Tag Archive for: patella

The Week in Research Review, etc 12-24-18

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The Week in Research Review, etc 12-24-18 only had two posts to social media this week but hopefully two very helpful posts for your practice.

The back pain post was a repost from a previous time but I thought it was very important to share it again. I also put a new post from my YouTube channel where I discussed patellar mobility assessment for instability. Check the post out at the link here or below to see the full version.

Physical Therapy First to Treat Low Back Pain

[ICYMI} Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Frogner et al Health Serv. Res. 2018

The Week in Research Review, etc 12-24-18This study compared the differences in opioid prescription, health care utilization, and costs among patients with low back pain (LBP) who saw a physical therapist as the first point of care, at any time during the episode, or not at all.

Patients aged 18-64 years with a new primary diagnosis of LBP, living in the northwest United States, were observed over a 1-year period.

Patients who saw a PT first had:

  • a lower probability of having an opioid prescription (89.4 percent),
  • any advanced imaging services (27.9 percent),
  • and an Emergency Department visit (14.7 percent), yet 19.3 percent higher probability of hospitalization.

Interestingly enough, 80% of the patients in the sample had no PT at all. Furthermore, 8.7% saw a PT first and 11.5% saw a PT later (avg 38 days). The most common provider seen 1st was a chiropractor.

Assessing for Patella Instability

Assessing Patella Mobility

💥Assessing for Patella Hypermobility💥

This Instagram snippet shows how I assess a patient with suspected patella hypermobility who may have sustained a subluxation, dislocation or instability episode.

To see the full video at my YouTube Channel, click the link here!

Basically, we’re looking at how mobile the patella is when the knee is locked at full extension compared to when the knee is flexed to about 25 degrees.

Normally, the patella should become relatively stable when the knee is flexed to 25 degrees because it engages the trochlea groove.

In patients with underlying patella hyper-mobility, the amount of mobility with the knee slightly flexed will be similar to when the knee is in full extension (and not locked into the trochlea groove).

This is often the case when the patient’s trochlea groove is too shallow to offer bony stability.

The test should help the clinician gain a better understanding of the patient’s anatomical make-up and prognosis for the long term.

Check out the full video at my YouTube Channel.

The Week in Research Review, etc 11-19-18

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Great ‘Week in Research Review, etc 11-19-18’ that I hope you find helpful to your practice.

I’ve always touted the importance of the subjective portion of the exam so I wanted to share a slide from a recent talk I gave to a group in Canandaigua, NY. Obviously, the squat is a fundamental movement and I wanted to give some basic positions that I use to help assess. So excited that I’ve launched a brand new Medbridge course that helps the rehab specialist better eval and treat the baseball pitcher. On my YouTube channel, I discussed my thoughts on setting the scapula with various upper and lower body exercises. And finally, my co-worker Kiefer Lammi discusses the landmine with exercise.

 

Importance of the Subjective Exam

Assessing the Squat

My New Baseball Medbridge Course

Set the Scapula with Shoulder Exercises?

6 Ways to use the Landmine by @kieferlammi

 

💥Subjective the most important aspect of the Evaluation💥

This slide, taken from this past weekend’s course in Canandaigua, NY is always a favorite of mine.

I try to keep a slide like this in all of my lectures because I have found that this portion of the examination can give the rehab specialist a huge look into what is going on with the person in front of them.

Don’t get me wrong, I still consider the biomechanical aspect of what may be causing their symptoms.

It often comes down to a tissue capacity issue but it’s up to me to determine the appropriate course of treatment.

These questions will help build confidence in your client and guide the early stages of rehab.

Do you have any specific questions that you like to ask your clients during their 1st few sessions? Remember, these questions are just not for the evaluation. You should be asking these questions periodically to gauge progress and help guide the next phases of rehab, too!

 

🔅Assessing the Squat 🔅

Squatting is a fundamental movement that all of us have to do on a daily basis.

Utilizing several different positions can help the rehab specialist better assess the squat and develop a treatment plan that enables their client the ability to improve their squat pattern.

In the above videos, I have utilized 3 different squat patterns and will outline them by the degree of difficulty.

✅The Overhead Squat- by far the most challenging version which challenges the shoulders, thoracic spine, lumbar spine, pelvis, knee and ankles.

