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Please look over the case and answer these questions:
1. Based on the body chart and subjective, what is your primary hypothesis and top 2-3 differentials?
2. With the subjective and objective information, does this patient fit a clinical pattern?
3. Do you feel like you need more subjective/objective information for this case, and if so, what?
4. What is your treatment for day 1 and what are you reassessing next visit? -
1) primary- PFPS; differentials- patellar tendinopathy, adductor strain, tibial plateau stress reaction/fracture
2) With PFPS and patellar tendinopathy would have expected more pain provocation with functional assessment, so doesn’t quite fit a pattern but potentially more in line with patellar tendinopathy due to pain with hopping and TTP
3) A few things-
– How long to alleviate after running?
– No mechanism of injury- does that include no reported changes in activity level?
– With patellar tendinopathy on differential would want to do resisted knee extensor testing for provocation
– Any sagittal plane deviations with squat, hop, etc? Only SL hop painful?
– Pain with adductor palpation or resisted testing?
– at follow up would want to get on treadmill and do running gait analysis4) May consider taping and would re-assess pain provocation with functional assessment; exercise wise she seems to have pretty poor mechanics with most things so start targeting proximal weakness
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1. Based on the body chart and subjective, what is your primary hypothesis and top 2-3 differentials?
-Patellar tendinopathy
-PFPS
-Pes anserine tendinopathy2. With the subjective and objective information, does this patient fit a clinical pattern?
From the subjective and objective information provided, I don’t see a specific pattern in which this fits. I would lean towards patellar tendinopathy d/t nature of repetitive action and tenderness to palpation.
3. Do you feel like you need more subjective/objective information for this case, and if so, what?
- Subjective
How long has she been running recreationally?
Any training intensity/duration recently altered?
Does the intensity continue to intensify as she continues to run?
Has she changed shoe wear recently?
What position of sitting (i.e knees straight, at 90 deg, doesn’t matter)?
What part of the squat/stairs does her pain come (ascending/descending)?
Previous knee/hip/ankle pains?
Any other activities, hobbies outside of running?- Objective
Knee resisted testing
Adductor resisted testing (testing in seated position or supine?)
Patellar positioning (static/dynamic)
Any core strengthening assessed?
With SL squat, did patient have contralateral leg in front or behind?
With the functional testing, anything noted in the sagittal plane?
At what point did she experience the pain during the SL hop?4. What is your treatment for day 1 and what are you reassessing next visit?
I would see if her mechanics would change with cuing during DL squat, if she can demonstrate decreased knee valgus and proper form, I would do STS or a mini-squat
Bridging – While lower level, would help strengthen some of the hip musculature while placing some stress through the knee
(Potentially challenging) Side plank + clam, target glute med and core musculature
Reassess – squat mechanics, and SL hop after cuing -
1. Based on the body chart and subjective, what is your primary hypothesis and top 2-3 differentials?
-**PFPS**
-Patellar Tendinopathy
-Tibial plateau Stress Fx
-L3-4 radic2. With the subjective and objective information, does this patient fit a clinical pattern?
At this point I cannot identify a clinical pattern, but I would lean towards PFPS given the altered movement patterns and the effect this may have on the PFJ during cyclic loading.3. Do you feel like you need more subjective/objective information for this case, and if so, what?
Subjective –
Running experience?
Recent change in running volume/intensity?
Does she only use a treadmill? – has this changed at all?
Any other training she participates in
Symptoms like this before?Objective –
-Knee resisted testing – At different degrees of knee flexion for provocation
-Patella Compression test
-Step down – does knee over toe positioning change symptoms in SL squat/CKC knee bend?
-Heel drop – At this point there’s not much to rule out a fracture and this may provide some info
-Running assessment?4. What is your treatment for day 1 and what are you reassessing next visit
At this point the only true impairments are the hip weaknesses and the altered mechanics with squat/SL/hop. I would address the hip weakness with a very isolated movement such as clams or sidelying abd, and reassess strength, and reassess squat or SL squat. This may improve mechanics or at the least provide information about whether this is a true strength issue, an “activation”/motor control issue, or if more in task motor control training is something to attempt in the future. -
1. Based on the body chart and subjective, what is your primary hypothesis and top 2-3 differentials?
Primary: PFPS
Differentials: meniscus injury, MCL injury, patellar tendonopathy, stress fx2. With the subjective and objective information, does this patient fit a clinical pattern?
Not a very clear pattern – now between PFPS and patellar tendonopathy based on functional assessment. Doesn’t seem to be a ligamentous injury.3. Do you feel like you need more subjective/objective information for this case, and if so, what?
– Palpation of quads/adductors – wondering about a pes anserine irritation vs restrictions in her quad that may lead to more of a patellar tendonopathy diagnosis.
– As Taylor and Brandon mentioned, more info on running history: is this new for her, treadmill vs outside, how old are her shoes, what’s her normal mileage, any cross training?
– Observation/assessment: foot/ankle – arch strength/positioning while walking/standing/running; pronation/supination
– resisted testing of adductor; quad testing in a variety of ranges4. What is your treatment for day 1 and what are you reassessing next visit?
– education on preventing dynamic knee valgus
– lateral steps with band at midfoot with cuing for proper form
– reassess squat at next visit -
1. Based on the body chart and subjective, what is your primary hypothesis and top 2-3 differentials?
Primary: Patellar Tendinopathy
Differentials: PFPS, myofascial (quadriceps, pes anserine referral, adductor), Tibial Plateau stress fracture
2. With the subjective and objective information, does this patient fit a clinical pattern?
This patient fits a similar clinical pattern for PFPS and/or patellar tendinopathy. Both pathologies have similar presentations and symptoms: Pain with squatting, stair climbing, and long-duration sitting, along with biomechanical faults. The tenderness to palpation of the patella tendon and lack of pain with patellar accessory motions allows me to be more partial to this patient fitting more of a tendinopathy pattern.
3. Do you feel like you need more subjective/objective information for this case, and if so, what?
Additional PFPS testing: Q-angle, patellar tilt test, patellar apprehension test, and compression test.
Additionally, I would like to know is this pain superficial or deep? And where on the patellar tendon the patient is painful. Is it specific to the inferior pole of the patella or is it in the mid-substance? Also, what information was gathered from AROM vs. RROM? Something that may bias PFPS is isotonic contractions potentially being more problematic due to movement of the patella in the trochlea. On the contrary, if RROM elicits the patient’s chief complaint of pain then perhaps the tendon is the culprit.
4. What is your treatment for day 1 and what are you reassessing next visit?
Near pain-free knee extension isometric contractions. If tolerated well can perform pain-free isotonics (i.e. LAQ). Reassess the subject * that most closely reproduce their chief complaint.
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