2011 Annual Conference

Boucher, Brenda

Evidence exists to support an impairment-based physical therapy examination to guide treatment for knee pain.  In addition, evidence supports use of manual techniques directed at the lumbar spine to positively affect pain and function at distant segments, including the knee.  Finally, evidence exists to support the use of manual techniques to address positive neurodynamic examination findings to reduce pain and increase function of distal joints. The purpose of this case report is to describe an examination process, inclusive of spine and neurodynamic impairments, and intervention approach to treat a patient with primary complaint of anterior knee pain.

50 y/o female with a 3 week history of left knee pain following an incident in which she missed a step while descending stairs, resulting in twisting of the left knee.  She reported no immediate pain; however, the following day she experienced swelling and pain in the knee.  Within one week, she experienced two episodes of sharp, posterior to anterior, knee pain while walking.  She presented to therapy with report of anterior knee pain, knee joint swelling, inability to fully straighten the knee or bear weight through the left leg.  She was referred to physical therapy with a medical diagnosis of patellofemoral arthritis and hamstring contracture.

This case report describes physical therapy management using an impairment-based examination and movement dysfunction approach to treat a patient with anterior knee pain.  Outcome measures included the Knee Outcome Survey for ADL's (KOS), the Lower Extremity Functional Scale (LEFS), Numeric Pain Rating Scale (NPRS) and Global Rating of Change (GROC).

Examination of the patient's left lower extremity revealed primary findings of decreased ROM of the hip (IR & flex) and knee (flex & ext), decreased passive accessory ROM (tibiofemoral joint ER), hypomobility of joint accessory motion (tibiofemoral and patellofemoral), pain with muscle resistance testing (quadriceps) and knee joint swelling. 

Treatment was initiated with grade III-IV knee and hip joint mobilizations in the direction of restriction and grade V long-axis thrust manipulation to the hip followed by exercise to facilitate motion, strength and neuromuscular movement training for visits 1-6.  By visit 6, the following gains were measured:  increased knee AROM (Flex=125°, up from 100°; Ext=-1, up from -10°), decreased pain (1/10 down from 4/10) and overall perceived improvement of +4 on the GROC, indicating a moderate change for improvement.  At this time the patient's primary complaint was a "dull" ache on the medial aspect of the knee at rest, sharp 3/10 medial knee pain with 2 inch step-up and pain (6/10) with full knee extension when walking.

Further examination found hypomobility of L5/S1 and left SIJ, positive Slump with posterior knee pain and reproduction of the patient’s knee pain with neurodynamic testing with bias to the left Saphenous nerve.  Treatment was progressed to include thrust manipulation to L5/S1 and left SIJ, nerve gliding with Saphaneous nerve bias, followed by neuromuscular movement training to facilitate optimal movement patterns.  At the conclusion of visit 9, the patient demonstrated no knee joint swelling, full knee extension and reported ability to bear full weight during gait and 100% functional return at work.  GROC= +7; KOS = 98%; LEFS=93%; NPRS=0/10.

Initial examination identified subjective and objective findings consistent with anterior knee pain similar to PF jt pain syndrome.  Knee symptoms began to diminish with intervention directed at the hip and knee; however, lingering symptoms persisted.  Further examination identified impairments of the lumbo-pelvic region and nervous system that reproduced the patient’s lingering symptoms.  Manual techniques directed at the lumbar spine and nervous system, followed by neuromuscular training, resulted in immediate reduction of the patient’s symptoms.  At visit 9 (three additional visits), the patient reported abolishment of all symptoms.

This case report describes an impairment-based and movement dysfunction examination and intervention approach to treat a patient with anterior knee pain that presented with symptoms similar to PF joint pain syndrome.  Varying impairments have the potential to contribute to knee pain, and findings of this case report suggest contribution from the spine and neural tissues.   Although no cause-and-effect relationship can be established, this case report suggests that use of an impairment-based and movement dysfunction approach, including examination of and intervention of the spine and neural tissues, may be an effective strategy for patients with knee pain.