Patient Case Discussion

[Justin Pretlow]

Hey Folks,
I recently eval’d a patient with a seemingly straight forward injury but many possible contributing factors.
Subjective: 59 yo male runner with right knee pain of gradual onset 5 years ago, worsening over last year. Runs 3 x week, 4-6 miles, prefers trails over road, uses elliptical occasionally. Noticed deep mild knee pain 5 yrs ago, switched to Hokas and pain resolved. Sharper anterior knee pain experienced when running in last 3 months, decreases around 1-2 mile mark. No change in mileage or pace, no MOI. Sharp pain made him consult Ortho. X-rays showed medial tibiofemoral joint space narrowing. Pt’s goal is to decrease pain, and run one more marathon before he’s 60. PMH significant for Left Achilles rupture/repair in 1991, rupture and repair again in 1992(basketball injuries). States left leg has been weaker ever since. Occasional spasms/tightness in bilateral piriformis region without obvious cause that is relieved by pigeon type stretch. Wears powerstep arch supports which he says cured his chronic shin splints.

LEFS: 69/80
NPRS: C: 0/10 W: 5/10

Aggs: Running(especially uneven terrain), stairs when Sx are flared up
Eases: rest, Hokas

Objective:
Observation: DL stance: High arch bilat, Left foot externally rotated, Achilles deformity left.
Gait: Genu varum bilat, min to no pronation bilat

Functional Testing:
DL squat: Mild weight shift right, both heels lift off
SL stance: R lateral column loading, loss of first ray contact
SL mini-squat: R trendelenberg, lateral column loading bilat(more apparent on right) Mild Sx aggrav. right
SL step-down: Poor control bilateral, Loss of first ray contact, trunk sway, loss of balance on right
Hip Swing: Lumbar extension compensation bilat.
DL hop: heavy landing

LE MMT: 5/5 grossly bilat

AROM: bilat knee and hip WNL. 90/90 hamstring moderate tightness bilat

Joint mobility: tib/fem med/lat ant/post normal, nonpainful bilat
patellar mobility normal all planes, nonpainful

Special tests: patellar compression neg. No joint line tenderness tib/fem. No TTP with palpation. Passive SLR neg. bilat. Mcmurray’s neg. Apley’s compression neg. Obers positive bilat(left severely tight, right moderately tight) Prone Ely: tight bilat, no Sx reproduction.

Hypothesis: Medial tibiofemoral joint pain secondary to altered lower extremity mechanics/increased compressive forces to medial knee.

This patient referenced the recent x-ray with joint space narrowing several times during the subjective when I asked questions about the location and nature of his pain. His movement patterns and impairments seem to fit the pattern for medial knee joint degeneration. I ran out of time before further assessing his foot.
Discussion questions:
Is there additional information or asterisks you would like to know to rule in this diagnosis?

This patient seemed to have quite a few impairments or movement dysfunctions that might be contributing to the stress at his knee. I sometimes have a hard time deciding on the most important aspects to address first – proximal vs. distal factors, flexibility deficits, etc. What are your thoughts on home exercise prescription?

To lateral wedge or not to wedge was another question I found myself pondering on the first visit. Does anyone have thoughts on deciding if and when to lateral wedge?

Mike’s comments this weekend also got me thinking about what the low hanging fruit is with this patient presentation. Thoughts?

[Stephanie Roane]

Hey Justin,

Nice collection of information. I think your exam sounds pretty thorough. I had the exact same thought in my head….go for the low hanging fruit; which in my opinion would be a lateral heel wedge. Sounds like this guy is a big believer in product assistance (hokas, powerstep orthotics, etc.). One additional item I like to screen in runners is mid foot mobility with movement in the transverse plane. So have him stand in bilateral stance and rotate his upper quarter each direction to quickly screen how much tibial internal/external rotation is achievable as well as how much pronation/supination occurs. I would have likely thrown a lateral wedge in his shoe first day. There’s probably no convincing this guy to ditch his orthotics to promote midfoot pronataion which sounds like he needs more of so I would place the lateral wedge right under the powerstep to hopefully gain more rearfoot valgus/knee valgus to gap the medial tibiofemoral compartment. The only other thing I would do day one is some easy first ray stabilization exercises to train out of lateral column loading. Encourage him to go run per usual and follow-back up and reassess. I think he would buy in to that approach since he was very connected with his imaging and had good success in the past with orthotic use and new shoes.

Keep us posted! Thanks for sharing.

