February Journal Club

[Katie Long]

February Journal Club

Subjective: Pt is a 14 yo female with 2-year history of knee pain. Over the past 2 months, she has been experiencing R knee pain that began around when basketball season started (for which she is the manager), but denies specific mechanism. Her preferred sport is softball, she is the catcher. Denies hip or ankle pain. Knee occasionally pops, which is painful when the knee is hurting, feels unsteady and like it will give out on her, although it has not done so with this current episode of knee pain.
-descriptors: dull ache, denies NT
-location: all around the kneecap, occasionally can travel medially and inferiorly, feels like it is under the kneecap
-aggs: walking, sitting for >1.5 hours during class, jumping, landing, running, “stomping up stairs”, squatting in catching position for softball
-eases: ice (not really, but maybe)
-irritability: 5-10 minutes
-goals: run faster, play softball (catcher), squat, stretch, PE activities (12 minute mile run at end of semester)
-LEFS: 68

Objective:
-DL squat: increased hip ER with anterior knee translation and early heel raise bilaterally, reproducion of her sx
-SL squat: excessive dynamic valgus (R>L), preferentially loads lateral column and collapses into rapid pronation when unable to remain laterally
– Step down (R): dynamic valgus and pain provocation
-Ambulation: increased femoral IR and increased midfoot pronation bilaterally
-Joint mobility:
-knee: hypomobile inferior patellar glide, painful hypomobility with superior patellar glide, hypomobile medial TF glide, hypomobile
-ankle: AP TCJ, hypomobile medial STJ glide, hypermobile midfoot in STJ pronation and supination
-hip ABD MMT: L=4/5; R=3+/5
-knee extension: L=5/5 (knee bent) 5/5 (knee straight); R=4-/5 p! (knee bent) 4/5 p! (knee straight, less pain)
– (-) McMurray
– (+) Thessaly for apprehension and pain with ER
– (-) Valgus
– (+) Varus medial knee sx
-observation: notable infrapatellar fat pad hypertrophy
-observation: static stance in genu varum and recurvatum
-palpation: reproduction of sx with palpation to right medial patellar facet, right medial TF joint line, inferior pole of patella at patellar tendon insertion (bilat)
-ROM: +5 knee extension AROM, +15 knee extension PROM, all other ROM WNL and nonpainful. No pain with quadrant testing
-flexibility: limited rectus femoris length R>L

Primary Hypothesis: PFPS 2/2 proximal and distal factors

Asterisks: (+) DL/SL squat testing, (+) resisted quad testing at 90 deg> 0 deg, (+) Thessaly, (+) hip ABD strength, (+) Varus testing

HEP: lateral side stepping w/ tb, wall squats w/ tb, quad stretch

PICO: In patients with peripatellar knee pain, is addition of orthotic management, in addition to current POC, effective in reducing pain and promoting return to PLOF?

Discussion Questions:
1. At what point do you consider putting this patient in an orthotic? Is it a first follow up? Or is it something you utilize after several visits to facilitate progress?
2. In patients with significant hyperextension and fat pad irritation, what are some cues and strategies that you utilize for motor control and/or decreased tissue compression?
3. What are some special questions you ask or objective measures assess day one with suspected PFPS to help you differentially diagnose?

See everyone soon!

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[Tyler France]

Hey Katie,

In this situation, I probably would not prescribe orthotics at the initial evaluation. Similar to what we discussed regarding the case that I presented last weekend, I would be interested to see how your patient did with some cueing for more equal weight bearing throughout the foot and I would consider orthotics if it became apparent that she would not be able to control it after a few sessions. It does not seem to be a structural issue, so I would not jump right to orthotic prescription. As far as special questions to rule in PFPS, I do not think that I know of any. Taking care to ask the special questions that would help you rule out other diagnoses at the knee would be the special questions that you need to come to the conclusion that this would have to be PFPS.

[Justin Pretlow]

Hi Katie,

I think I would consider an orthotic for this type of patient presentation if they did not respond to treatment strategies addressing the more obvious impairments over the course of 2-4 weeks. I think the dynamic knee valgus, signif. quad and hip abduction weakness, and poor control of loading the foot during single leg activities are all things that may respond to teaching and cuing proper movement patterns. If she wasn’t able to improve her control and decrease symptoms over multiple sessions, then maybe I think about an orthotic. My personal bias makes me hesitate to turn to an orthotic too quickly for someone who is 14 and may still be able to improve/change the way they move to address their symptoms. I’d also want to see how she moves/transitions to the squatting position for catcher and determine if that has some role vs. just the demanding position of squatting for long periods.

[Justin Pretlow]

As for cues/strategies to decrease hyperextension and fat pad irritation- I usually try to make sure they understand how their standing static posture may be contributing to that irritation. I ask pts to pay attention to how they stand and make sure they aren’t hanging out in hyperextension. One idea I’ve heard, but haven’t tried, is to use a piece of kinesiotape with very little tension on the posterior knee/thigh just to give the patient a tactile reminder when they hyperextend.
Not too sure about special questions to help narrow down PFPS.

[Myra Pumphrey]

Hi Katie – First, thank you for this interesting post. Second, I agree with the previous posts, that I would assess the ease of improving foot mechanics without an orthotic first. If the patient is having difficulty improving neutral foot with verbal cues and other techniques for neuromuscular re-education, I would use an orthotic (not hard plastic) to assist her in improving neutral foot position. You could use your functional squat test and maybe your thessaly to reassess with orthotics to help to determine if there is additional benefit with the orthotic.

In regards to her knee hyperextension in stand – I could not tell by your examination above whether there was hypomobility in the talo-crural joint and any limitation into ankle dorsiflexion, either due to joint hypomobility or muscle tightness. If there is restriction here, I would treat these impairments since this could be a strong associated factor to standing in knee hyperextension. PNF techniques are a great tool for improving control in weightbearing in terminal knee extension while avoiding hyperextension. You could use slow-reversal hold with manual contact proximal to the knee or rhythmic stabilization at the pelvis or shoulders while the patient maintains knee extension (w/o hyperextending) or in slight flexion. You could also have the patient do resisted upper quarter patterns while maintaining the desired knee position in weightbearing.

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