A movement limitation at any of these joints will most likely cause the squat pattern to break down. Using overhead resistance would further challenge the system and potentially cause the squat to further breakdown.

✅Arms Crossed Chest Squat- alters the challenge by taking most of the shoulder and thoracic spine out of the equation and isolates the motions to the lumbar spine, hips, knees and ankles.

I often use this position as my fundamental motion because most people don’t have to squat with any weights over their head. This position, in my opinion, should be the most informational and utilized.

✅Counter-weight Squat

This position changes the center of mass by moving some of the weight distribution more anteriorly (front) and making the squat motion slightly easier. I use this position as a regression, for some, which allows them to squat with less stress and potential difficulty.

There are many other variations to the squat that you can make but I wanted to highlight a few of the major changes that you cause successfully. Assessing the squat is essential and can give the rehab specialist a nice picture of the function of multiple joints during a common movement.

 

My BRAND NEW course on Medbridge’s platform

…that helps the sports and ortho rehab specialist (PT, OT, ATC) better understand the anatomy and biomechanics involved in the baseball pitching motion.

Advanced Rehab for the Baseball Pitcher to Improve ROM & Strength@medbridge_education

The goal of this course was to allow the clinician to be able to evaluate and treat the baseball pitcher using evidence-based guidelines that I use on a daily basis.

Numerous research studies discuss the adaptive changes that occur with the pitching motion followed by numerous videos to help guide the treatment process.

If you’re already a Medbridge subscriber, then you have immediate access today.

If you’re not a Medbridge member, then you can use my promo code “Lenny2018” to save up to 40% off a yearly membership.

This gets you unlimited CEU’s for 1 year and potential access to their online HEP and a lot more!

Students can also get 1 year of unlimited courses (no CEU’s) by using promo code LennySTUDENT2018 and pay only $100.

Check out my other shoulder courses as well by using the Medbridge platform…along with many other great speakers!

Hope you enjoy and good luck!

 

💥Should you Set the Scapula with your Shoulder Exercise?💥

In this video excerpt from my YouTube channel, I wanted to discuss my opinion on setting the scapula during common exercises.

I think there’s an obvious role for setting the scapula during a heavier lower body lift like a deadlift.

But for a classic upper body exercise like the Full Can (Scaption Raises) or prone T (horizontal abduction), prone Y (Prone full can), etc then I definitely want the scapula to freely move along the rib cage.

I did a quick literature search and didn’t see anything obvious that helped to guide my thoughts so most of this is anecdotal. Check out the video and comment below.

Do you coach your clients to set their scapulae before a rotator cuff workout? If so, why? If not, do you think we should reconsider?

 

6 WAYS TO USE THE LANDMINE!⁣

Great post from our own @kieferlammi at @championptp on various ways to use the landmine in your client’s workout routine.

If you don’t have one, then I’d highly recommend you try to obtain one because they are highly versatile and can be used in many stages of rehab. See Kiefer’s original post below 👏🏼

_____________

6 WAYS TO USE THE LANDMINE!⁣

The landmine attachment is a super versatile tool for loading that is traditionally known for being used for angled pressing variations. While that’s probably my most programmed use for it, it also provides benefit to a ton of other movements by placing the load and direction of force at a bit of an angle, which can help to promote a particular path of movement, like sitting back more in a squat or lunge. Here are 6 of my favorite ways to use the landmine:⁣

1️⃣1-Leg RDL⁣

2️⃣Split Stance Row⁣

3️⃣Reverse Lunge⁣

4️⃣Deadlift⁣

5️⃣Squat⁣

6️⃣Russian Twist⁣⠀

Save 25% off our OnLine Knee Seminar Course…all this week!

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If you want to learn more about how I treat ACL’s or the knee in general, then you can check out our all online knee seminar at www.onlinekneeseminar.com and let me know what you think.

We cover the anatomy, rehab prescription, ACL, meniscal injuries knee replacements and patellofemoral issues. Furthermore, the course covers both the non-operative and post-operative treatment.t

This is an awesome course if you’re interested in learning more about rehabilitating the knee joint. And if you’re a PT, there’s a good chance you can get CEU’s as well.

The Week in Research Review, etc 11-12-18

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This week in research review for 11-12-18 we focused a bit more on assessment and also dabbled in some basic treatment strategies for the back and shoulder. Check out the topics below and like them or comment on Instagram to keep the conversation going…thanks all!

