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Hey guys! I hope y’all are doing well. Here’s a case I had recently, let me know what you think.
Subjective:
Patient was going from sit to stand and felt a pop/click in his right anterior medial knee followed by a sharp pain. Slow onset of swelling with some posterior knee pain. Initially reported clicking with feelings of giving out. Currently feels stiff in the mornings and pain with jogging. Has fear of returning to high intensity exercise due to potential knee pain.
Goals: return to high intensity workoutsAggravating Factors: jogging, squatting, pivoting, mowing the lawn
Relieving Factors: ice, staying away from aggravating factorsObjective:
Gait: mild antalgic, decreased terminal knee extension
Functional screen: Increased weight on R LE during squats with minor pain, SL squat increased L knee valgus with hip drop and pain
LEFS: 62/80
AROM: (-2 – 130) pain with overpressure (flex> ext)
Strength: Hip ABD 4/5 L 5/5 R, Hip Extension 4-/5 L, R 5/5, Knee flexion: L 4/5, R 5/5
Special Test: + Thomas (rectus femoris/ IT band)
Palpation: Joint line tenderness, + Thesley’s, – Valgus, – VarusPICO:
Would a patient with medial knee pain cue such as walking softly compared to no cueing help improve symptoms?Article Reviewed: The relationship between landing sound, vertical ground reaction force and kinematics of the lower limb during drop landings in healthy males. Kevin Wernli, Leo Ng, Xuan Phan, Paul Davey, Tiffany Grisbrook. J Orthop Sports Phys Therapy. Jan 2016.
Inclusion criteria: 21.1 (+/- 2 years), 1.79 meter (+/- 1 year), 78.3 (+/- 12.2 Kg). 26 healthy active males were recruited for the study.
Exclusion criteria: a lifetime history of lower limb surgery, a 6-week history of lower limb injury.Patients were instructed to jump from 30 cm with no instructions. The participants were instructed to remember the sound from the first normal landing and then perform the task as before but listening to their landing sound. The goal was try to make a softer/louder sound. The performance of the task was repeated 5 times for each sound condition with a minute rest period after each condition to minimize the influence of fatigue. A linear relationship between landing sound and vGRF (vertical ground reaction force) were found. As landing sound decreased, so the vGRF It was also found that soft landing conditions resulted in greater ankle and knee excursions while the loud landing condition resulted in decreased ankle joint excursions and increased hip joint excursions compared to the normal sound landing condition. Using landing sound as feedback helps decrease cost, it’s a simple way of decreasing vGRF and potentially decreased the prevalence of lower limb injuries. Even though my patient is 41, he is still very active and he continues to participate in high intensity exercises. This cue of landing softly would be great to help decrease his vGRF when landing.
Limitations: only healthy males, landed only onto a hard force plate (limited varied surfaces), participants were not blinded
Questions:
•We know that a soft landing resulted in increased excursion in ankle and knee mobility and a loud landing had decreased ankle and increased hip excursion. Do you think that increased joint excursion may potentially increase the risk of injury?
•Have you used any other cues that have been beneficial in decreasing ground reaction force when landing?
•My patient is 41 yo, do you think that makes a difference for not fitting the inclusion criteria? Where do you draw the line?
•Is there anything you would have done differently in this study? Any other limitations you saw?
•Do you think not blinding the participants may have had an impact on the results?
•Have you used “land softly” in the clinic and what results have you seen?
Have you noticed any difference between males and female landing with this cue?
•This study was conducted on healthy males, how do you think the results would be different given a lower extremity injury?You don’t have to answer every question; I just wanted to hear your thoughts.
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Oksana – thanks so much for posting the case and the article!
I was curious as to what you thought the primary tissue at fault was in the case – it looked to me like there was potential meniscal pathology, however I was curious as to what your differential list included and what you think is most likely.
What has your treatment consisted of thus far?
I love the article – it is always helpful to know that the clinical measures we use (i.e., landing sound) correlate with variables we are attempting to correct but are harder to measure (i.e., vertical ground reaction force). The breakdown of the joint excursion was also helpful and provides another way of cuing – this is one answer to your second question.
One thing I found particularly interesting was the change in hip excursions. I would have expected a much more direct and linear change in vGRF with hip excursion – that is, I would have expected quiet landing to have shown much greater hip excursion, loud landing much less hip excursion. However, after reflecting on this, it seems that the drop height (30 cm = 12 inches = 1 foot) was probably not enough to elicit this. I bet that a double leg drop from 4 feet would have shown reduced sound and decreased vGRF with increased hip excursion.
With regards to your first question – I think this study itself (including the literature review they perform) points us in the direction that increased joint excursion has the potential for decreasing, not increasing joint injury. However, we must of course ensure that patients are moving through joint excursions in the proper plane and with proper motor patterns, or else the risk of injury may indeed increase. For example, I bet I could decrease my vGRF upon landing with increased hip adduction/ankle pronation excursion and knee valgus, however that is certainly not reducing my risk for injury.
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Oksana – thanks so much for the response!
