked off because he's doing something that's out of the ordinary. Which again drives me nuts and if you're a patient listening like you know look at the image report or ask the physician that you're dealing with. Drives me nuts when they say like a sprain but it doesn't say acute or degenerative which would be called off edema which is what they're usually calling things off of. You can also have

know, less a coke response, you're going be thickening, you know, all these things and they just might call it a spring. You're like, well, is it old? Is it new? And that's kind of what we were just talking about. So that drives me out telling the impression of the reporter, it's just like spring. New, old, what are we talking about? Yeah, I feel like they usually do that on a fracture, they don't on the soft tissue side. The stress fracture, yeah. They'll call like signs of recurrent healing or non-healing or something like that. Yeah, just, I feel like get impressions in general.

Which is funny, did you guys see the impression from my patient that went to the open MRI? The MRI that you can just go on your own, no referral. Had grades on there, for... Yeah, the report was huge. I don't think the read was awesome, but the report was just massive, which is kind of funny for this cheap open access MRI. The report was like 10 sentences long. Going off of that as well, I know it's kind of side note. I didn't realize that...

Was it the stress reactions? that what we looking at? Had different grades to them or something like that? was like grade one through like five or something like that. That's based on percentage, right? Of healing you're saying? No, progression of basic.

how much the stress reaction might go on from the periosteum.

I would assume we can look it up real quick. A grade three would be where you can probably pick up on an x-ray if you have that 60%. So let's keep going. Yeah, I'll keep going. So just a recap. Top tier dysfunctional, non-painful, all cervical, upper extremity patterns, multi-segmental flexion, extension, right rotation and single leg stance on the left. He was functional non-painful with left multi-segmental rotation and single leg stance on the right. And then...

Dropping down inline lunge, dysfunctional non-painful with right knee down, left leg up. And then I tested a little bit more just because there was a discrepancy in rotation. I used lumbar lock to see if maybe anything with like his mid back. He was dysfunctional non-painful bilaterally there, just in his back in general. I mean, it's very, very stiff, which I'll get to in terms of palpation. But I also use it as well for just a passive knee flexion, because he said he gets pain with squats.

So I just use it as a passive knee flexion to see if it was like load that really like bugged it and he had no pain when he did that. Other exams, so orthos. Varus stress was painful. Thesales was a little painful when he rotated out. I did Nobles test, which is just a little bit for like some IT band stuff. If you like, know, flexion extension.

poke on the IT band, sure, whatever. But more so just kind of compressing the bursa that's underneath there and then taking them through extension, no pain there. What's Obers? Obers. Obers is a side lying pull the leg behind it and the hip extension and let it fall. So what's the- That's IT band. Abduction, is it? IT band is Obers. What's the one with abduction? Internal rotation. rotation. Is that Faiers? Fai-deer? Fai-deer? Where you're like letting it hang in and see-

There's fey bears, o bears, fey deers, and fey air, and feyers, and then leg air in the air. In the air. the air. I did not do belopment. I'll just tell you that.

The grading for stress reaction fractures.

which starts out with periosteal edema.

Yeah. Sweet. Then I went over and did a little bit of palpation. So easiest way to check LCL is put it in like a fey bear test almost. So you kind of put heel, I guess put it like a little, how would you put that? Quad lock? I don't know how to put, say that bend the knee, flex it, lay it on the other knee. And palpated is LCL from there, painful. And then.

Lumbar orthos, negative, couldn't reproduce anything, just looking for any low back referral, checking those out, couldn't do anything there. Presentation, if I had him prone, a little bit of hollowing of his left glute. And our last intern, Patrick, was in the room and he even picked it up. He's like, that glute looks different. So when you lay him down, his left glute just sunk in. It's not as full as the right one. So it's kind something I just took into note.

No.

