Case Study – Runner with Knee Pain

Below is the case study of a runner who was experiencing knee pain, not just when she tried to run but all day.  I was able to work with this woman eight times over a four month period (about two sessions per month) and the outcome was pretty exciting – especially considering the number of professionals this woman had seen for this issue over the past several years, with no improvements in her symptoms.

Background Information

• Chronic right knee pain for 5 years has kept this woman from running.
• She has had three kids, exercised through all of her pregnancies, including running, and had brief periods of back pain, but worked through them.
• Currently also has pain the right sacro-iliac region.
• She has seen various doctors, physical therapists, and chiropractors for this issue and the problem has not been solved.  Her husband is also a chiropractor who has been adjusting her frequently to try and help the situation.  He was present during the assessment to offer any other additional information about her condition.
• The knee pain is constant throughout the day.
• When the client was asked if she has found anything that has helped make it better she began to cry and stated that, “Nothing has ever made it better and I am afraid that I will never get to run or do normal exercise again.”
• The pain after her third pregnancy had gotten much worse and her whole body hurt, to the point that she felt she had fibromyalgia.  The pain all over her body has currently subsided and she only has chronic pain in her right knee and right sacro-iliac region.
• The last PT she went to told her to put some inserts into her shoe and then gave her open chain hip extension exercises which she claims did nothing except hurt her lower back.  So she stopped performing them and the inserts have not been successful in helping with her knee or back pain. 

Key Findings

• Extreme anterior pelvic tilt and very forward drawn.
• She barely had a toe touch (non-painful)
• Client has an upper chest breathing pattern just lying or sitting passively, which gets worse when she talks about her injury or is presented with movement challenges.
• Multisegmental extension was dysfunctional and painful
• Single leg multisegmental extension breakout showed the right side to be more restricted than the left.
• She was unable to perform rolling patterns in any of the four quadrants from either supine to prone or prone to supine.
• Thomas test was positive bilaterally (lower leg was almost in a straight line with the quadriceps!).
• Ober’s test was positive bilaterally (leg wouldn’t even drop down once I took my hand out from under it and emphasized that she needed to relax the leg, which she replied “was as relaxed as it gets”.). 
• Interestingly, the client had difficulty even just getting into side lying as lying on her side caused her to roll forward or backward.  Obviously if getting into the position is difficult, her side lying hip abduction was very poor.
• Active straight leg raise was asymmetrical, with the left leg raise being more limited than the right.  She was barely able to even lift the left leg off the table into flexion without the right knee flexing and the right hip rotating into external rotation.
• Prone hip extension showed the right leg to be more limited than the left and biased towards lumbar extension, anterior pelvic tilt, and hip rotation.
• Patella mobility is normal however she is very apprehensive when I move the right patella around.
• There is a leathery end feel with passive dorsiflexion and the client comments that her calves feel very “tight”.
• Right iliopsoas is very tender and produces a jump sign (I thought she was going to levitate off the table).
• Right TFL, Gluteus medius, and QL are more toned than the left.
• Trigger points present in the right rectus femoris refer knee pain which mimics the pain she feels daily.
• Trigger points in the right vastus lateralis refer knee pain that is familiar to her.
• There is tenderness at the quadriceps tendon and when the lateral and medial tissue around the patella are palpated or when the patella is passively moved from side to side it produces tenderness that is familiar to what she feels everyday.

