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Case presentation: A 50-year-old woman. Retired after 17 years of full time as a secretary in a hospital setting. Fitness activities in which she participated included water aerobics, swimming, and walking. Recreational hobbies included sewing, using a machine that also required use of a right foot pedal. Current Complaint: A gradual onset of bilateral knee pain started 3 months ago following activities related to moving into a new home, such as, packing and carrying household items without a specific injurious event. Aggravating symptoms • Sitting with her knee flexed for more than 10 minutes • Standing for more than 30 minutes • Descending stairs • Participating in water aerobics. Medical History • Hypertension • Past complaint • Lumbar spine included low back pain, with radiating pain into her left posterior thigh and foot. Physical Examination Observation: The patient stood with the femur in medial rotation which was excessive during single-limb stance. Small Knee bend test (SKB): the patient demonstrated increased hip adduction and knee valgus, and reported that her pain increased compared to standing. Functional activities: • Sitting: Tibial Lateral rotation UCM • Stairs: Tibial Lateral rotation UCM • Gait: Tibial Lateral rotation UCM AROM Knee flexion in prone: Tibial lateral rotation was observed and pain was reproduced. When the lateral rotation was limited by physical assistance from the examiner, the patient was able to flex her knee painlessly (Symptom modification procedure) Ankle dorsiflexion: 0° with the knee extended and 15° with the knee flexed; the findings are indicative of a short gastrocnemius. Hip lateral rotation: limited - Given biomechanical relationships between the hip and knee, examining the entire lower kinetic chain should occur when evaluating patients with knee pain. Rowe et al, 2007 - Femoral or hip joint asymmetry may be related to anterior nee pain joint pain. Cibulka et al., 2005 Joint Flexibility and Muscle Performance Modified Thomas Test: Decreased extensibility of tensor fascia lata (TFL) of the left lower extremity Decreased muscle performance of the hip lateral rotators and the iliopsoas. - Women with anterior knee pain are more likely to demonstrate weakness in hip abduction as well as external rotation. Lloyd et al., 2003 - Motion impairments at the hip may underlie injuries such as anterior cruciate ligament tears, iliotibial band syndrome, and patellofemoral joint pain. Powers et al., 2010 Hypothesis MSI diagnosis of tibiofemoral rotation. Treatment interventions (a) Correct performance of functional activities The patient was instructed how to modify her sitting position while at work and while using her sewing machine by positioning her knee over her foot and pointing her foot directly forward. (b) Exercise program to address muscle and motor control impairments - Knee extension with ankle dorsiflexion in sitting (Do not allow the thigh to roll in) - Hip lateral rotation with abduction in side lying (Activation of hip abductors and lateral rotators have therapeutic benefits for the treatment of Anterior nee pain. Alammari et al., 2022, Jellad et al., 2021) - Knee flexion in prone, Point toes to the inside (toward opposite leg), controlling tibial lateral rotation - Hip lateral rotation in prone Hip joint mobilization has an immediate positive effect on eccentric hip abductor/external rotator muscle strength in patients with AKP with impaired hip function Pfluegler et al., 2020 - Hip lateral rotation isometrics with knees flexed in prone Adding hip-strengthening exercises to patients with anterior knee can decrease pain and increase functional status. Shain et al, 2014 - Hip abduction in prone - Weight shifting in standing. In standing shift your weight to the left foot and squeeze the left seat muscle Do not let your knee roll in (c) Taping Strips of tape applied to the patella in the medial direction to prevent excessive pull of the iliotibial band on the patella. (McConnel et al.,1986) Outcomes • VAS:Her average pain intensity rating was 5/10 at initial visit, 2/10 at 1 week, 2/10 at 5 weeks, 0/10 at 10 weeks, and 0/10 at 1 year. • Functional activites: no difficulty with sitting, standing, ascending/ descending stairs, or participating in water aerobics. • ADLS-KOS: increase in the scores compared to scores at the initial visit.She had a score of 73% at the time