Range of motion, external rotation of his left hip is limited and then he had limited ankle dorsiflexion on the left, neuro normal and then palpation wise. Limited and extension of left hip, tibial ER on that side, TL thoracic and CT junctions. He had a trigger point and lateral gastroc, vascular lateralis and then tone of his left glute musculature. I just put tone of like whole musculature on that left side.

because I wouldn't say it was like trigger point, but I'd say it's just like holding on for dear life with the hollowing there. Functional audit, I actually used the glute as one of mine. I had single X-stance on the left and then his central stabilization strategy is pretty bad. Pain audit, bearish stress and tenderness of touch. So I came with my diagnosis, LCL sprain.

Treatment day one, I did a little bit of grasslander, instrument assisted over the LCL just to kind of promote some healing. Because again, it's been going on for two weeks. It's kind of promote a little bit of something going on there. Looked at three months supine for his IAP because laying down on his back, he has a pretty significant like rib flare. So I just want to see like how he breathes in general. He's also a pretty tense person. So like whenever you're moving him around, I mean, it's like kind of fighting a bear the whole time. He can't relax. I'm like, hey, just let your leg go and.

that actually makes it worse where he just like holds his leg up in the air for you. And I'm like, all right, do what you were doing before. So then I wanted to attack honestly his left hip just because I noticed the way the hollowing of his left hip. So I knew that he had a little bit of trouble, I guess, absorbing some load on the left side with the mechanisms of injury that he has. So I was like, let's try and calm down some musculature on the hip. So I put him in a five month rolling position. He could not roll.

So I lay him on his left side and have him like just push back into me and he literally can't produce like any force into me. So when you say hollowing, you're saying like atrophy of musculature or active like contraction? Active like contraction. that was the thing I was like, can you get this to relax? And he can like slightly for a second. But I mean, for the most part, he couldn't like eventually he couldn't just like let it all the way relax. So again, put him a five month sideline on left side.

have him push back into me and he can't. So like we can't even do like step one. So then I was like, let's try and roll you a little bit farther and see if I can't get a stretch on it. And then you push back into me. He still can't do that and actually catches a cramp on like his like right hip trying to do this. Which while we're doing this, you can feel him using his right leg the whole time in order to push back into me. So I was like, okay, well how can I do something with this left hip in general? So I put him in actually a little star plank on that left side and had him just hold, which he started.

kind of seeing like, okay, hey, my left glute like burns holding this position. And then we worked a little bit trying to get him to like lower down in that position just to get some stretch on it. And then taped his LCL, which I did a little bit different than you described in our meeting, which I just put a piece of tape down kind of lower third of the thigh all the way down to like the top third of the calf on just the outside. And I took a piece just because I noticed he had a little bit of like tibial external rotation.

limitation, I took tape and wrapped it so it kind of almost like pulled it into external rotation to kind of help offload his LCL a little bit. And it's also just some pain relieving just because it's over the LCL. So adjustment, CT thoracic, TL left ankle, homework, send home, Starplank and IAP work. Second visit, which this technically was actually visit four because the second visit he came in, we worked on his neck because he got laid back in a

dental chair and had like, I don't know, his neck got smoked from it. And then third visit came in with some like right low back complaint. He got up that morning and I don't know, he like couldn't hardly stand up. So we worked on those two things. So second visit, feels much better today, which I would say this is probably a week later. Did not feel it while skateboarding this week. Still a little tender to touch, but I think the first visit.

And then various stress is still slightly painful, but he said it's like a one or two. His glue, he said, is super sore from the exercises that we sent home. So the next visit I did some grass and again, some IAP, like review and star plank review. And then we moved into a rotational plank, cause he still couldn't do the, like sideline position. So I moved into a rotational plank to see if he can maybe use his elbows as a little bit of like a prop, to work on the left hip.

So I sent him home with rotational plank. Third visit, no tenderness to touch this time. No orthos are provocative either. And then treatment, reviewed IEP rotational plank, did a hang position to start kind of getting his foot involved because again, we're still dealing with a fractured toe on his left foot. So he's still trying to offload his toe a little bit and then worked on some 90-90. Fourth visit, which how far do you want me to keep going down? Because I have...

