Knee Pain Treatments
Knee pain is an increasing problem, and not just because you are getting older. You are paying for all of your previous activities, good decisions, and especially your bad decisions. Some of those decisions were conscious, and some were because you did not know better. Most patients do not come into the office after falling, twisting, hearing a pop, or experiencing any type of trauma.
These are questions healthcare providers answer every day. But do they give you the best possible advice? How much does your provider keep up with chronic knee pain treatments?
Of course everybody wants an easy fix. Everybody wants to hear that's it's a very simple solution and they'll be pain-free by tomorrow. That's just not the case. If it was easy, your knee would be better by now.
Many people think if anything hurts, you should get an MRI. The advanced test will tell you what's wrong. That type of thinking doesn't actually get them to the next step; which is finding out, "what do I need to do to improve my knee function so it does not hurt anymore."
Many times patients would rather hear that they need knee surgery to fix their knee pain, because that will solve all of their knee pain forever.
This is definitely not the case. It is not easy and not always the most effective or efficient path.
Because the knee is an incredible, complex joint, "fixing it" often requires multiple types of treatment that address the muscles, tendons, ligaments, joint movement, muscle patterns, and movement of the foot, ankle, and hip joints.
The body is a complex mechanism of movement with some simple and basic guidelines and patterns. Throughout time most of us have managed to screw up how the body normally functions. The body is tremendously capable of compensating for muscle weakness, back pain, loss of flexibility, and low-grade repetitive trauma over time. Eventually the soft tissue just can't keep up with the compensations anymore and we develop low grade chronic knee pain.
If the answer was simple we could inject the knee with a steroid and it would heal. Most times that is not going to work or be an advantage for long term healing. Short term pain yes, long term no.
Before the Nuts and Bolts of Therapy, You Should Know This
If you have skimmed the previous page, slow down and read this next section. It is going to guide your understanding of your knee and what it will take to get better.
The European Society for Sports Traumatology, Knee Surgery, and Arthroscopy reported on the best practices for knee injuries and conservative treatment. They reported most patients present with a variety of symptoms and clinical findings. Weakness of the quadriceps muscle, especially during eccentric contractions, is usually present in the majority of anterior knee pain patients. These patients usually have loss of muscle and reduced function of the vastus medialis, and an imbalance between the vastus medialis and lateralis (inside and outside of the quadriceps muscle).
This muscle imbalance needs to be corrected before quadriceps exercises are started. The non-operative rehabilitation protocol should be divided into different phases based on the patient's progress. The goal of the first phase is to reduce pain and swelling, improve the balance between vastus medialis and vastus lateralis, restore normal gait, and decrease strain on the knee. The second phase should include improvement of postural control and coordination of the lower extremity, increase of quadriceps strength and when needed hip muscle strength, and restore good knee function. The patient should be encouraged to return to or to start with a suitable regular physical exercise. Therefore, the third phase should include functional exercises. Towards the end of the treatment, single-leg functional tests and functional knee scores should be used for evaluating clinical outcome. A non-operative treatment of patients with anterior knee pain should be tried for at least three months before considering other treatment options.
The European Society for Sports Traumatology, Knee Surgery, and Arthroscopy says the many people with knee pain have multiple problems that are resulting in their knee pain. There is a process and progression for getting better, and you should follow it for at least three months before more aggressive treatments (including surgery)!
People do not notice how their foot, ankle, knee, and hip bend when they squat to pet the dog or tie their shoe. Or how their knee dips inward when they squat. When you pick a shoe up off the ground, do you hinge at the low back or drop your waist toward the ground?
You are losing function over time, leading to tissue damage.
Realistically, most people do not care about their body's function until it stops working or hurts. The average person does not work toward maintaining optimal function, they only want it to not hurt when they go through their day. Unfortunately, this can lead to slow changes over time that cause dysfunction in movement patterns and pain.
The initial goals of treatment are always to:
The knee system includes the ankle, knee, hip, and low back (more on importance of hip strength and knee pain from International Journal of Sports Physical Therapy). We will discuss why this is important at a later date, but think of your car. When one tires goes bad, does it go bad all by itself? Or does the alignment and other tires play into the damage? Movement is a system.
There are multiple treatments to help decrease pain and inflammation around the knee. The most common therapeutic modalities people are familiar with include ultrasound, heat, ice, and electric therapy. These will initially help control the pain.