 

  • A quick fix for a sore low back?
  • Knee Fat Pad Testing and Diagnosis
  • How to Assess the Elbow for a Tommy John (UCL) Sprain
  • Lumbopelvic control on shoulder and elbow kinetics in elite baseball pitchers
  • Full Can or Empty Can? – by @mikereinold

 

Looking for a quick fix for a sore low back?

I’m speaking from personal experiences when I post a few of the common exercises that have helped me tremendously in the past.

I’m not saying that this is all you have to do but I do think that new onset of low back soreness, you know that tightness that you feel on either side of your spine, can be somewhat alleviated with some foam rolling and active range of motion.

I would definitely include more focal strengthening of the core like deadbugs and bird dogs, squats, deadlifts (when they’re ready), etc.

But for the purpose of this post, I think some foam rolling and motion to the area can take the edge off of someone’s soreness and get them feeling a little better. That’s my goal for many and hopefully those small gins can add up to big gains in the long run!

Do you utilize these techniques as well? If you don’t, then I suggest that you try! They’ve helped me numerous times and continue to help me when my soreness gets a bit out of control.

Tag a friend who may want to check out this post…thanks!

Thanks @corrine_evelyn for the demos!

 

Knee Fat Pad Testing and Diagnosis

Here’s an excerpt from a previous blog post where I talked about anterior knee pain fat pad irritation. Link in bio!

Keep in mind, my differential diagnosis is all over the place at times. With knee pain you need to consider:

Meniscus (see my previous blog post)⠀

ITB

Osteochondral lesion

Patella tendonitis

Pes anserine bursitis

MPFL sprain

Hamstring strain

Plica syndrome

MCL/LCL

Tumor

Infrapatellar fat pad irritation can be functionally debilitating. I believe it presents itself pretty often in the clinic, more than most PT’s realize.

Use this test to see if it truly is a fat pad issue.

 

How to Assess the Elbow for a Tommy John (UCL) Sprain

In this excerpt from my YouTube channel, I discuss the tests that I use to help identify an elbow sprain, typically seen in the baseball players that I treat.

In the full video, I discuss:

✅Joint Palpation

✅Seated Milking Sign

✅Prone Valgus Test (maybe a new one for you!)

✅Supine end range External Rotation with Valgus Extension Overload (VEO)

I also wrote a blog post about this topic so hopefully you’ll go to my site and read a bit more about this.

If you treat baseball players of all ages, then you should know how to diagnose a UCL sprain.

 

The influence of lumbopelvic control on shoulder and elbow kinetics in elite baseball pitchers

Laudner et al JSES 2018.

This study looked at 43 asymptomatic, #NCAA Division I and professional minor league baseball pitchers. They measured the bilateral amount of anterior-posterior lumbopelvic tilt during a single-leg stance trunk stability test.

The Level Belt Pro (Perfect Practice, Columbus, OH, USA) was used to assess anterior-posterior lumbopelvic control. The LevelBelt Pro consists of an iPod–based digital level secured to a belt using hook-and-loop fasteners.

This test has been used and studied previously by Chaudhari et al (JSCR 2011) and he showed that pitchers with less lumbopelvic control produced more walks and hits per inning than those with more control.

Also, pitchers with less lumbopelvic control have been shown to have an increased likelihood of spending more days on the disabled list than those with more control (Chaudhari et al AJSM 2014).

“The results of our study show that as lumbopelvic control of the drive leg decreases, shoulder horizontal abduction torque and elbow valgus torque increase.”

Have you tried this simple test? I will say that having the ability to detect millimeters of motion is clinically difficult.

It is good to see such a simple test utilized clinically can help aid in determining the need for more core/hip exercises for our pitchers. In all, I think it’s a safe bet to incorporate these exercises in all pitchers’ programs.

 

Full Can or Empty Can?

– by @mikereinold 

Great Post by @mikereinold on which motion is BEST to isolate the supraspinatus during arm elevation. I know you can’t isolate the supraspinatus but numerous studies have (Kelly et al 1996, Reinold et al 2004) shown that the full can (or thumb up position) is better than the empty can position.

