NM control: lunges with rotation. Thoracic/lumbar rotation I’m assuming? just wanted to clarify this exercise.
Where did the patient feel her pain with the slump test. Feeling it in the back/buttock vs posterior knee would lead to different clinical reasoning.

Is her R Low lumbar pain her same pain as she has had over the past 25 years, or is this new onset of lumbar pain since the knee injury?

1)Any other exam techniques you would have performed?

I would look at the PFJ a little more closely. This could easily refer pain to the medial knee. compression of the PFJ at different angles, Mcconnell’s test ( http://special-tests.com/knee-tests/mcconnells-test/ ). Likely an MCL sprain but who knows, maybe she has both things going on, and pain could cause the quad weakness which can lead to PFJ pain as a result of her MCL sprain.

2)Any other treatment you would provide?

Love your choices for NM control and lumbar treatment. Good re-assess with the lumbar techniques. Any re-assess after NM control drills (I know this can be hard to re-assess, and may take many visits before you see expected changes, just asking!)

I understand the idea for the anterior tibial glides; how were they working for her? did her extension improve? I’ve seen patient’s like this before who don’t improve extension after that specific technique due to hamstring spasm/guarding

In order to get those last few degrees of knee extension, depending on irritability, I like using the screw home mechanism mobilization. in supine, passively internally rotate the femur and stabilize with that hand, then use your other hand to externally rotate the tibia as you push down into extension. This might be a terrible choice for your patient, but if her pain levels and irritability improve, you can try it.

3)Does anyone have specific parameters they use for return to run/walk program?

Ability to walk without pain for 10-20 minutes, good NM control of hip/knee/ankle

Return to run program (from OCS current concepts) and soreness rules (from University of Delaware) is attached:

When they say soreness, it’s not muscle soreness, but their **pain –> https://www.thompsonhealth.com/Portals/0/_RehabilitationServices/PT%20Mgmt%20of%20Knee/Soreness_Rule1.pdf

4)I have not used manipulation with this patient as of writing this. Articles describing the use of manipulation for pnts with knee conditions usually describe the benefits stemming from increased quad and gluteal activation reducing PFPS or improving pnts muscle activation following ACLR. How do you think this case varies from those presentations and how would you have you added lumbar intervention to treatments if at all?

https://www.ncbi.nlm.nih.gov/pubmed/25540713 – Our boy Dhinu’s article on the subject.

I think this case differs in that the patient has had a longstanding history of LBP, and meniscal pathology is obviously much different from PFPS. Either way if you have decreased quadriceps activation it can lead to changes in gait mechanics which further stress the pathological tissue. I think that pain desensitization benefits can be had as well.

Anecdotally, I have a 55 year old female patient with a jacked knee (3-4 surgeries, followed by PRP and stem cell treatments in September, significantly worse after the injections), and she had significantly decreased knee pain and pain free ROM with heel slides post lumbar treatment including manipulation. N=1, but that’s what i’ve got in my experience.

• This reply was modified 7 years, 3 months ago by Scott Resetar.

1)Any other exam techniques you would have performed?

Like Scott, I may have checked patellafemoral glides for pain and mobility. It may have given you an additional asterisks to treat and monitor. I also likely would have check her ability to perform a SLR with resistance and compared bilaterally for quad lag or resistance.

2)Any other treatment you would provide?

Due to the lack of knee extension, I likely would have performed the screw home mobilization Scott mentioned and followed that up with passive physiologic extension with OP, if tolerated. Since this has been going on for awhile, coupled with tenderness throughout HS and (+) neurodynamic findings, I may have performed STM to posterior chain in a position of knee extension.

Your therex selection I thought was good. I may have given a bridge with progressions as appropriate to incorporate lumbar and LE strengthening together. You may have given additional exercises for her HEP that did this as well, as you therex in clinic did but just thought I would mention it.

3)Does anyone have specific parameters they use for return to run/walk program?

Unfortunately, I have seen very little of these patients and have not had to answer this question for patients very much. However, the few times I have, I have given them the JOSPT patient perspective (attached) and explain a slow progression to prevent re-occurrence of pain. I like what Scott posted as it is much more specific and is certainly better than saying “progress slowly”.

This is also a good blog post by Chris Johnson and Nathan Carlson on return to run as well:
http://www.running-physio.com/when/

4)I have not used manipulation with this patient as of writing this. Articles describing the use of manipulation for pnts with knee conditions usually describe the benefits stemming from increased quad and gluteal activation reducing PFPS or improving pnts muscle activation following ACLR. How do you think this case varies from those presentations and how would you have you added lumbar intervention to treatments if at all?

I think I may have added a thoracic manipulation at some point due to the the (+) slump to see if that made an improvement in that asterisks. This is likely, primarily, due to the research I did with Aaron.