My Thought Process

1. There is obviously a large psychological component to this clients knee problem, as she has been in pain for a long time and is visibly distraught about not being able to run, which is an activity that she loves and would like to some day do again.
2. The fact that the client was unable to even lie on her side tells me that she is incredibly weak.  The side lying posture and the side lying hip abduction are not only an appraisal of hip mobility and hip strength, but also the coordinated stability of the inner unit to fire appropriately to prevent any other unwanted movement.  Her husband, the chiropractor, even commented that he has a hard time adjusting her because she can’t lie on her side and stay there.
3. Treating the trigger points in the rectus femoris and vastis lateralis will be important because of their referral, which mimics her knee pain.
4. Addressing the anterior pelvic tilt and tone of the hip flexors along with glute strength will be important for creating stability in the sacroiliac region and taking the client out of the forward drawn posture.
5. Improving mobility prior to working on strength will be paramount in each session.
6. This client will need to start with the most basic, primitive patterns including straight leg lowering, toe touch, and multisegmental rolling from supine to prone.
7. Even though the client has a toe touch, she barely gets there and does not have a good posterior weight shift when doing so.  Because the multisegmental extension pattern was painful, I decided to begin by improving multisegemental flexion since it was dysfunctional but nonpainful.
8. Active straight leg lowering is an important pattern for her to re-learn, with a focus being on the left leg up in flexion and the right leg moving through the pattern, as this was the most dysfunctional in the assessment.  The fact that the right leg is unable to maintain hip extension when the left leg attempts to go through flexion is an asymmetry that I find to be very important for this individual to address.

Treatments 1-2

We began initially with soft tissue work to treat the trigger points in her right quadriceps and treated the psoas, iliacus, rectus femoris, and TFL bilaterally.  Muscle energy techniques were used for the hip flexors following soft tissue work to help improve hip extension mobility.  During the soft tissue work I coached her through appropriate diaphragmatic breathing.

Following the soft tissue work we performed active straight leg lowering progressions performing more reps with the left leg up (right leg moving) and superset it with crocodile breath to work on breathing.  We then got off the table and performed toe touch re-patterning progressions.

After toe touches were finished, and we saw an improvement in range of motion for the active straight leg raise and toe touch, we worked on rolling patterns from supine to prone.  At first I used an airexpad to give the client assistance in getting over from supine to prone.  Additionally, while on the floor, I would perform soft tissue work and muscle energy techniques on areas to help drive the rolling pattern.  Most notably, I was working on the neck to try and better drive the rolling pattern.

By the end of the second session the client was able to roll from supine to prone in all four quadrants and could perform a healthy toe touch.  We began to work on rolling patterns from prone to supine in session two, and again soft tissue work and muscle energy techniques were used during parts of the rolling pattern to help facilitate the movement. 

Treatment 3-4

The client was excited to report that her knee was starting to feel better and she had periods of the day that were pain free.  She does not  feel confident enough to run on her knee yet, but has started walking more outside.  Client has maintained her toe touch.

We again performed soft tissue work to the structures listed above and followed it by working on breathing, straight leg lowering and rolling patterns.

During the fourth session the client was now able to roll proficiently in all four quadrants from supine to prone and prone to supine.  Once she could perform these movements, we moved to performing bird dogs, tall kneeling chops, and stick RDLs (double legs first).  All exercises were superseted with breathing activities.

Treatments 5-7

Client is starting to do more walking outside, has started hiking, does not have pain in her SI-joint region, and has decreased knee pain that is only “minimal” after walking/hiking.

Soft tissue work on the structures above was repeated.  Client has maintained a toe touch and her rolling patterns.  The active straight leg pattern has improved substantially and is now symmetrical 2′s.

Warm ups include breathing, hip flexor active isolated stretching, straight leg lowering, 1-leg glute bridges, and bird dogs.

Exercise includes single leg RDL, half kneeling chops, and half kneeling 1-arm cable rows.  We also started performing box squats with body weight and an RNT knee pull into valgus using a pink cook band and emphasizing a more vertical tibia.

Treatment 8

Client was 20min. late to the session.  She came rushing in and was crying a little bit.  She apologized for being late and told me that she was out hiking before the session and felt so good that without even thinking about it she began to run and ran pain free for 20min. for the first time in five years.  We skipped the soft tissue work, did our warm ups, and worked on a few exercises and called it a day.

Patrick
patrick@optimumsportsperformance.com