I've seen him probably like 10 times and I did to like visit five is kind of where I stopped for this. But fourth visit did some low oblique this time with rotation because I wanted him to start kind of seeing what it felt like to use his foot and lower leg in order to rotate around his left hip as we're instead just kind of like pivoting around his knee more so using his hip. Couldn't figure out how the life of him to do that.

which I kind of just like helped him like pin his foot down. He figured out what that felt like and was able to kind of do it from there. So sent that home with him. And then fifth visit, I worked on some rotation just because he had that discrepancy if I'm not mistaken, it's to the right. Yeah, right rotation. So I did a diagonal RDL because I know it's going to his left when he's doing a like some rotation to the left, but then also did a half kneeling kettlebell rotation to the right.

because it helps work on some like left hip extension and right rotation, which is two things that he's lacking. So homework, I did some diagonal RDL. But after this visit, this was, think, this was Thursday. No, this would be Wednesday morning. I saw him, yeah, Wednesday morning. And then he started the 100-miler for the, I guess, the endless mile on Thursday. And on this visit, he had no pain, was ready to go. I saw him again Friday.

which it was kind of just like a little bit of like a tune up, let's make sure you're still feeling okay to get through this thing. He was like 50 miles in when I saw him on Friday, and then he hit his goal of 100 miles by the end of Saturday. So. Okay, so let's break that down for patients listening. Guy came in with lateral knee pain from stomp.

Why did he choose us?

He just talked to me at a race and liked what we did. He had heard good things about us. We've seen him in past. So he's an old patient. Seen him for Achilles stuff and things like that. So have a history with him and then we're in his face.

Permanent history stuff, you know, like he'd have had yet ever had knee stuff before. So there's like no big orthopedic injuries. kind like, what's going on here? he's got all these things he's wanting to do. you know, again, just trying to break down for patients listening, like the big findings aren't that, you know, in my opinion, that Seth thinks it's an LCL sprain. It's like, like you had a weird little injury. Let's work on your hip.

and kind of these other findings around it so we can alleviate undue stress on that thing that might be occurring all the time, not just in skateboarding. It's probably hard to pick up the translation of a lot of, if you're a patient of when we say things like, we sit or low bleak sit or five month sideline. But basically, if we had to really break this down, it's this guy, like Seth said, has a hard time.

dampening load around his left hip and in particular like sucks at creating a rotation or like stopping rotation on that side. So then if we had to take the two mechanisms on the side of your knee that might check rotation, one of those being LCL, like it might be getting beat up because of that. I think that's why Seth was working on that. And then in terms of like future plans, like you said, you've seen them a bunch more times. Like, is there anything that you think you should be doing in terms of like, you know, lifestyle shifts?

You know, in terms of like train a big goal in here, I think we try to take whatever we're working on immediate realm and then say, Hey, let's like, we're going to play the, apply these concepts into like what you're doing in cross training or something. there anything that you're like, you know, if I see this guy consistently over the next year, like this is what I'd be working on. Anything different or is it just kind of same theme and just more of the same, you know, build it up.

I know you sometimes we kind of lean heavily on like potentially just being like, he just needs to go like into a gym or something like that. but I do think that that is something that he would benefit from because he doesn't do that. His only form of exercise is literally just like, so he started walking a mile, because I'm not mistaken that someone like in his life passed away, went through like a hard, hard block there where he got like super depressed. so.

His goal was just to get back into it was just to start walking a mile every day. And I think every month he added 10 % to that. Andy had been to a point where he couldn't run anymore. was a guy that was at recurrent acutely saying that I think he had a stress fracture, a legitimate fracture at one point in his foot. And like he had all this stuff and that's, you know, there for a while. was like every time we saw him in a race, he was racing. He'd walk up and like, I can't do this. And then he like, I don't know if he took time off or just started walking instead of running. don't know.

Yeah, he took like two years off of like not doing anything just because of life. But yeah, so he's up to where he's like, so his exercise consists of he does longer like ultra trail runs with I would say minimal running during the week and like a mile and a half walk is like his like big form of exercise along with skateboarding.

