So the next step in this series is talking to you about some case studies, the reader needs to keep in mind that this blog is for reference only, as I’ve mentioned, every complaint is unique and individual, this blog should not be used as a treatment pathway, this should always be discussed with and managed by your Physio.
Nonetheless, this might give you a different insight into how some of us in the physio world will approach management of a Patellofemoral dysfunction. Again, I like to remind the reader that there are a multitude of treatment approaches that Physios use, different algorithms of treatment, different levels of experience, different considerations for each therapist and patient relationship.
Let’s take a look at how I would approach the situation in these 2 scenarios.
23 year old male amateur contact sport athlete
Plays twice a week, trains with a team 3 times a week, runs 10km per week on top of that individually.
Was training on step climbing 2 weeks ago trying to ramp up mid season fitness. Ran 20 reps of 150 steps at high speed. Has never done this type of training before, was training with a more conditioned training buddy. There was no memorable issue at the time, just sore the next day.
The athlete shows up to assessment with a swollen knee, pain with walking up and down stairs, a painful click in the kneecap getting out of chairs and a dull ache in the front of the knee that is exacerbated with running.
My assessment shows that his knee otherwise is in good shape, ligaments and cartilage are all good and he is a strong athlete, lots of leg muscle bulk and his quads are powerful, but inhibited by pain at the assessment. His ITB is fine, its the same as the other leg and the kneecap moves well. He is definitely sore with compression of his knee cap but with some support pushing on his knee cap offering stability, his symptoms are reduce able.
Through some further questioning I find out that although he has had no previous knee injuries, he did have a couple of serious sprains to the ankle on the same leg a couple of years ago.
A bit more investigation shows that this strong fit athlete has some relatively poor hip control on the same leg and the strength of some of the hip muscle groups is noticeably reduced compared to the other side.
GOAL ONE: Educate the patient and Reduce the symptoms. There may be an argument for a patient like this to use some anti inflammatories and/or analgesia. This is always discussed in the context of the patient and what they feel comfortable with – balancing pain and function against their belief of using medications, because some folks don’t like to, and it’s not always necessary.
We might use some ice and compression as well to manage the swelling and there is evidence to suggest that the compression may help to recruit some more muscle activity. With a patient like this, I will use some knee strapping because I tested it earlier with the kneecap support and it yielded some benefit. I will advise him not to use steps if he can avoid it and to limit his running for a couple of days (this always needs to be looked at in the context of the demands of the sport and team and symptoms).
Remember as a patient, if you don’t leave knowing why this is being done, turn around and get the answers!
GOAL TWO: Start attending to the contributing factors. With a patient like this, all the ITB rolling in the world won’t change the more obvious biomechanical factors at play. That technique may be an element of what is required for longer term, but in this circumstance, there is a suggestion that the old ankle injuries may have contributed to a longstanding biomechanical issue on that leg, that was previously well compensated for, but now that the knee is sore, is adding to the problem and slowing the recovery.
I will be focusing on getting the pelvic and hip control back in check as this will be adding undue load to the knee. Any tightness in the hip flexors that may be inhibiting glute activity will be managed with treatment and stretching and we will get stuck into getting the glutes working more efficiently immediately. Remembering that in this case, although the symptoms are locally, there is massive contributions from other parts of the biomechanical chain above and potentially below the knee. Painfree exercises (or exercises that don’t make the pain worse) will be commenced early and graduated through to more dynamic and functional exercises as strength, control and symptoms allow. Ensuring considerations are made to strength and endurance aspects of the muscle groups and other contributing muscle groups around the region. Isolation and global exercises are really important with these issues.
GOAL THREE: Make sure he knows what the long term requirements are and why. Again education is paramount. Together, we need to make sure this isn’t going to be an ongoing issue. These things can take time, particularly with an athlete who needs to train and play. Return to sport and the considerations given to graduating back to training and playing in sport is a huge area that I won’t discuss here, but these things should always be considered by your Physio and discussed with you.
There will potentially need to be more strapping and potentially a supportive brace to allow for return and maintenance in sport, there may also need to be modification tot raining regimes for a while. this patient will definitely continue to work on strength and biomechanical factors through the season and eventually incorporate things into his normal routine for the future, not necessarily as “rehab” but more so for good balance in his program.
A middle aged female office worker who normally works 8 hours a day and walks for 1 hour, 4 times a week. There has been about 5 years history of on and off soreness in one knee at the front of the knee, with no specific injury as such. No other leg injuries have ever occurred. Pain is worse going up and down stairs about 3/10 pain, and always about a 1/10 ache is present. The knees both click and always have but this is not painful.
Assessment shows pain with compression of the kneecap and pain is aggravated with compressive loading exercises. If I stabilise the kneecap position the pain is reduced.
When I assess this worker’s biomechanics and muscle strength around the knee and hip, there is nothing obvious, the ITB is ok, the other quad muscles are strong and not tight.
A bit more questioning determines that this patient walks in shoes with very thin soles and no support. Assessment shows substantial pronation of the feet which is resulting in biomechanical changes around the knee with prolonged walking and fatigue. It is equivalent on both legs but only one knee is sore.
A little further questioning determines that this patient has never had an ergonomic assessment done in her workplace and that when she is particularly busy, she will sit on one of her feet on the chair, the same leg that has the knee pain. The knee pain started about the same time as the job did.
GOAL ONE: Educate and reduce the soreness. Now this patient doesn’t have a lot of soreness anyway AND she has told me she has an allergy to tape adhesives, so strapping is out of the question. This might mean modifying a bit of activity to reduce the symptoms. In this case, I’m thinking that the footwear she is walking in isn’t helping, nor is her work desk and office chair situation.
Here is a situation where biomechanics and activities are both contributing to the problem.
Therefore, with this patient, more appropriate walking shoes are sourced. Orthotics aren’t always necessary. Sometimes they are excellent, but in this case a basic sports shoe has countered the foot position and provided better biomechanical support. Secondly the workstation is assessed by the workplace health officer, and the patient modifies her sitting position to avoid bending her knee to sit on her foot.
Within one week the symptoms have halved and within two they have resolved altogether and the patient is back to her normal routine with no further issues.
So what this means is that although two people will have the same part of their body hurting, there is no recipe to treatment, each situation can be markedly different. Good diagnosis is the key and this requires lots of communication. Communication is King!
Keep an eye out for the next series.
Have I missed something? Do you have some feedback? Would you like me to talk about anything in particular?
Find me at www.inclinicphysiotherapy.com.au