Light motion and movement will further help block the pain signals traveling to the brain and enhance your pain-free movement. Usually a worksheet, diagram, or website of knee exercises are given.
The above treatments are the first phase and you should progress from this point quickly. If you are in severe pain you will stay in this phase of treatment a little longer, but you should progress to the treatments that really provide "the bang for your buck." If after a few weeks you notice every other knee patient is doing the exact same thing as the first week, leave now!
Treatment exercises begin without weights at the beginning if you have severe knee pain. With improvement we can expect light resistance movement with elastic bands or rubber bands. Rubber bands provide a mild resistance with minimal risk of aggravating your knee pain. These exercises are given because you can do them at home with a simple and inexpensive rubber band to enhance strength and neuromuscular control (Journal of Sports Rehabilitation 2014). No expensive equipment required.
If this is where your treatment progression has stopped in the past, it's better than some offices but it's still not great.
The next progression integrates more active therapeutic exercises. Some are going to help teach the neuromuscular and proprioceptive systems in the brain to work together again. These are standing balance exercises. These exercises are going to help keep the foot and knee in a neutral position, prevent internal rotation, and engage the hip muscles.
I compare this stage of treatment to building the base of a pyramid. You have to have a solid and strong foundation to build upon it. If you skip steps or fail to master each level, you will not have a strong foundation. This will catch up with you later when you stop improving. Before we get to the next level of exercises we want to discuss more of the treatments available for addressing soft tissue injuries for the knee.
Graston Technique is a popular treatment for muscle, tendon, ligament, and soft tissue injuries. It is very effective at speeding healing and recovery, in both acute and chronic injuries. It is one of the most well-known manual therapy approaches that utilizes instruments or tools. Graston Technique is utilized in many professional, Olympic, and collegiate sports therapy programs. Specifically-designed stainless steel instruments have rounded and curved edges to detect and effectively treat soft tissue fibrosis or chronic inflammation.
Fascial restrictions or scar tissue develop in muscles, ligaments, tendons, or fascia. Scar tissue forms when tissue does not heal correctly, or is under chronic, repetitive stress. Scar tissue is weaker than normal muscle and connective tissue, which in your knee becomes chronically tender to the touch, especially after you are more active.
Scar tissue is like the body's duct tape; it is meant as a short term patch to help support tissue. However, in some cases the scar tissue is not replaced with normal collagen fibers. Scar tissue is also referred to as fascial adhesions, as it causes restrictions between the body's fascia. Stiffness, loss of normal range of motion, and chronic pain develop from patches of fascial adhesions.
The next time a scar tissue patch undergoes stress and strain, it becomes aggravated and flares up. This process causes more scar tissue to be added to the outside of the patch and the process repeats itself over and over, leading to larger accumulation of scar tissue patches.
For more Information on Graston Technique, watch the following Graston Technique Video.
Graston Technique and A.R.T are often utilized by a provider during the same treatment. Often times you will see a provider using A.R.T concepts with the Graston Tools, mainly to reduce the strain on the provider's thumbs.
Massage therapy, manual therapy, and other soft tissue treatments can also be used during treatment. Each of the soft tissue therapies have their own advantages. Every provider has their own preferences, and you will find a substantial difference in skill levels between soft tissue treatment providers.
Chiropractic Manipulation of the Low Back
Chiropractic manipulation of the lumbar and sacroiliac regions has been shown to increase activity of the gluteus medius and vastus medialis muscles. In this study on chiropractic manipulation and knee pain, they also found patients had better pain scores and function on the step down test post manipulation.
There are multiple ways to adjust or manipulate the lumbar spine. Click to read and see examples of different types of chiropractic manipulations.
Patients with knee pain often have dysfunction in their pelvis and low back muscles, which leads to injuries and joint dysfunction in the low back. Chiropractic is exceptionally effective at restoring joint motion. Chiropractic provides the greatest bang for your buck for any low back injury.
Like many things in healthcare, not all lasers are equal. Different lasers have different power levels, depth of penetration, and amount of energy produced. Class IV are the newest and most powerful. Class III lasers will not provide the benefit you are looking for to help with chronic knee pain.
