User:Madison Grigsby/Miserable Malalignment Syndrome

Miserable Malalignment Syndrome, also known as MMS, Torsional Malalignment Syndrome, Rotational Deformity, or Torsional Abnormality is a relatively rare medical condition that involves a bio-mechanical dysfunction of either one or both of the lower extremities, causing chronic, intense pain (for which the disorder is named) to those afflicted with this syndrome.

Characteristics
There are a number of interrelated bone misalignments which characterize this condition. The Academy of Clinical Massage describes them to include, "a broad pelvis, a large Q angle, femoral anteversion along with a squinting patella, genu valgum (knock knees), and excessive pronation with internal tibial rotation." In other words the chain-reaction of dysfunction begins with the femoral anteversion, which is an inward rotation of the thigh bone beginning within the hip joint. The patella, as a result of the femoral anteversion, cannot point forward as it should, and so rotates in as well. This is oftentimes referred to as a "winking knee" or a "squinting patella". Finally the tibia is rotated outward and the foot is subject to pronation. The Q angle, an imaginary angle that is drawn from the tibia (shin bone) and through the middle of the patella (kneecap) upward to the anterior superior iliac spine (the hip), is used to measure alignment. More than twenty degrees for women and more than fifteen degrees for men are considered abnormal.

Causes
The causes for this syndrome are speculative. Repetitive movement most commonly done by athletes, sports injuries, and sitting with the legs in a "w" position often or for long periods of time during childhood are sometimes attributed or at least listed as contributing factors. Genetic predisposition, however, is generally cited as the cause.

Symptoms
The dominant symptom of Miserable Malalignment is excessive knee trouble, including pain (both anterior and inferior knee), stiffness, popping and clicking, locking, and instability (the knee often "gives"). Movements like climbing up and down stairs, sitting with the knees bent for too long, and exercises that require much leg activity such as squatting, lunging, running, and even walking can cause the pain to appear or worsen. Pain occurs primarily in the knee because the inward rotation of the femur and the outward rotation of the tibia create stress within the knee joint. This stress pulls the patella laterally, instead of up and down, causing what is called a tracking disorder. Hip, ankle, and back pain are also common among Miserable Malalignment sufferers, as the body attempts to compensate for the misalignment.

Diagnosis
Most cases of Miserable Malalignment Syndrome go unnoticed because a rotational deformity is not as obvious as an angular deformity. Additionally, it is easier to hide or compensate for a rotational deformity than an angular one (although doing so would cause more pain). Diagnosis is somewhat rare but can be done by an orthopedic physician through X-rays, CT-scans, and gait analysis (observing the patient's walk). X-rays and CT-scans are the more difficult ways to diagnose Miserable Malalignment Syndrome because the legs can look just as normal as they may plain sight. The Craig's test (where the patient lies on their stomach and the physician raises the shin 90 degrees to see if it is aligned properly in comparison to the femur, as well as move the shin left and right to assess the movement in the hip socket) is especially used to observe misalignment which can lead to diagnosis.

Treatment
There is no cure for Miserable Malalignment Syndrome. However, different kinds of treatments, ranging from practical, minimal care to advanced surgical procedures, are available for varying levels of misalignment and pain.

Management
Most cases are mild enough to simply utilize ice therapy, rest, and over-the-counter pain medication when pain occurs. Restricting leg exercises that put pressure on the knees like running, squatting, lunging, and walking for extended amounts of time can be helpful. Isolation exercises that strengthen the leg muscles without putting very much pressure on the knees, such as swimming or elliptical training, may be beneficial in decreasing pain. Wearing a knee brace during exercises or throughout the day is suggested to help guide the leg to move more properly and avoid more pain. Massage techniques can be applied to the tissues surrounding the knee to reduce pain and inflammation and increase positive sensory awareness in the area. Shoe insoles can also be used to help lessen foot pronation, which can potentially ease leg pain as well.

Being overweight, as well as sudden weight gain, can contribute to or aggravate pain by causing the leg joints to bear unnecessary weight. Maintaining a healthy diet and remaining as active as possible can avoid this excess joint stress.

What should be avoided at all costs is underestimating the severity of a patient's condition. This “benign neglect" approach can cause terrible knee injury or further damage to the underlying cartilage and possibly require surgeries to remedy. One such serious risk of neglecting to properly care for Miserable Malalignment Syndrome is patellar dislocation.

Surgery
Less than 10% of cases are severe enough for corrective surgery. A bilateral osteotomy, performed by an orthopedic surgeon, is a procedure where both the inward torsion of the femur and the outward torsion of the tibia are corrected as much as possible. According to a study of bilateral osteotomies done by Doctors Francesco Leonardi, Fabrizio Rivera, Alessandra Zorzan, and Syed Mohsin Ali, "All surgical procedures were performed without complication of infection, neurological problems, or compartment syndromes. All osteotomies healed without complications," and, "In all patients a good result was obtained. At final follow-up all patients reported progressive marked relief of symptoms during normal activity after surgery and consequent progressive increase in function." Another study conducted by Dr. Peter M. Stevens and his colleagues also showed that among fourteen patients, each one was totally satisfied with the results of their surgery. Basically, although a bilateral osteotomy is an advanced procedure, the outcome is positive.

Naturally the length of the healing process is unique to each patient. Dr. Mitchell Bernstein performed a bilateral osteotomy on his patient’s left leg, and then waited six weeks before performing the same procedure on the right leg. Each leg took around four months to fully heal.