Check it out below! 👇🏼

Full Can or Empty Can? – by @mikereinold⠀⠀
-⠀⠀
🧠 WANT TO LEARN MORE FROM ME? Head to my website MikeReinold.com, link in bio.⠀⠀
-⠀⠀
I’m still surprised after all these years that I still see the empty can exercise kicking around. I analyzed these two movements many years ago in an article in JOSPT and showed that the full can exercise (thumbs up 👍) had similar EMG of the supraspinatus with lower levels of deltoid EMG, while the empty can (thumbs down 👎) had higher levels of deltoid EMG.

Why does this matter?

Well, think about it. If you are performing this exercise you probably are trying to strengthen the rotator cuff. And if you are weak and performing an exercise with more deltoid, the ratio of cuff to deltoid will be lower and you’ll have more potential for superior humeral head migration.

Plus, let’s be honest, the empty can just hurts… It’s also a provocative test, and I don’t like to use provocative tests as exercises. 😂😂😂⠀

 

The Week in Research Review, etc 10-29-18

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This week we started the week off with a couple shoulder posts, specifically the rotator cuff and SLAP tears. As usual, I can’t resist a good ACL paper so included that NM control program that should be in all knee patients’ programs. We ended the week with a recorded knee scope as the surgeon was mobilizing the patella. It was a very informative and fun way to see the patella. We closed the week off with an old school video of myself performing a proprioception drill for the shoulder. I recommend you read these posts and like them on Instagram. Take a look at The Week in Research Review, etc 10-29-18

 

  1. Topics on the Rotator Cuff including post-op
  2. Classifying SLAP tears
  3. Essential Components of a neuromuscular control program
  4. Live Patellar scope during mobilization
  5. Shoulder Proprioception Drill

 

 

Topics on the Rotator Cuff including post-op

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff- Jancuska et al OJSM 2018

Nice summary of systematic reviews for you guys if you treat patients after a rotator cuff surgery. I’ve been doing a pretty good literature on the topic and wanted to share some of the articles that I have found helpful.

Their conclusions:

❇️There is substantial evidence indicating that the most accurate physical examinations for diagnosing RC tears are a positive painful arc and positive ER lag test

❇️Considerable evidence showing that rehabilitation is better than no rehabilitation for non-op management of RC tears, although RC repair was shown to be superior to rehabilitation alone.⠀

❇️No evidence to support the use of injections for nonoperative management of RC tears.

❇️Double Row repair results in better outcomes and fewer re-tears than Single Row repairs, especially for tears >3 cm.

❇️Predictors of re-tears and poor postoperative outcomes:⠀

✔️older age⠀

✔️female sex⠀

✔️smoking⠀

✔️increased tear size⠀

✔️preoperative fatty infiltration⠀

✔️preoperative shoulder stiffness⠀

✔️diabetes⠀

✔️workers’ compensation claim⠀

✔️decreased preoperative muscle strength⠀

✔️concomitant procedures.

Overall, a good review of the literature on rotator cuffs and anything associated.⠀

 

Classification of SLAP Tears

If you treat patients with shoulder pain, then you may run into different labral tears of the shoulder.

This post hopes to summarize the 10 different types of #SLAP tears that are currently known.

Type 1️⃣: Fraying but intact biceps

Type 2️⃣: Superior Labrum and biceps detached from the glenoid rim

Type 3️⃣: Bucket handle tear of the superior labrum but biceps anchor attached

Type 4️⃣: Bucket handle tear of the superior labrum that extends up into the biceps tendon

Type 5️⃣: BankartTear and also a detached biceps anchor

Type 6️⃣: an unstable flap of the superior labrum with a detached biceps anchor

Type 7️⃣: Anterior superior labral tear that extends to the middle Glenohumeral ligament; Biceps anchor detached

Type 8️⃣: Superior and posterior labral tear along with detached biceps anchor

Type 9️⃣: 360° labral tear

Type 🔟: Superior labral tear along with reverse Bankart tear and a detached biceps anchor.

That’s a lot and some are pretty rare but it helps to be able to communicate effectively with the medical team or to read an operative report.⠀

 

Neuromuscular training to reduce ACL injuries in female athletes

Critical components of neuromuscular training to reduce ACL injury risk in female athletes: meta-regression analysis. Sugimoto et al BJSM 2016.