FAKTR emphasizes the kinetic chain and treatments look for anything wrong or dysfunctional in the lower extremities or gait. FAKTR combines multiple types of treatments and though process for rehabilitation. It looks at solving problems in the system to improve your function.
Many patients utilize acupuncture to manage chronic knee pain. Many feel relief from their moderate or severe arthritis pain. Acupuncture can help reduce swelling and promotes blood flow around the knee. We have also seen patients respond very well to acupuncture if they have chronic swelling behind the knee.
An orthotic helps maintain the proper foot arch when standing or walking. By keeping a proper arch, it helps prevent excessive tibial torsion and strain on the knee. Some people will notice a significant improvement when they wear them.
A study in Clinical Biomechanics showed an orthotic helped maintain proper foot and knee positions which enables the gluteus medius to properly engage and contract to stabilize the pelvis.
Interestingly enough, off-the-shelf, less expensive orthotics can provide some of the same benefits. In a study by Hertel, they found improvement of vastus medialis and gluteus medius activity with off-the-shelf orthotics during slow, controlled exercises such as single leg squat and lateral step down. The benefits were not as dramatic during more explosive and dynamic activities such as jumping.
A 2013 Study by Sports Health studied the effects of chiropractic manipulation by itself and with kinesio tape applied to activate the gluteus medius. Patients treated with manipulation and kinesio tape showed improvement on a balance and squat test.
There are several kinds of neuromuscular tapes that are easily purchased, such as kinesio tape or rocktape. Find what works for you.
Be careful about the amount of calories you are consuming. Excessive calorie intake will add on the pounds, and this is very common when a semi-active person gets injured. They are used to burning several hundred more calories a day through exercise. The injury prevents the exercise but people do not reduce their calorie consumption.
More active individuals can run in water. Running belts help keeping you floating in water allow your legs to stride without touching the ground. Your legs will feel the resistance with both striding forward and extending the leg backwards.
Ever heard of people feeling much better after they started taking a single supplement or nutrient? My guess is that many of these people were taking an anti-inflammatory that was providing a benefit throughout their system.
Overall, a healthy diet of fruits and vegetables is the gold standard, especially when eliminating all of the things you know are not healthy (processed foods, trans fats, junk food, etc).
Turmeric, ginger, glucosamine chondroitin, and fish oils are all popular anti inflammatories and have an outstanding effects on the body. Even if it does not directly help with the knee pain it will be a benefit to the body by decreasing systemic inflammation.
TENS units can be used throughout the day. Many people find themselves using them both pre and post activity. I prefer to use the TENS in combination with ice whenever possible. The combination helps block pain and reduce inflammation.
To make this exercise a step harder close one eye. At this point we're losing input from our eyes which helps with our stability. By losing a little bit of depth perception, it requires your body to listen to the ankle, knee, and hip joint receptors to keep stable. Closing both eyes makes the exercise much harder.
With chronic knee pain, many people become very eye dominant for their proprioception. They this system stopped listening to their foot, ankle, knee, and hip joint receptors. For long term improvement you need to reactivate the. Closing your eyes is one of the fastest ways to engage joint proprioceptors and enhance your recovery (be safe when and where eyes - no falling you close your).
From the tandem stance we can progress to a single leg stance with the knee slightly bent. We want to maintain proper posture in the back and hips, which then require the lower leg, upper leg, hip, and back muscles to work together. Single leg stance is making several muscular and nervous systems work together. This may sound simple, but I think you should try it before reading the next paragraph.
Rule of Thumb:
You should be able to hold your single leg stance position for two minutes with your eyes closed. Now that you're able to stand on one leg with your eyes closed and the knees slightly bent, we can progress to single leg squats. Slowly squat lower towards the ground while keeping the back straight. As you lower yourself you'll notice that at some point you will want to hinge forward. The point of the hinge is a sign of your strength levels.
You were probably only able to squat another six to eight inches before hinging forward. This is your breaking point. Past this point you are unable to stabilize the knee, pelvis, or back because of muscle weakness. Your body went to its usual compensation method of hinging forward, lowering your shoulders towards the ground without moving your hips anymore. And yes, you should be able to squat lower on one leg then you just did for this test.
