Proactive clinical methods for how to avoid knee surgery and dealing with lower extremity injuries by starting with the feet
Most musculoskeletal injuries and conditions can be managed conservatively, with surgery an absolute last resort. My experience in working with athletes at all levels has opened my eyes to the importance of proactive wellness and care in injury prevention. Creating a patient mindset through education is a vital key in helping the patient understand the crucial role between proactive care and injury prevention, such as how to avoid knee surgery and other intrusive measures.
Proactive clinical methods
One of the primary goals for proactive care is to help create the optimal physical environment to prevent or minimize the severity of injuries. Although there are indications for surgical intervention, sincere efforts should be made to prevent surgically indicated injuries from occurring. In the athlete, lower extremity injuries involving the ankle, knee and hip are the most common musculoskeletal injuries reported. There are many proactive clinical methods that can be implemented that can have a drastic effect on the management and prevention of these common injured areas.
After completing a thorough evaluation of the patient, the clinician should have a relatively clear picture as to the severity of the condition presented. The patient should then be classified as either an immediate surgical candidate, possible surgical candidate or non-surgical candidate. Concerning the latter two classifications, putting in place a personalized care plan addressing the patient’s musculoskeletal needs is paramount. This requires a specific evaluation addressing the patient’s alignment, mobility and compression issues.
It is through chiropractic manipulation/mobilization techniques that these three issues are effectively managed, and posture is brought back into balance. Along with addressing postural/alignment deficits, the clinician should also be aware of the patient’s fitness issues.
By definition, fitness is a balance between strength, conditioning and flexibility. It is deficits in one of more of these components that can be a significant contributor to the patient’s presenting condition or the potential risk for future injury. Lastly but most importantly, it is the feet that provide the foundation for the musculoskeletal structures. Addressing technical issues, such as pronation in the foot, is vitally important in the management and prevention of injuries to the ankle, knee, hip and spine.
The role of foot stabilization in recovery
Evaluating the feet for technical issues became crystal clear to me during my experience in working with Olympic track and field athletes. The foot is our foundation, and with every step, the foot will either effectively absorb impact or negatively transfer impact up the kinetic chain. Supporting the technically-challenged foot can greatly reduce impact on the kinetic chain and help with musculoskeletal alignment.
These technical issues can be effectively addressed with custom orthotics. Administering a laser foot scan provides valuable information about the patient’s feet which can then be used to educate the patient on the foot structure and its relationship to the structures throughout the kinetic chain. Along with addressing technical issues concerning the feet with custom orthotics, increasing strength, and improving reaction time are the keys to how to avoid knee surgery and hip surgery, and general injury prevention and recovery.
Seventy percent of ACL injuries are non-contact in nature. These injuries result from a faulty foot foundation as well as lack of intrinsic strength, coordination, balance and reaction time. During the gait cycle, the foot strikes the ground, and a cascade of events happen throughout the kinetic chain. The result is proper support or failure at the ankle, knee and/or hip, depending on how the foot responds at impact. In order to reduce the risk of lower extremity and back sports injuries, the practitioner must gain an understanding of simple lower extremity anatomy and biomechanics, and then consider custom orthotics as a primary treatment option.
Once the foundation is addressed, then the clinician should focus on the components of fitness, looking for strength, conditioning and flexibility issues. For example, co-contraction between the quadricep and hamstring through single leg squats to 30 degrees provides significant dynamic stabilization in the knee. Increasing these co-contraction strengths can reduce the risk of more serious injuries to the knee. Core strengthening for the back helps to engage our body’s built-in back support structures and finally, flexibility training can provide our muscles with adequate length, thus allowing our musculotendonous structures to move freely through its full ranges.
Practically speaking, shortened hamstring and hip flexors have a negative impact on the back. Improving flexibility in these two muscle groups will help to minimize posture stress and maximize free movement when walking, running, bending and lifting.
