It is quite common to see structural conditions in our clients, such as knock-knees, overpronation, forward head posture, sway back, and a host of other physical alterations. However, these do not always cause our clients discomfort; in fact, people can go for years without ever having symptoms or pain.
Alignment problems abound in the lower extremities and it is not uncommon for them to lead to soft-tissue pain. In many cases, biomechanical dysfunction in one area leads to issues in another, as in overpronation leading to patellar-tracking disorders. In more developed cases, dysfunction continues to move up or down the kinetic chain, causing pain in multiple regions of the lower extremity.
Sadly, in some cases, and in particular with knee pain, clients may go years in pain and see a variety of health-care professionals, but still not have an explanation as to why the pain exists. For about 10 percent of the population, there are fundamental structural alterations in the lower extremity bones that produce a complex cascade of dysfunction in the lower extremities. This composite of problems is called miserable malalignment syndrome (MMS) and can produce compounded biomechanical issues that can generate pain.
In this article, we discuss how to identify and assess six key conditions or components of this dysfunctional syndrome. In my next article, Part 2, we’ll explore the main treatment protocols for MMS and the role massage can play as a helpful intervention.
Assessing MMS
In MMS, the tibia and femur bones play key roles in the dysfunction. In most cases of lower leg pain, it is the soft tissues and biomechanical alterations that are at fault and produce painful symptoms. The following conditions and structural components are often seen in the clinic, but typically not all at once.
Broad Pelvis
Some clients who have MMS have a broad pelvis; that is, a pelvis that seems wider in proportion to the stature of the person. There is no commonly used standard by which to measure the broad pelvis, so it is more of a general visual perception. With a broader pelvis, the femoral heads are farther away from the midline of the body. The distal femurs, however, naturally angle in toward the midline of the body, and a broader pelvis produces even more of this angulation, making the femurs less vertical.
The weight of the body is most efficiently distributed when the femurs are closer to vertical, so this increased femoral angulation results in more of the soft tissues around the knee being engaged to absorb the load. Because women have a wider pelvis for childbearing, and because it broadens more during pregnancy, this component of MMS is seen more frequently in women than in men.
Excessive Q Angle
A large quadriceps angle (Q angle) also plays a part in knee problems related to malalignment, and assessment should include at least an estimation of the Q angle. The size of the Q angle is also affected by the width of the pelvis. The wider the pelvis, the greater the chance of having a large Q angle.
The Q angle is measured by drawing an imaginary line between the tibial tuberosity and the midpoint of the patella, which continues in a superior direction. Another line is drawn between the anterior superior iliac spine and the midpoint of the patella. The angle between these two lines is called the Q angle and is a measure of how much the femur angles in a medial direction from its proximal end to its distal end. An excessive Q angle is considered to be more than 20 degrees in women and 15 degrees in men.
Clinical evaluation of the Q angle remains somewhat controversial because it is difficult to accurately measure.1 However, the concept of the Q angle is still pertinent and helps us understand biomechanics of the extensor mechanism at the knee. An increased Q angle causes an increase in lateral patellar displacement and is a common cause of anterior knee pain in MMS, as we will see.
Increased Femoral Anteversion
Femoral anteversion is one of the more challenging facets of MMS to identify. Anteversion of the femur refers to the amount of twisting or torsion that is present in the femur, with the lower portion of the femur appearing more medially rotated than the upper portion. It is best observed by comparing the angle of the femoral neck relative to the condyles of the femur (in relation to the coronal plane).
Femoral anteversion causes problems with correct tracking of the patella. When the lower portion of the femur is medially rotated in relation to the upper portion, the patella will not move straight up and down between the femoral condyles. As the patella tracks improperly between the condyles, it may lead to a host of knee issues, such as patellofemoral pain syndrome or chondromalacia patella. Chondromalacia is a softening of the cartilage on the underside of the patella that occurs as the patella is dragged across the top of the femoral condyles during flexion and extension movements.
Anteversion occurs with greater frequency in infancy and lessens as people age. Infants may have a normal anteversion of about 30 degrees, while adults are about 15 degrees.
Squinting Patella
A natural result of femoral anteversion is what is called the squinting (or winking) patella. When the distal portion of the femur is medially twisted, the top surface of the patella no longer faces in a straight, anterior direction. Instead, it faces somewhat medially, and the forces on it are unequal, causing it to track improperly and toward the lateral side. A patellar-tracking problem is a common cause of anterior knee pain and there are numerous causes. However, in MMS it results from the described structural dysfunction of the femur and altered patellofemoral mechanics.