Further enhancement of the proprioceptive system involves unstable surfaces. There are a variety of unstable services that can be utilized. Anything soft and squishy, such as foam or rubber discs, works well. From here we can progress to more unstable services such as a wooden wobble or rocker board. Many people are familiar with BOSU balls, which have a rubber dome on one side and a hard plastic side on the other. We can stand on both the rubber or the hard plastic, and each have a different level of difficulty and enhance activation of muscle stabilizers (Journal of Strength Conditioning and Research).
Each of these exercises can be enhanced by closing one or both eyes. The more you require the body and brain to listen to the joint sensors in the ankle, knee, and foot, the faster you will improve.
All of these neuromuscular pattern exercises can be enhanced with a vibration unit. Vibration units continually knock you off balance, which requires the system to pull you back to neutral and stabilize. In the meantime you have been shifting to the opposite direction again and your body has to respond. The speed, amplitude, and frequency of vibration can be adjusted and each has a therapeutic advantage.
Rule of Thumb:
Stimulus and Response. The body responds to changing stimulus. If you want a reaction or different outcome, you need to challenge the body. The more stimulus we challenge you with, the faster you will respond. This is why level one exercises are great at the beginning but you need to progress past these to more challenging exercises.
Most people are amazed at how difficult it is to maintain balance on a vibration plate. Every exercise is significantly harder and more challenging, which speeds your overall neuromuscular control and recovery.
Vibration, Unstable Surfaces, and Proprioception
Vibration plates have been around for many years and are used by all advanced or high-tech rehabilitation or sports training facilities. Athletes can utilize vibration therapy to further develop their proprioceptive sensors, enhancing their stability and neuromuscular control. Even a person who is in great shape can find vibration therapy difficult.
It's all about challenging the system and getting the body to respond. Every individual has their breaking point, and as a provider it is my job to identify your weakness and move you past it. We have had exceptional athletes get even better while challenging their one leg squat with their eyes closed. Of course they usually squat much lower and require more repetitions to reach their weakness. But the theory and process are the same.
More Exercises can be found at:
Think of a penny jar. Over time, every penny jar fills up with change. Some weeks you add more pennies and other weeks you take some out of the jar. It may take years for the jar to fill, but it will eventually overflow with pennies. You can't remember all of the times you put change in the jar, you just have a sense that you added to it.
Just like the stress you place on your knees. You know you are doing it, but not realizing how quickly you are adding change to the jar.
How Long Is It Going To Take to Get Me Better
The European Society says plan on at least three months before questioning the process; however, the most important question everyone asks is "how long is it going to take to get better?" My answer is that it depends.
It depends on how hard you work and how consistent you are working through your dysfunction. It also depends if you are getting the right treatment for you, or following a worksheet for knee pain created 15 years ago. If you spending more time doing exercises by yourself in the office, then go somewhere else. Go where a provider is working the soft tissue and enhancing the muscle strength, endurance, and neuromuscular patterns.
In the office we will work through the pain and identify all of the muscle dysfunction throughout the lower extremities. We will show you all of the exercises that you won't want to do at home. Your consistency and dedication will shorten your recovery and accelerate your improvement. So when you ask "how long is this going to take," it depends. It depends how much effort you put in at home, how much work the healthcare providers have to do instead of work with you, and how good of a plan and treatment options are included in treatment.
Do the exercises with the highest priority first and work to the least important, that way the most important get done. Has anyone told you the most important, or just given you a worksheet?
There are some exercises that you will be forced to do only in the office because we have the expensive equipment. It's not worth your bang for your buck to have these pieces of equipment at home. Similarly, we can make recommendations for less expensive equipment that will provide you value at home, only if you use it.
I believe you will have a better outcome if you understand the problems and solutions.
Over time you will notice improvement in your ability to perform the exercises. You will be able to do it longer and with better control. Eventually you will fatigue, but it will take longer to hit your failure point.That is improvement.
Treatment is a progression from getting you out of pain to maintaining long-term benefits. It is also a combination of strategies and principles to get you to heal as fast as we can and as efficient as possible.
We want to develop stabilization throughout the entire lower extremity as quickly as possible so that you get the biggest bang for your buck.
Your knee also has a slight amount of rotation. This rotation locks and unlocks the knee when standing straight-legged. Many times people will feel a pop as they extend or flex a knee; some of this feeling is from the rotation.
Your knee is a complex joint. A simple version to that statement is that it has a lot of stuff in it. This stuff includes the bones. The weight-bearing femur sits on top of the tibia and the smaller fibula that is on the outside of the lower leg. Most of the weight is transferred from the femur to the tibia.
