Weekend 6 Case Presentation

[Tyler France]

Hey everyone,

I’ve attached the case information for the final course. See y’all next weekend!

1. Is there any other information that you would want to find out at the initial evaluation?

2. Are there any supplementary techniques/modalities such as taping that you have found to be beneficial in this patient population?

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[Katie Long]

Hi Tyler,

Im wondering what her foot posture looks like? Did you assess her TCJ, STJ or midfoot mobility at all? Im wondering if there are some obvious impairments that might benefit from an off-the-shelf orthotic? I am not very familiar with taping at all, but it something I would like to become more familiar with for patients such as these. If it can be beneficial in the short-term in order to work on some long-term strategies/goals, I could see the benefit of trying to relieve some pressure off of the patella.

[Tyler France]

Hey Katie,

There was nothing jumping out at me regarding her foot posture at the evaluation during the functional screen that would have pushed me toward assessing joint mobility at the ankle. Most of her faults seemed to be hip-driven. However, she came in with some different symptoms at her second follow-up visit that led me to use some cueing aimed at foot positioning. Have not reached the point yet where I think orthotics are necessary (though they may help anyway), but I see her again this week so we will have to see what happens before Saturday!

[Jennifer Boyle]

Hey Tyler thanks for this case! I was wondering if you looked at her patella position/ mobility? I’ve seen great results with patellar taping techniques in the past with similar presentations. For this assessing the position that her patella sits in is very helpful for your directional force you use to with the tape and if you need to put a tilt or rotational direction on the patella. Of course this is a short-term fix but as Katie said it can be used as a starting point.

[Tyler France]

Hi Jen,

I did not really have any objective way of assessing this, but I felt that her patella was more inferiorly tilted. I taped her at the first follow up into more superior and lateral tilt with some rotation, but she did not see much benefit. She said that she may have noticed less pain medially, but it did nothing to change the pain she was experiencing lateral to the patella. Does anyone have any good methods of objectifying patellar position?

[Justin Pretlow]

Hi Tyler, thanks for the post –
1. Regarding more info I’d like to know – I’m curious about rectus femoris tightness and iliopsoas. And soft tissue mobility of quad and suprapatellar pouch?
2. As for taping, I’ve had some success with kinesiotaping for patellofemoral pain. A medial and lateral “C” taping around the patella – easier to demonstrate than explain.

[Tyler France]

Hey Justin,

I never went in and assessed muscle length of rectus and iliopsoas because she had normal knee flexion and hip extension ROM. I have not assessed her suprapatellar pouch specifically, but she has not had any complaints in that region and she is not tender to general palpation superior to her patella. You’ll have to show me the tape job that you’re talking about. I experimented with the fat pad unloading as well as a lateral “C” type technique. Neither had a profound impact on her symptoms.

[Cameron Holshouser]

Nice post Tyler,

1. I would also assess her running mechanics if time allowed for it during the evaluation. I would also be curious to see how she performs a lunge and bilateral squat at the gym.
2. Due to the patients hyperextension and inferior tilt of the patella, it could be placing a lot of stress on the infra patellar fat pad, especially if she stands statically with her knees locked at rest. I have seen success with McConnell taping by placing a superior tilt on the superior portion of the patella in combination of scrunching up the fat pad with an inferior to superior pull surrounding the patella bilaterally. This could help with unloading that fat pad and decrease pain levels. See how she does functionally (running and step downs) with tape on afterwards.

[Tyler France]

Hey Cam,

Great thoughts. I have not assessed her running mechanics to this point because it is not really a large pain producer for her and we have had plenty of other things to address during our sessions. However, I am planning on watching her run at her next visit because her symptoms and some other impairments that we have been working on are improving. Her bilateral squat is non-painful and there are no obvious faults with her mechanics. She has more difficulty with single leg activities such as the lunge.

I agree that some infrapatellar fat pad irritation and hypertrophy is likely the cause of her limited and painful end range knee extension. Tried some fat pad offloading taping techniques without any real success, though there is a good chance that that’s due to user error on my end.

[Tyler France]

One additional point that I did not make clear in my original post: she does not have knee pain while running, but she does have some lasting discomfort in that area 10-15 minutes after her run. Also, I mistyped in the original, she is running 20 miles a week, not 30.

[Sarah Bosserman]

Definitely agree that I would look at her foot posture. Sounds like you have found some impairments at the hip and some good functional re tests. The difference in knee extension side to side and functional hip weakness seems like a good starting point. Sounds like running was the original aggravating factor (and something she continues to do) so I think I would also like to assess her running mechanics along with treating the other functional limitations. Looking forward to hearing more about her case this weekend!

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