This meta-regression analysis looked at the effects of combining key components in neuromuscular training (NMT) that optimize ACL injury reduction in female athletes.

They looked at a total of 14 studies that met the inclusion criteria of the current analyses. A total of 23 544 athletes were included.

They showed that there are 4 Key components

✅14-18 years old better than other age groups

✅2x/week for 30 minutes/session

✅Balance, planks, ‘posterior chain’ and plyometrics

✅Verbal cues like ‘Land softly’ or ‘Don’t let knees cave in’

Furthermore, inclusion of 1 of the 4 components in NMT could reduce ACL injury risk by 17.2–17.7% in female athletes. A great look that really specifics what age groups would best benefit from a NMT program. Do you incorporate any of these key concepts into your programs, even 1-2 of them?

I know I try to with most of my clients, whether or not they’re returning from an ACL or not.

 

Patella mobility during a knee scope

Great video by @physionetwork looking at the patella during a knee scope. This stuff is just exciting to see (in my opinion) because it gives us a little bit of insight into what is exactly going on during a patella mobilization.

In my opinion, the PF joint is often overlooked when it comes to knee surgery and it can affect joint mechanics, quadriceps activation and patient function. You need to mobilize the patella and normalize the motion…can’t stress this enough!

Check out the post below…good stuff!

Patellar mobilization is important to avoid stiffness after surgery. In this video, you can see from an arthroscopic view that little motion outside the knee, translates into a significant motion inside the knee. Mobilization may help prevent the formation of scar tissue and allow for better biomechanics of the knee joint.

We review the latest and most clinically relevant research in physiotherapy. Click link in bio to learn more and boost your knowledge 🔗

Video by Jorge Chahla, MD, PhD – Orthopaedic Surgeon -Sports Medicine Specialist

 

 

Active Reposition Drill after a Passive Motion

Loss of proprioception after a shoulder injury has been documented numerous times in the literature and can affect long-term function.

This drill may help the rehab specialist to test proprioception by measuring the exact active position difference that the patient attains.

You can also use this drill as a treatment reproduce the exact position that you passively brought them into.

Give it a shot and see what you think…you can use this drill for any joint in which you have assessed proprioception loss.

 

Documenting Knee Extension Range of Motion

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I’ve talked a lot about the importance of regaining knee extension range of motion (ROM) after a knee injury or surgery. In this post, I want to talk about how exactly I believe we should be documenting knee extension range of motion.

I think it’s important because I hear many other medical professionals and students document differently. Hope this post clears the air and gets everyone on the same page.

Knee Extension after ACL

I’ve written about getting knee extension back after an ACL and how to figure out if it was a cyclops lesion or not. You can read this recent post if you like..it should help you gather more information on diagnosis and treatment of a cyclops lesion.

Therefore, I can’t stress the importance of obtaining not just knee extension, but symmetrical hyperextension after a knee injury or surgery.

With that, I feel as if many practitioners are all over the place with their documentation. This makes it difficult to communicate with each other and with the patients.

Documenting Knee Extension Range of Motion

In this video, I discuss the rationale for how I document knee hyperextension. I think it;’s important that we’re all on the same page to avoid confusion.

 

Does this make sense to you? Is this how you document knee hyperextension?

Let’s discuss in the comments section or on social media. You can find me on Twitter or Instagram @lenmacPT.

If you want to learn more about how I treat ACL’s or the knee in general, then you can check out our all online knee seminar at www.onlinekneeseminar.com and let me know what you think.

We cover the anatomy, rehab prescription, ACL, meniscal injuries knee replacements and patellofemoral issues. Furthermore, the course covers both the non-operative and post-operative treatment.t

This is an awesome course if you’re interested in learning more about rehabilitating the knee joint. And if you’re a PT, there’s a good chance you can get CEU’s as well.

Anterior Knee Pain- A Test for Fat Pad Irritation

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We as physical therapists are constantly seeing patients with anterior knee pain with a very vague history. Often times, there’s not a specific onset or mechanism of injury. With that, it seems as if the retro patellar fat pad is a common source of pain in many people and is commonly overlooked.

What actually hurts in the knee?

Whenever I am evaluating someone with knee pain, I always keep in mind the Dye et al AJSM article from 1998. In my opinion, this is a keeper for all PT’s and future PT’s to have in their arsenal of top literature papers.