Each of these long bones are covered in a layer of hyaline cartilage that reduces friction and increases the sliding movement of the ends of the long bones. It also helps protect the bones against damage.
Next we have thickened shock absorbers, made out of fibrocartilage. Fibrocartilage is a very dense cartilage that absorbs a massive amount of stress and strain without breaking down. When people talk about their medial meniscus, this is what they are referring to. Fibrocartilage absorbs a tremendous amount of stress daily.
There is a dense joint capsule that connects the femur to the tibia. This is not only a protective ligament complex that resists stress and strain, but it also helps contain the inside of the knee from the outside. Inside of the joint capsule is another membrane that secretes synovial fluid. Synovial fluid is much like a WD-40. It helps reduce friction and increases the glide between tissues. The synovial fluid also helps absorb some of the forces that cross the knee joint.
There are several very large ligaments that connect the femur to the tibia and fibula. They are stabilizers to protect the knee joint. These ligaments resist shearing motions and prevent twisting or bending in the wrong direction.
The medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL), and posterior cruciate ligaments (PCL) are these large structurally supportive ligaments that cross the knee joint. Damage to these structures can ruin your fantasy football team.
There are several small bursa in the tissue around the knee. Bursa are fluid filled sacs that help reduce friction between muscles and tendons that glide past each other. In some cases, the bursa can become irritated and inflamed, causing swelling and pain. This is referred to as bursitis.
We will soon discuss in great detail the muscles that cross the knee joint. But first we should consider the patella bone. The patella is technically a sesamoid bone, which means a bone inside of the tendon that helps transfer its directional pull. Your quadriceps muscle is a very strong and powerful muscle that eventually becomes the quadricep tendon. The tendon inserts on the top of the patella but also crosses in the front of the patella bone where it reaches the bottom of the patella. From the bottom of the patella bone to the insertion on the tibia is called the patella ligament. Tendons connect muscle to bone, whereas ligaments connect bone to bone.
Tendons attach muscles to bone and have a better blood supply than ligaments. Tendons are responsible for transferring the contractile forces from muscles to bone. When muscles contract, they shorten and pull the bone on the other side of a joint, which is how movement occurs.
Ligaments tend to be much more dense than tendons and have a limited blood supply. This is why when we stretch, tear, or damage a ligament, it takes much longer to heal. The poor blood supply means less nutrients are going to the ligaments and thus prolonging recovery.
Underneath the patella is another layer of cartilage which faces the front of the femur. The femur is also covered in hyaline cartilage which allows the patella the glide up and down the femur. This area is called the patellar surface. Chondromalacia patella is when the cartilage underneath the kneecap is irritated. Patella femoral syndrome is when the cartilage on the femur is damaged. These are common locations of damage and pain with chronic knee pain
If you are sitting with your knee bent, place your finger on the top of your kneecap. As you straighten your knee you feel the patella get pulled towards your hip. The contraction of the quadriceps muscles are shortening and pulling the patella towards the hip. The patella ligament is pulling the tibia and extending the knee. The quadricep is shortening to produce movement, or concentric contraction. Now slowly lower your leg back down by allowing the quadriceps to lengthen. The quadriceps muscle is slowly elongating, or going through eccentric contraction. Eccentric contraction places more strain on muscles and is more likely to cause muscle damage. Eccentric contraction is why you are more sore after running or walking downhill compared to flat ground.
These are all the main structural elements that make up the complex knee joint. Every one of these tissues can be damaged, which either acute trauma or slow chronic repetitive stress and strain. Each of these soft tissues, cartilage, or bone can send pain signals back to the brain whenever stress is increased upon the injured tissue.
We also have movement and positional sensors inside much of the tissue, muscles, tendons, ligaments, and joints. These sensors send a massive amount of feedback to the brain to let it know where every part of your body is in space. If you were to close your eyes and extend your elbow and pointer finger, you can then slowly flex your elbow and touch your finger on the tip of your nose. The body knows exactly where the finger is in space and can guide it to your nose because of these sensors. These sensors and process of knowing where the joints are in space is referred to as proprioception.