So I think that that's something that will play really well with the gym is just like, honestly, you sometimes have to set yourself up or get the joints, tendons in those areas to actually be ready to handle the stress that you're putting through it, right? At least increase the muscular endurance through there. Just again, he had, it sounds really cool, right? He got my knee pain, he's back skateboarding, we're in the Sun and All the Rays. We'd be setting up.

soon we're like we're just another person that's you maybe better than other offices and getting people out of pain moving but we actually didn't like push them to be like a healthier person or a more resilient person so I think that's something that's highlighted is in our framework we're never just like to get out of pain get you moving get you do that race that is a goal but like hopefully that's motivation and then we can kind of build off that to like hey we get you moving a little bit different and you feel better like we think you got to work on these things whether it's

something that we're supplying or just frameworks and concepts that we educate them on. But that is extremely common theme in the ultra running community. It's just, you're only doing that thing where you're vastly underprepared for the competitions you're doing. And I fall into that category sometimes too, if you're just going to stuff and I'm know, credit bearer. Yeah. Cool. Anything else with that?

He also told me that he prints off every time, the, whenever I send him like, our rehab, my patient, he prints off all those. Cause he's like, I want to add these to my routine. So he goes, I kind of get up. And even though we haven't done these in a while, I still kind of do stuff from the very beginning. Cause he, he told me he's like, I know, cause he said I can see the difference from what we've done in here to when I go out and I do run and I do walk. He's like, I can tell that there's a, there's something different about how I feel when I go do them.

And he's like, so I just thought, well, if I feel this good now and I continue working with you, what could I feel like in a year? So he does have like a long-term play like in his mind. And he's like, I want to get to where like we start taking this stuff, like to some weights. mean, he mentioned about doing some weights. That's why I brought it up. mean, that's intrinsically motivated. You didn't tell him to do that. He's also setting up an amount of time with stuff that we would all be like, well, that's not really changing.

shifts. But then we can just do what? It's like say, hey, we don't want to add more time. We just want to slowly progress those drills, challenge more, use the same amount of time, whether it's daily or a couple times a week. like you can literally start to really have a big change. And that's the tough thing is when somebody is looking for a quick fix, get out of pain, get me out of here. And you know, there's bigger lifestyle thing, like you don't, you know, they have to come up with the idea. So these are the literate telling you that. it's teed out, which is nice. And then the other thing is

You mentioned like stuff that we're like going to continue working on. his mid back, I know that's something I brought up because I mentioned central like his central stabilization strategy, but I can throw that on anybody almost I feel like. But for him specifically, he had that melanoma removed back in 2000 around, I would say like if you want to get specific T6, T8 range. And he's actually like tender over like where it got removed on the left side. And I would say that's probably one of the stiffest spots for him.

especially when he tries to create rotation, which the half kneeling like kettlebell rotation, he can do it if he's just body weight. I add a five pound weight to that. can't, he can't hold the, he can't hold that up at all. So it's honestly just like getting him there in that position. And then I honestly just apply a little bit of pressure, but that kind of goes back to like, you know, what do you start with for like the most like functional piece? It's like,

to a point, like I gotta treat the injury here, like almost like touch him where it hurts, treat the bigger underlying thing, but then it's like, you mentioned, do I set him up for, you know, a potential, not catastrophe, but like, fall because he has more confidence in the left side, even though we didn't actually address like, hey, how you stabilize around your core is like not great, a med-back super stiff.

That's the key to what we're doing. It's like, yeah, like everybody's got this thing like, my left hip doesn't move like my right. I should work on that more than I do, but it doesn't mean that I'm just doing mobility stuff for 15 minutes every day. Like you could program, you could do that sometimes, and then you can program stuff specifically. And it's, in my opinion, it's not that one's, I think we kind of get in this discussion of like load management, weight room fixes everything, quit doing your stupid mobility stuff.

like that's not completely true. mean, there's stuff that you have to do tissue work on, you know, things like that. yeah, it's a little bit both, but that's the end goal for all of our people is a healthy person, not in pain. And, know, that's rarely just like get their T-spine moving or their T-spine moving different to the office. The other thing, the reason why I started working on it is because he said that he went on a longer run this, this weekend and started feeling like his upper neck or like upper back between his shoulder blades.