Love the movement correction in single leg stance – would try and progressively load it over time as appropriate further with dynamic movement with similar cues for the proper movement pattern
Any manual work on him? I have tried lots of tibifemoral distraction techniques with patients with meniscal pathology in the past and feel I have had some success
His lack of full knee extension is also certainly something to look at – Eric and I saw a patient together at the beginning of the residency who had combined ACL + meniscus tear who lacked a good 10 degrees of extension. We played with his tibiofemoral IR/ER ROM and coaxed it down into full extension within a minute or two. It was really amazing and a learning experience I will never forget. I would try the same and see if you can get his extension to full. I have been assuming (as I often but should never do) that his opposite LE has full extension if not a normal amount of hyper?
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“Something that I don’t understand is no matter what we do a torn meniscus will still be a torn meniscus.”
We all have torn menisci, labrums (hip and shoulder), degenerative disc pathology, etc. – get the tissue to calm down (think “fat lip” analogy from hip labral lecture); improve the rest of the system to tolerate load better; primary goal should be restore full ROM (extension) as a gauge of irritability.I’d manually work on terminal knee extension, before strengthening into terminal knee extension.
With the patient Nick was referring to – we did a “reverse McMurrays” to “reduce” the meniscus. Osteopathic technique which works about 50% of the time. Internal rotation with a valgus load to open up the medial joint line, and cycle it through graduated stresses into full extension.
Again no research – just a technique to asses/re assess.
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Oksana – just for some more concrete evidence on what Eric was saying: see the attached article, read the conclusion and check the charts at the bottom. If nothing else, read the conclusion.
I can show you the reverse McMurray technique this weekend.
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Nice topic Oksana! Thanks for sharing your case, this has been really helpful. Can’t wait to see the Reverse McMurrary’s, mind blown.
Yes, I agree with you guys that a louder landing should have correlated with less hip excursion and therefore less force absorption through the lower extremity joints. BUT, in this study the participants were TRYING to create a louder sound. Therefore, doesn’t it make sense for a person to lean onto that side to create more force into the ground? Like the authors said, the participants were not aware that they were measuring ground reaction forces but trying to create the loudest sound they can. I think this makes the “louder” trials negligible. The more important differences are between the normal and the quiet, where we saw more hip, knee, and ankle excursions in the quiet landings.
“However, we must of course ensure that patients are moving through joint excursions in the proper plane and with proper motor patterns, or else the risk of injury may indeed increase. ” On point Nick!
I think gaining dorsiflexion will also be crucial for decreasing further injury. We can’t use what we don’t have. Joint mobilizations, STM, PNF, MET’s, flexibility exercises would all be great to use to decrease any torque or compensations up the system that could compromise the irritated structures.
I wouldn’t consider his age to be an excluding factor. I don’t think that age changes adjustment patterns during tasks, but presence of lower extremity injury does. Also the fact that he doesn’t even have the ankle dorsiflexion range of motion that was reported as average excursions for both the quiet and normal trials.
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Oksana –
Nice topic and article selection. I have used “soft landing” or “run softly” cues with patients’ often, to decrease GRF as well as patellofemoral joint compression forces. I’m surprised at the findings regarding decreased hip angle and GRF. I ran across an article a few months ago that looked at knee, hip and trunk angles and correlations with GRF and patellofemoral compressive forces. They found increased hip and trunk flexion resulted in significant decreases in GRF and joint compressive forces. I often cue athletes, when jumping or with SL squats, to drive their hips back and bend forward at their waist. This has been helpful for me and often results in decreased patellofemoral pain.
To comment on the patients’ symptoms with his squat and single limb squat. You mentioned you noted some abnormal movements and it was painful. I would try to immediately follow that up with trying to correct his movement with verbal and tactile cueing and see if that changes his pain level. If it does, I’d use that as treatment to help him move better and assist with decreasing GRF and tissue irritation and spend a lot of time educating him on the rationale. -
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Oksana – thanks for posting. Great article!
I think his age shouldn’t necessarily be a problem, especially if the intensity of activity matches what was assessed in the study.
Nick made a great point in regards to injury risk with quality of movement. Especially considering his lack of DF, it would be interesting to see how he compensates – DKV, pronation, tib IR, hip IR etc. and why (depending on where hypomobility is coming from)
Laura – good point about the importance of the “louder” results. It’s good to know the results, but I agree that the other results are more clinically relevant.
I’ve used the “land softly” with only 2 pts so far, but had pretty good results. It was a lot easier than trying to break down the mechanics and cue them on everything separately. I’ve also used the hips back/trunk forward cueing in combination with the soft landing and that’s helped me quite a bit with cleaning up running form.
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Reverse McMurray’s treatment- give it a try – no research – mild to moderate success, but worth trying
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My take on the decrease use of health care expenditure with early PT and yet not necessarily superior outcomes: yes, our research could certainly be better, and if so may show an improved result. However, MOST cases of acute LBP have a predictable course of recovery, and that recovery timetable is perhaps only modestly improved by what we have to offer. A large proportion of what we are providing is EDUCATION/FEAR REDUCTION such that, though all patients must continue to go through the similar healing/recovery process, those who see PT’s have a greater understanding of that process and therefore are less vigilant about their condition/pursue less advanced imaging/meds/injections/etc…
Don’t get me wrong, I DO think that early PT in many instances does indeed improve the patient outcome, however I think a lot of what we do through education is what results in the reduced health care utilization.
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Disregard the above post – got lost in all my tabs and posted in the wrong location!
#residentidiot
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