Hundreds of thousands of joint movement sensors send information to the brain, which integrates the information and sends specific signals to the stabilizing muscles during movement. When the information is compromised, the body cannot respond optimally or stabilize the joints. Many times this leads to poor joint movement and control, ultimately damaging the tissue.
Ever feel like your knee wants to "give out" when you step awkwardly? If you were to step on a rock the sudden movement is recognized by the the proprioceptors, which tells the brain your knee is shifting to the side and your brain responds by activating stabilizer muscles to pull it back into position. However, if your knee shifts too far and your brain doesn't think it can safely stabilize the leg, your brain allows you to fall instead of tearing some ligaments. Your brain decided your risk of damaging the knee was greater trying to stabilize than hurting yourself falling on the ground.
Most times a patient will have tenderness throughout the knee and pain with bending, turning, twisting, and squatting. They will have pain with several of the tests that we ask them to do, and often times they can localize the pain to the outside of the knee. If you can touch the spot that hurts then it is definitely a muscle, tendon, ligament, or fascia that's crossing the knee joint. You cannot push on the meniscus and cause pain (except in very rare instances).
Many people do not like to hear this because they are secretly hoping that they can just go have surgery and that will fix the problem. Unfortunately, that is not the case and we see many patients who undergo knee surgery and do not have better functional capabilities or pain levels a year after the surgery. We then end up going through treatment for soft tissue injuries and pain, even after they had surgery to "correct" the problem.
Several studies show surprising information on knee surgeries that might be of interest to you.
Jeffrey Katz M.D. found in Surgery vs. Physical Therapy for Meniscal Tear and Osteoarthritis similar results of pain and functional abilities at both 6 and 12 months for people with mild to moderate arthritis symptoms and meniscal tears. They compared results from people who went into surgery and had physical therapy with individuals who only had physical therapy. Similar outcomes were obtained by both groups.
Another study looked at the increasing number of knee surgeries occurring in the United States. The study examined the last 20 years of data for x-ray findings of osteoarthritis and compared that to the number of knee surgeries.
The results suggest that the prevalence of knee pain has increased substantially over 20 years, independent of age and BMI. Obesity accounted for only part of this increase. Symptomatic knee osteoarthritis increased but radiographic knee osteoarthritis did not. We are having more surgeries but the level of osteoarthritis is not worsening.
Likewise, if the worst case scenario is that you end up in surgery, then you are considerably stronger going into surgery, which will only enhance your recovery.
Many patients are still doubtful but agree that going through several weeks of treatment can only help their surgical outcomes. These are the same patients who are very surprised when they feel significantly better in just a few weeks. At this point they are acknowledging their muscular weakness and stability issues, and are noticing how they have compensated through the years.
When these treatments are incorporated into a treatment plan patients heal faster and are less likely to have long-term pain or soft tissue fibrosis or scar tissue in the injured muscle. These soft tissue treatments are incorporated with therapeutic exercise and flexibility programs.
MRI and X-rays will not usually be ordered to evaluate mild to moderate muscle, tendon, and ligament injuries. Severe cases may utilize advanced imaging to rule out bone fractures, edema, nerve entrapments, tendon or muscle ruptures. NCV testing may be utilized in cases that also involve muscle, sensory, or reflex loss.
Many therapeutic exercises can help restore proper strength and endurance to the leg muscles muscles. Isometric exercises are often the initial treatment exercises. Followed by single plane rubber band exercises for hip, knee, and ankle; flexion, extension, adduction, abduction, circumduction, inversion, and eversion. Dynamic exercises involving stability foam, rubber discs, exercise ball, and BOSU balls can be performed on the floor. The more unstable of the surface the more effort and stabilization is required of all the lower extremity muscles.
Vibration plates enhance neuromuscular learning throughout the ankle, knee, foot, hip, and back muscles. Additional strength exercises can be found on the hip, knee, and foot strengthening pages. More information for injuries and treatments for back pain and foot pain.
Our Chandler, AZ Chiropractic & Physical Therapy clinic treats patients with a variety of muscle, tendon, joint, and ligament injuries. The clinic provides treatment for runners, tri-athletes, and weekend warriors in addition to common headache, neck, and back patients traditionally seen in Chiropractic, Physical Therapy, Massage Therapy clinics. We work with all ages and abilities of the residents in Phoenix, Tempe, Gilbert, Mesa, and Chandler AZ.