For those that are not familiar, let me explain it a bit.

Basically, San Francisco orthopaedic surgeon Dr. Scott Dye had his knee scoped without any anesthesia. That’s right, classic beast mode!

He did have local anesthesia (for the record), so they could make the incisions…otherwise, he was awake and alert for the whole procedure.

This allowed him to report back to his colleagues (one being his brother) an actual pain response as they were poking away at the different structures within the knee. He ranked the pain on a 0-4 scale with 0 being pain-free (patella cartilage) and 4 being a severe pain (fat pad, anterior synovium, joint capsule.)

You can read the article to get the full gist (and I HIGHLY RECOMMEND this!) but my point is to let you realize that there are only certain structures capable of causing severe pain in the anterior knee.

Their Findings

Cartilage is avascular and aneural. It has no blood supply or nerves that innervate it. None! So the whole chondromalacia patella diagnosis attempting to implicate a maltracking patella is often hogwash.

But the fat pad, anterior synovium, and anterior capsule are extremely painful and are often involved, I believe, in patients that we see on a daily basis.

In my opinion, this is a diagnosis that sees us more than we see it. Like thoracic outlet syndrome… we can talk about that a different day though.

Back to the point of the blog.

1 Test for Fat Pad Assessment

Assessing the knee and asking the right questions is critical. Besides a tremendously great subjective, there’s one test that I use to rule in or out a fat pad irritation. Check out the video below:

I promise you this test is a great way to establish a pretty clear diagnosis and reassure the patient that a specific structure may be the issue.

When it’s painful, its pretty obvious and the patient can immediately report back to you their symptoms. I test for this a bunch in a given week and it’s not always present. But when someone presents with a positive finding, it’s pretty relieving to them (believe it or not.)

Differential Diagnosis

Keep in mind, my differential diagnosis is all over the place at times.  With knee pain you need to consider:

  1. Meniscus (see my previous blog post)
  2. ITB
  3. Osteochondral lesion
  4. Patella tendonitis
  5. Pes anserine bursitis
  6. MPFL sprain
  7. Hamstring strain
  8. Plica syndrome
  9. MCL/LCL
  10. Tumor

That’s a bunch to consider for someone who can’t really explain why or when their injury occurred. That’s why I still believe this overuse injury sees us more than we see it.

Treatment of Fat Pad Irritation

This one can get a bit tricky. Again, it’s often due to an overuse injury. In others, it’s attributed to kneeling on it for too long or banging it against something. In those more acute cases, the answer is pretty straightforward. Ice, motion and progressive return to their function.

In the overuse group, which is more prevalent in my opinion, we need to figure out which stimulus is causing the issue. It’s often due to starting a new program or ramping up too quickly during some training event.

In these people, I need to modify their volume of training or destress the area by giving them new activities that they can do pain-free…but only for a short period of time.

Along with activity modification, a course of some form of modality (yup, the M-word was used) can help expedite the pain control. I still have a special place in my heart for iontophoresis with dexamethasone. I’ve had tremendous results in patients with fat pad irritation.

I also like to use a low-level laser to help with the healing process (future blog post alert!) I’ve used it on my self for various ailments and even my dog after her ACL surgery. I’m definitely a believer in the healing power of the laser when applied in the correct situation.

Besides all of that, I would also want to assess the person’s movements and attempt to adjust any motions or movements that I thought could contribute to the knee pain. Often times, there’s an underlying weakness or misconception of a weakness that needs to be explained to the patient.

These things run their course for a few weeks but should improve pretty quickly if handled correctly. Patient gratification is pretty obvious because their pain diminishes after a session or 2 and they buy into the program pretty quickly.

Fat Pad Conclusions

Infrapatellar fat pad irritation can be functionally debilitating. I believe it presents itself pretty often in the clinic, more than most PT’s realize. Use my test above to see if it truly is a fat pad issue. Here’s a nice open-access article that you can read to learn more about the fat pad.

Remember, the test should be pretty obvious and locally oriented. If pain-free, then move on. If not, then try some of my above recommendations. It’s usually an overuse issue so you need to adjust their volumes and maybe some form of mechanics.

Mike Reinold and I discuss this and much more about how we treat the knee conservatively. Check it out in our acclaimed all online knee course www.onlinekneeseminar.com.