How to avoid knee surgery and other invasive surgeries with proactive exercise for muscle strengthening
With the lower extremity being the most common area for musculoskeletal injuries, the following are proprioceptive, strengthening and flexibility exercise that each active patient/athlete should routinely perform in order to reduce the risk of ankle, knee and hip injuries:
- Single Leg Stance: Using a stability trainer, stand upright and balance on one leg for one minute. Perform three sets for one minute daily.
- Single Leg Stance 30 Degree Squat: Using a stability trainer, stand upright, balance on one leg and slowly bend the weight-bearing knee to 30 degrees focusing on keeping the patella tracking in line with the second toe. Maintaining knee alignment is critical. If necessary, have the patient gently hold on to something while doing the exercise until they can accomplish the alignment without assistance. Perform three sets of 10 reps daily.
- Ball Wall Squats: With or without hand weights, position an exercise ball behind the back and against a wall. With the feet shoulder width apart, push into the ball and squat to 30 degrees. Perform three sets of 10 reps daily.
- Hamstring Muscle Stretch: There are two effective stretching techniques for the hamstring muscle. A passive stretch is a slow progressive stretch. A PNF, or contract/relax stretch, is the procedure of choice for increasing both passive and active flexibility. This type of stretch involves elevating the target muscle to tension and then performing an isometric contraction of the hamstring using 20% of a maximum voluntary contraction. After holding this contraction/stretch for 10 seconds, elevate the target muscle to a new point of stretch and repeat the process, allowing pain to be your monitor. The hamstring muscle crosses the knee joint and is therefore intimately connected to the knee. Increasing hamstring muscle flexibility helps the athlete maintain a more upright posture and reduces compression forces on the knee. Ninety degrees of hamstring flexibly is a reasonable goal. Perform hamstring stretches daily. PNF stretching techniques can be performed once per week to help maintain the flexibility gains. Perform three reps on each side. To passively stretch the hamstring, sit on the floor with the back as flat against the wall as possible and then fully extend the knees. Sit in this position for 5-10 minutes daily.
- Evaluate the feet! Prior to providing a 3D laser foot scan, pay attention to the patient’s feet while performing the single leg stance closed chain kinetic exercises numbered above. While weight bearing, note the technical issues of pronation and its effect on the lower extremity. If the foot rolls inward during this exercise, the clinician will see the effect it has on the tibia, knee and hip. In the pronated and compromised foot, the tibia and knee will follow the medial longitudinal arch. This results in the tibia rotating medially and a dynamic genu valgus presentation at the knee. This must be pointed out to the patient in order for them to fully understand the relationship between the feet and the kinetic chain. Correcting the technical issues within the foot is of utmost importance in the prevention of injury and maximizing performance.
Proprioceptive rehab training
Proprioceptive training is the rehab procedure of choice in addressing the lower extremity injury and injury prevention. This type of training will develop strength, balance, coordination and most importantly, reaction time. Developing this form of kinesthetic sense is the key to injury prevention and post-injury recovery. Treating the active patient/athlete’s lower extremity issues thoroughly and efficiently will get them back in the game with confidence, restoring their physical as well as emotional health.
The body is truly an amazing machine. It has a built-in support structure that, given the right environment, can meet most of the physical demands that it faces. It is our distinct privilege to get to work with this extraordinary machine every day in our offices.
Through proactive care of administering techniques and providing support aid such as custom foot orthotics, the clinician can help the patient maintain or improve their active lifestyles as well as prevent many musculoskeletal injuries and avoid preventable surgeries.
KURT A. JUERGENS, DC, CCSP, is a graduate of Brigham Young University and Texas Chiropractic College. He is the owner of Juergens Chiropractic & Sports Rehab Center in Houston, Texas, where he continues to treat school and professional athletes in all fields from around the world. He has been a member of the sports medicine team for the United States Olympic Track and Field Trials, the NCAA Track & Field Championships, and the ATP World Tour‘s Tennis Masters Cup and U.S. Clay Court Championships. As a member of Foot Levelers Speakers Bureau he travels the country speaking on chiropractic topics with a focus on sports medicine. See upcoming continuing education seminars with Juergens and other Foot Levelers speakers at footlevelers.com/continuing-education-seminars.