whenever he ran, whenever he started like getting up to a jog, he started having like pain up through there in which, know, first thing I started getting like nervous. I'm like, yeah, you have like any heart issues or something like that. But then like, I put him to like a little FCS test, which is just 90 seconds of can you split the weight 75 % and I actually did it like half his body weight and he barely passed. mean like at 90 seconds, he was like going to the ground.

body weight split in which

seconds and see you in eight.

really and you should be able to do 75 % of your body weight split between two implements for 90 seconds but not a big struggle at all. Then there's proxies if you have grave issues and stuff like that. Yeah, it's a good test overall. Alright, so not a full case presentation but you have a similar, it's in a tag, lateral knee pain? Yes, lateral knee pain and it's not the case we discussed on Thursday.

So just give us for this instead of the whole thing like give us similarities like this is LCL case is something different You know why they come in obviously it's lateral knee pain or knee pain And then you know what differed from sess even though because again what I'm trying to highlight for people listening is All of us in the room could have lateral knee pain. We get all of gun something. I tripped on the trail. He was skateboarding

He was playing flag football, you just been training for a race and all this have a lot of knee pain when you come to the office. we could all be very orthopedically minded, poke on, everybody's got an LCL sprain. And then what's that mean? So what's giving you rundown on that? Yeah. So this is a 43 year old female, a former collegiate runner. Her and her husband both were, and then now her kids are pretty high level runners as well. They were on vacation in Colorado.

And she had this, hers is also an LCL sprain. Hers was a traumatic singular incident where she was, they were walking the Manitow stairs. last stair she fell coming back down. mean, I think it's 2300 stairs. and she's prone to be a little clumsy, which looking back on her original intake now, I

I remember. 2768. 27. Yeah. It's a lot of stairs. Actually, technically it'd be 5400 because she went up and down. she fell on the last one down? yes. She fell the whole way? No, stair. The last stair before the parking lot. Yes. Yes. but she had also had a fall right before that. and she, mean, clumsy, but she's not a motor moron.

to put it lightly. But now looking back on her intake, I did make note that she has major visual discrepancies and visual acuity from left to right, legally blind in one eye. And she does wear glasses, but sometimes doesn't wear them when she runs. So there's also a possibility. However, so this was two weeks, no, was a week after it had happened when I saw her generalized swelling around the knee. She had not been able to run.

And had a bunch of abrasions around it too. that was, she's also, all right, this is sore cause I landed and cut my leg up. but so initially we, she did have some pain on orthopedic tests, Thessaly, Alpe's compression, no laxity in the ligaments, just pain on that outside by the LCL and really not a, a true functional audit at this point. Cause she was.

She had fallen and it was a tingly event. And so we were really focused on trying to get the swelling out. Did a lot of her pain and limitation was in knee flexion. or no, sorry. She had pain with flexion and extension and, she could tolerate knee flexion with gapping, putting a bolster behind her knee. So we use that to help get swelling out, interest instrument assisted soft tissue. and then I had just sent her home that first day with knee gapping flexions.

Over the first few visits, we did some more maneuvers of pumping that fluid out with knee-gap inflections, plantar inflection sits, had done some voodoo flossing around the area to continue getting the swelling out, and we taped the outside of her knee. And so for her, I saw her, I guess the actual trial care was 12, 13 visits over the course of, that was early July, and the last time I saw her was late October, and we were at the point where

She had gotten back to running sometime in August, late August. So six to eight weeks before she was back to running again and gradually increased that. But over the course of starting to introduce load, kind of similar to you with him was that I went to a side plank so that she could get some isometric load on that LCL and then progress that from there to...

various forms of lateral stabilization in a lateral squat with diagonal single leg deadlift. And she's one that kind of similar different in running because she's mainly road running, but she doesn't do any sort of cross training and your resistance training. And she had gotten to her, she was a little more open to that because her daughters that had been in here had also, they could benefit heavily from doing some of that. And they've started to do some of that in addition to their training.