Steph

[Justin Pretlow]

Thanks for the response Steph,
Screening his midfoot mobility with upper body rotation is a good call; I definitely missed that. I think you’re correct that he is not likely or eager to take his orthotics out of his shoe. In the moment, I was questioning whether or not adding a lateral wedge would be negated by his powerstep orthotic. So, I started him with Single leg first ray stability with a posterior and posterolateral contra leg reach. This was definitely challenging, so I threw the mirror in front of him and let him practice. I also gave him a modified version of an IT band/TFL stretch(as it corrected a stretch that he was already attempting on his own poorly).

[Tyler France]

Hey Justin,

I agree with Steph on a couple of points. It seems like your examination was pretty thorough and that you got a lot of good information. I would try him with a lateral wedge and see if that changes his symptoms at all. That seems like the low-hanging fruit to me. Your hypothesis sounds pretty reasonable from a symptom standpoint, though I would expect some ROM loss or joint mobility issues if you think there is joint degeneration. Any reports of stiffness after prolonged positioning or is it just running and stairs? One thing Eric has drilled home during residency is trying to utilize exercises that can address both proximal and distal factors at the same time when treating knee pain in order to get more bang for your buck.

[Jennifer Boyle]

Hey Justin! Thanks for posting! I agree with Tyler and Steph’s points about low hanging fruit and utilizing the lateral wedge. Hopefully with this you are able to unload the medial compartment enough for his sx to calm down to help perform more pain free exercises. In regards to exercises, I would base HEP and ther ex on his impairments to work toward his goals. Like Mike said this weekend you ask what was reasonable for him to do at home and potentially incorporate that return to run algorithm we were utilizing in the course.

[Katie Long]

Hey Justin,
It sounds like you have a ton of things to work on with this guy! I think a lateral wedge, yes, is a “low-hanging fruit”, but I wonder about the utility in such a significantly cushioned shoe such as a Hoka? I just remember from the running med course about how Jay was talking about “accommodating” a foot type rather than “correcting” a foot type. He is likely going to blow through that wedge in the cushion of those Hokas. But, like you said, its a low-hanging fruit and easy to implement, so its worth a shot! In thinking about the running med course, I think that Jay’s presentation on foot strengthening is going to be great for this guy. A lot of people already touched on 1st ray stability, and I think that is definitely a place to hit hard so that he is better able to stabilize during his running mechanics.
Interesting case, keep us updated!!

[Sarah Bosserman]

In thinking about this patient, I may question whether I think the lateral wedge would make a big difference. The 2017 systematic review in BMJ highlights that the addition of arch support to a lateral wedge normalizes ankle and foot motion, but limits reductions in the knee adduction moment. I think katie has another interesting point, in his choice of Hokas, following that he seems to have some neuromuscular control and strength deficits with SL squat/step down and a heavy landing with hopping…Jay talked about how too much cushioning may promote landing with increased limb stiffness and can lead to instability due to less proprioceptive feedback for stability. There just seems to be a lot going on with him trying to use this path to control symptoms (orthotics to manage shin splints, Hokas to manage previous knee pain). I definitely get the reasoning behind its use and to keep him running, but would want to encourage those proprioceptive/motor control exercises (i.e. first ray stability with exercises to promote moving out of lateral column loading) and discuss his training schedule to hopefully give him a feeling of more internal control over his symptoms along with external support. In my experience, runners are always a difficult patient population to manage expectations and find the right workload ratio – keep us posted!

[Laura Thornton]

There seems to be a debate at play on whether there is a structural vs. neuromuscular component to your “low hanging fruit”, since there was no report of obvious training errors at eval.

I would think about his fear of medial joint line narrowing.

How could your approach to his initial treatment (including communication to him) either validate this fear into more avoidance/passive strategies or give him more positive active approach to his goals?

Would love an update when you do a run analysis with him.

Here’s a food for thought article discussing running economy with different factors.

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[Justin Pretlow]

All very good points regarding lateral wedge effectiveness in Hokas and/or with medial arch support, and patient’s fear of the medial joint line narrowing.
I was uncertain if the lateral wedge would be effective with the current powerstep orthotic. So, I did review the BJSM article that Sarah referenced. It’s still tricky to make that decision, as adding the lateral wedge will be less effective in reducing KAM with the arch support, but removing the arch support will change his ankle mechanics. After considering that, I’m more likely to try the lateral wedge on the orthotic initially to see if it makes an appreciable difference in Sx.
Katie makes a good point about the extra cushion of the Hoka’s limiting the effectiveness of the wedge.

I think the patient’s discussion with his Orthopaedic about the joint space narrowing made a significant impression on him. During the subjective exam, when I asked him to point to the specific location of his knee pain, he would not. He stated the pain is where the joint space is narrowing. I acknowledged his concern and explained that imaging results do not correlate well to symptoms.
Thanks for the running economy article.
I will send an update once I get to see his running form.

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