Genu Valgum
Genu valgum, commonly known as “knock-knees,” is frequently caused by a broad pelvis and a large Q angle. It is an easily observable biomechanical and structural condition. A valgus angulation is a postural malalignment in which the distal portion of a bony segment deviates in a lateral direction. In genu valgum, it is the distal portion of the tibia that deviates in a lateral direction. In genu valgum, the distal femur and proximal tibia are both pushed in a more medial direction.
Genu valgum causes additional tensile stress on the soft-tissue structures on the medial side of the knee, such as the medial patellar retinaculum, medial collateral ligament, and adductor muscle attachments. Proper weight distribution also becomes problematic because the weight is not fully transmitted down the long axis of the bones, placing greater compressive loads on the lateral meniscus.
Genu valgum is assessed by looking at the client in a standing position. The long bones of the lower extremity (femur and tibia) should look like they are sitting almost directly on top of each other in a vertical line. In genu valgum, it will be evident that there is a bend in that vertical line as the knee appears to deviate more medially.
Excessive Pronation and Tibial Internal Rotation
Genu valgum can also lead to excessive pronation. Pronation is a diagonal plane movement that includes dorsiflexion, eversion, and abduction of the foot as it moves through the normal cycle of foot strike through push off. Alignment between the foot and the tibia is crucial for the weight of the body to be spread out evenly over the bones of the foot. Excessive pronation often leads to the tibialis posterior compensating for the improper alignment. Overuse of the tibialis posterior will then lead to the development of medial tibial stress syndrome, or if severe, stress fractures.
Gait analysis is the best way to identify overpronation. It is not enough to look at how someone stands; they should be evaluated during movement. Often gait analysis is performed on a treadmill where the foot mechanics can be observed, usually by a physical therapist or sports orthopedist who has experience and equipment for this evaluation. Sometimes the wear pattern on the client’s shoes provides evidence (wear on the medial side of the sole can indicate overpronation), but this is not always reliable, especially if the shoes are relatively new.
Additional Assessment Strategies
The visual observations described earlier are usually performed with the client in a standing position. It is relatively easy to see the overall potential for a broad pelvis, increased Q angle, and genu valgum. There are other factors that may be picked up during a more specific visual examination that could be indicative of alignment problems or structural dysfunction.
For example, when looking over the foot and lower extremities, blisters, calluses, or bunions may indicate postural or biomechanical disorders in the foot and ankle complex. In particular, calluses near the head of the first metatarsal or the presence of a bunion are frequently associated with overpronation.
Calcaneal valgus may also occur along with overpronation. This is an alignment disorder in which the distal calcaneus deviates in a lateral direction. In genu valgum, the knees are not aligned straight, but are more medial, which puts more weight on the medial side of the foot. Greater weight on the medial side of the foot forces the distal calcaneus to deviate laterally.
Femoral anteversion is often evident because of the squinting patella. Yet, the functional result of femoral anteversion, squinting patella, or genu valgum is dysfunctional patellar tracking. In addition, in some cases the vastus lateralis pulls the patella in a lateral direction. A simple physical examination can be performed to evaluate for excessive soft-tissue pulling that is contributing to patellofemoral dysfunction.
With the client supine, gently grasp the sides of the patella by placing your thumb on one side and your index finger on the other. Attempt to move the patella from side to side. Ideally, it should be able to move close to half its width to each side. Often, if there is excessive tightness of the vastus lateralis and a lateral tracking disorder, the patella will easily move in a lateral direction but won’t easily move in a medial direction because the lateral tissues are holding it too tightly.
Roughening or degeneration of the cartilage (chondromalacia) on the underside of the patella may also result from dysfunctional patellofemoral mechanics. This is often perceptible as crepitus or a grinding sensation during flexion and extension movements of the knee. To evaluate for this, have your client sit on the edge of the treatment table with the leg dropped toward the floor. Place your palm gently on the surface of the patella and instruct the client to slowly move the leg through flexion and extension while you maintain contact with the patella. If you feel grinding or grating sensations during movement, this could be indicative of cartilage damage associated with a tracking disorder.
Numerous soft-tissue disorders can result from the entire cascade of MMS, but more often from just a few contributing conditions. In the next article, we will explore common treatment options for these various components, and the role of massage. It’s very likely you have clients who have at least some of these disorders, and they will benefit greatly from your enhanced understanding of lower extremity biomechanics and knowledge of the treatment options.
Notes
1. D. Kaya and M. N. Doral, “Is There Any Relationship Between Q-angle and Lower Extremity Malalignment?” Acta Orthopaedica et Traumatologica Turcica 46, no. 6 (2012): 416–9.
2. P. Rodrigues et al., “Evaluating the Coupling Between Foot Pronation and Tibial Internal Rotation Continuously Using Vector Coding,” Journal of Applied Biomechanics 31, no. 2 (April 2015): 88–94.
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