So she got into where she was working out with one of her, I think her assistant coach twice a week and doing a lot of the things. Really it started by just doing a lot of the things we had shown her in here. And then now she's at the point where she's doing box step ups and lunges and skater jumps, things that we basically just progressed those forces up to including some plyometric. she's always had general, she mentions later, I've always just kind of had general knee pain going downstairs.

running down hills, getting up on and off the floor. You say you've always just had general weakness? Yeah, no. Well, she has not loaded her knees, you know, in any kind of way outside running. So she's not getting a lot of loaded knee flexion at all. And she says, you know, I'm just not I don't feel like I'm old enough for that to be a thing. And it's kind of embarrassing when I'm getting on and off the floor, like talking to my she teaches, she's like talking to middle school students, which I get down there level and I come up and getting up.

So long story short, she had started including some of those things and they were uncomfortable at first. She was a little resistant to any sort of tempo squats, that kind of thing. we backed it down to starting with a bear crawl where she could get some loaded knee flexion and then to a sled push. And then eventually to where she's doing some tempo goblet squats. And the last time I saw her, had run, she did a nine mile run.

which was the longest she'd done all year. She's running about 20, 25 miles a week. She's doing a half marathon in a couple of weeks, her and her husband are. And yeah, and now she's still continuing to strength train twice a week and feels a lot stronger doing those things. So yeah, it was more of an acute trauma that needed to be addressed. She didn't necessarily have a dysfunctional issue that led her to that problem, maybe other than not being able to see.

and then, but we were able to say, Hey, you know, I know you want to continue running for the foreseeable future. And something that I think that will benefit your longevity in that is some form of resistance training outside of the sagittal plane more than your body weight. cause I feel like I've heard from her, from other people in that age bracket who have run for half their life is that, well, you know, I do some resistance training. I, I do some body weight squats and I do some.

I've got some five pound weights at home and which we all know is not enough to stimulate any sort of buttressing against the forces that she's going to experience when she's running. Buttressing, man. I hadn't heard that word in a minute. Yeah. Go for it. You can steal it. You can use it. I'll copyright it. You can give me a couple of dollars at home, put it in the jar. So yeah, so that's where she's at now. And I don't think we, don't have a, an appointment on the books necessarily. It's more of a now she can use me as she needs me, but.

Well, I was looking for the chart. couldn't, it's on my hard drive, but you kind of said this happened back, happened during July. Yeah. Right. And then we're first week of November now, or second year, first week November. Four months. So it's also, you know, if we look at, so say somebody has an ACL surgery, right, the earliest NFL players get back nine months, which is pushing it, right. And a year is like the classic like ACL return to play. So even with, you know, if we graded those, I grade one for sure with

you know, Seth's case, I don't know. Maybe two. know, grade one plus two over here. So there's a timeline too, to when we expect that tissue to be more resilient just from a healing standpoint. You can throw all the loads at it. want the world, doesn't matter. The thing still has to be able to respond. Physiologically, you can just help. There's two things you're helping promote. You're helping promote a pro-inflammatory response when you load it or do soft tissue. Second thing is, which we talked about with like Keith Barr and

a bunch of other people, you look at Tom Smires, like the actual lines of stress that you're laying down across that area are a pretty big deal for expressing a full range of motion that can buttress the forces that are applied against it in the future. And that's something I don't think it's talked about enough of. General PT, right? If we leave people severely under-loaded, then maybe we didn't like...

You you get full range motion on the table and then you don't apply like the stressors when you're up off the ground. Like you said, outside of the front to back or sagittal plane. And if we thought about like the lines of tissue just on an LCL, like how are you going to respond to sagittal plane motion when you have to control current plane like shift in there? just adds something that gets missed quite a bit. You know, I would probably agree on like a lot of return to play criteria for like post-op TT stuff for an LCL is going to be like skater jumps and barrel bounds and stuff like that.

but I don't know how much that's getting stressed. know what mean? So I think that's a good point of timelines matter because we regularly see people, you know, getting around 10 visits for us is like maintenance stuff. So like you have to take that into account with the diagnosis of like, are we have legit trauma versus like, I think you're just having pain from, like you said, a trigger point or something. That's wildly different. It doesn't mean we kick you out of the office if we think there's stuff to work on. But again, that's taking into account with that exam.