I have added lumbar manipulation to 2 patients I can think of with knee pain. Both of those cases did benefit from the manipulation and had resolution of symptoms. I felt I added this late in their care as their pain persisted. So, to say I would have added manipulation only 4-5 visits into this patient’s care, I would probably be kidding myself (although I would like to think I would’ve at least thought about it based on their hx of LBP).

1)Any other exam techniques you would have performed?
What was the quality of her VMO contraction and VMO muscle bulk palpably/visibly? You and the article talk about treating centrally in order to improve quad activation, but once you got her to full knee extension maybe there could have been value in utilizing NMES with some of your strength/balance interventions.

I was curious about your clinical reasoning with the exam, why did you choose to do a slump/SLR after the lumbar spine was only minimally provocative and did not reproduce distal symptoms?

2)Any other treatment you would provide?
I think if you felt like there was a neural tension/low back component that needed addressing, performing some of the sidelying Elvey techniques might have been helping. You would be able to mobilize the back, potentially decrease neural sensitivity, and reinforce knee AROM if you have them performing knee extension slowly during your mobilization.

4)I have not used manipulation with this patient as of writing this. Articles describing the use of manipulation for pnts with knee conditions usually describe the benefits stemming from increased quad and gluteal activation reducing PFPS or improving pnts muscle activation following ACLR. How do you think this case varies from those presentations and how would you have you added lumbar intervention to treatments if at all?

I can’t say I would have gone to the lumbar spine as quickly as you did with this patient presentation. I think if it seemed like it played a component I likely would have included therex that incorporated hip strengthening with low back control like a bent leg kickback or streamboats on airex. I think I might spend time working on the lumbar spine if when you got them on the TM for returning to run and it seemed like lumopelvic control or mobility was impacting their mechanics with running.

1)Any other exam techniques you would have performed?

This has been mentioned previously, but again look at patellar glides more closely. Additionally, she subjectively reported performing stairs one at a time. Functional tests like a step-up or step-down may provide you with information on how she moves if this is an aggravating factor. She had moderate to severe irritability so maybe this and other functional tests, double limb squat, single limb stance, could be evaluated later one once she is not as irritable. Also, as Justin mentioned, I would have looked at a straight leg raise with resistance.

2)Any other treatment you would provide?

I would incorporate the external rotation component of the tibia at end range extension with a screw-home mechanism mobilization. As Justin mentioned, I like to perform physiological motion in open pack position following mobilization. If the patient was positive for neurodynamic testing and tender along the posterior hamstring, I may focus on soft tissue mobilization along this region and reassess knee extension with slump testing.

3)Does anyone have specific parameters they use for return to run/walk program?

I currently have a patient with medial tibial stress syndrome that I have been utilizing the graded running program described in the article I attached below. I have not had much experience with this but have been trying to incorporate some type of graded program with patients who want to return to running.

4)I have not used manipulation with this patient as of writing this. Articles describing the use of manipulation for patients with knee conditions usually describe the benefits stemming from increased quad and gluteal activation reducing PFPS or improving patients muscle activation following ACLR. How do you think this case varies from those presentations and how would you have you added lumbar intervention to treatments if at all?

This case differs in that the patient is somewhat older with a history of low back pain with a longer duration of symptoms (1 year versus no more than six months) and not as much PFPS but a meniscal pathology. I may continue to treat locally and with hip/lumbar strengthening. If there were no resolutions in symptoms, I may consider lumbar manipulation. Like Justin stated I utilize a thoracic spine directed manipulation due to positive slump testing. If this was beneficial I may move to the lumbar spine.

1)Any other exam techniques you would have performed?
I may have checked joint effusion just because of the recurrence of episodic pain. Especially if you found weakness in quad activation at any point. There are a few articles that demonstrate the reduction in quad strength and ground reaction forces with knee pain and joint effusion. That may be important for determining return to run status, so probably more beneficial at toward end of care.
Also due to back and knee pain, you could potentially check pelvic tilt during fwd bending if she is having reduced hip extension strength to determine gluteal motor control deficits. Possibly a source of her back pain over the years of higher activity. I have seen glute strength improvement with pelvic ant tilt mobilizations within 1-2 treatment sessions.

2)Any other treatment you would provide?
I like the dynamic training to help your patient feel like she is performing her normal exercise routine.

3)Does anyone have specific parameters they use for return to run/walk program?
I have used the JOSPT perspectives that Justin mentioned before but I rarely see this patient population. I had a CI who wrote up a return to running program that was based off intervals of running/walking for 30 days gradually increasing, wish I had kept a copy of that now!

4)I have not used manipulation with this patient as of writing this. Articles describing the use of manipulation for pnts with knee conditions usually describe the benefits stemming from increased quad and gluteal activation reducing PFPS or improving pnts muscle activation following ACLR. How do you think this case varies from those presentations and how would you have you added lumbar intervention to treatments if at all?
I have not used thoracic or lumbar manips for knee pathologies but I can see the benefit from the neuromotor aspects from that article you posted. I better step my game up!