Any other commentary on knee stuff in general or any of these cases? There was something to note when she started to get back into running. She was very hesitant about it. She obviously loves it, but she doesn't want to go back to square one. She doesn't want that to re-injure. The big thing for her was progressing those forces to where she's running.

on a more uneven surface and then she would notice when she'd have to take turns, those kinds of things that she's being challenged in the lot in this outside of sagittal plane. And I think that helped it click for her that, I need to do something that I have to do in this lateral stabilizing strategy to be able to load that because if I don't, me making these turns on trail runs and things like that isn't going to get any better because she could see the progress in, hey, if I just run on the track or if I run straight in the neighborhood, I'm fine.

So, yeah. I feel like that's also a community as well that doesn't prioritize strength training. Right. Yeah. Because I would, I would even say people who bike and swim still do more, I feel like than runners do. Cause it's like you go do some squats or something like that. People are always afraid of like, it's going to take out for my workout the next day and stuff like that. And it's like, well, upfront, yes, because you're like super sore. haven't done it. But if you stay with it, eventually like helps you run him because you come more efficient.

You're able to produce more force at the ground, keep your cadence and what happens, your pace starts picking up. So it actually like over the long term starts to help. But yeah, upfront, it's growing pains and it's nothing. It's just like anything else. And how many times when we were running, was it we would continue doing our normal strength plan for the week at the beginning of the season, even though, yeah, we're going to be a little bit sore from it, but come towards the end of the season, taper that off and you've got the benefit from the training over the last three months.

But now you actually feel poppy when you're not doing those things for the last two or three weeks of the season. And experience and goals matter. So like we're bringing Michael O'Neill, who's a local personal trainer here that just wrote a book to come on and talk about like hybrid training, you we're kind of talking fun out of concurrent training is what it's classically called. But again, if I took, you know, your patient, right, that a certain point of life just wants to be able to continue running, maybe drop into a race every once in a while.

They're actually gonna do better with concurrent training overall, right? That would be if you'll get data or just like, you know anecdotal stuff Because you're you're going for a longevity play All right, you know lean muscle mass is great for a of reasons and also power output diminishes VH versus if I want to be an elite runner there is for sure a lot of diminishing returns for strength training we get further into a cycle like you have you do have time trade-offs just from physiologic ability to adapt to training but also like

body mass, mean all these things come to effect but like that's, I don't know how many people you guys have on your schedule for the next two weeks. Any of those people are at zero, besides maybe our high schooler. Yeah. And we said last time, he could actually use a little more muscle mass. yeah. Like he's too far on that side. Yeah, so it's a dance but like very rarely it's like, God, I'm gonna miss my training. like, the two days that you think you're gonna lose from that like a road.

stuff you gain like power output in general, know, know movement efficiency and muscular endurance. Yeah, I'd rather her drop from five days a week to three of running due to days of strength training and she gets to where she feels like she can do two days of strength training and one of those days she does a double where she runs and lifts. Cool. But again, think of the mindset that gets pounded into you from the time you're in high school, then you coach people that are running, you're literally training them up. They're even different than what you're doing.

They fall into the same like schema like they're running with their athletes. They're like, I'll do what they do. yeah, it's not quite the case. So like I said, we have a podcast coming up talking about that. also, I don't know if it's going to happen. I'm trying to get Jason coupe on the podcast. So if you're familiar with who that is probably in my opinion, one of the preeminent endurance coaches out there, he's written same book now, second edition, which is kind of thought of as the ultra marathon, you know, training Bible. So

get him on and he'll go into the weeds, but we'll try to make up more lame as terms when Michael and Neil comes on. So that's coming up here pretty soon. Anything else?

If you're a doc, student, patient listening, and if you have specific areas you want us to address, because we're picking from our patient base, but if you're like, I've had a consistent problem with this as a patient, or I see a lot of this in the doc, let us know and we can try to hit that. So you can email us, hit us up on social media, but as always, appreciate listening, and we'll see you two weeks.