of her initial visit, 86% at the time of her final visit, and 96% at 1 year after her initial visit. References • Harris-Hayes, M., Sahrmann, S.A., Norton, B.J. and Salsich, G.B., 2008. Diagnosis and management of a patient with knee pain using the movement system impairment classification system. journal of orthopaedic & sports physical therapy, 38(4), pp.203-213. • Alammari, A., Spence, N., Narayan, A., Karnad, S.D. and Ottayil, Z.C., 2021. Effect of Hip Abductors and Lateral Rotators Muscle Strengthening on Pain and Functional Outcome in Patients with Patellofemoral Pain: Systematic Review and Meta-Analysis. • McConnell, J., 1986. The management of chondromalacia patellae: a long term solution. Aust J Physiother, 32(4), pp.215-223. • Ireland, M.L., Willson, J.D., Ballantyne, B.T. and Davis, I.M., 2003. Hip strength in females with and without patellofemoral pain. Journal of orthopaedic & sports physical therapy, 33(11), pp.671-676. • Powers, C.M., 2010. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. journal of orthopaedic & sports physical therapy, 40(2), pp.42-51. • Pfluegler, G., Borkovec, M., Kasper, J. and McLean, S., 2021. The immediate effects of passive hip joint mobilization on hip abductor/external rotator muscle strength in patients with anterior knee pain and impaired hip function. A randomized, placebo-controlled crossover trial. Journal of Manual & Manipulative Therapy, 29(1), pp.14-22.

Using a test of batteries before return-to-sport decision making is a key to confidently make such a decision and to decrease the risk of recurrent instability. Multiple upper-extremity tests have been described in this recent literature that can be used to direct rehabilitation and to safely return the athlete back to sport. PROM • Western Ontario Shoulder Instability Index (WOSI) Modified scores > 90 for return to practice and > 95 for return to full competition have been suggested. https://orthotoolkit.com/wosi/ • Shoulder Instability-Return to Sport after Injury (SIRSI)-Scale High scores correspond to a positive psychological response. https://www.vbg.de/SharedDocs/Medien-Center/DE/Faltblatt/Branchen/Sport/Fragebogen_SIRSI_englisch.pdf?__blob=publicationFile&v=3 • Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC) The score for an increased injury risk is currently accepted as <90 https://pubmed.ncbi.nlm.nih.gov/30140711/ Performance measures • Isometric strength of ER and IR at 0° and 90° using instrumented (handheld or fixed) dynamometry Shoulder IR and ER (at 0° and 90° of abduction) are measured for an isometric hold of 5 seconds for at least 2 trials on both sides. Look for asymmetry For throwers, 0.72-0.76 would be an appropriate goal for the IR/ER ratio • Endurance of posterior shoulder musculature (PSET) Limb symmetry index within 10% Modified version: 46 seconds for female individuals and 47 seconds for male individual https://www.researchgate.net/figure/Arm-position-for-the-Posterior-Shoulder-Endurance-Test_fig1_258188995 • The Athletic Shoulder (ASH) test Limb symmetry index within 10% The minimum detectable change was between 13.2 and 25.9 N https://www.researchgate.net/publication/326556046_The_Athletic_Shoulder_ASH_test_Reliability_of_a_novel_upper_body_isometric_strength_test_in_elite_rugby_players • Upper Quarter Y Balance test performance (UQ-YBT) Limb symmetry index within 10% Normative reference for active adults and young adult https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253144 • Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST)   Generally, ≥21 touches is considered normal and reflective of a decreased injury risk https://www.apta.org/patient-care/evidence-based-practice-resources/test-measures/closed-kinetic-chain-upper-extremity-stability-test-ckcuest • One-Arm Hop Test (OAHT) Expected asymmetry of 4.4 seconds between dominant and nondominant sides https://www.researchgate.net/publication/11217721_One-Arm_Hop_Test_Reliability_and_Effects_of_Arm_Dominance • Seated single-arm shot-put test (SSASP) Expected asymmetry of 3%-13% between dominant and nondominant arms https://journals.humankinetics.com/view/journals/jsr/30/3/article-p521.xml Read The Full article https://www.sciencedirect.com/science/article/pii/S2666061X21002601

Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline •Extrinsic risk factors(type of sport practiced) although outside of the patient, may provide a significant increase in the risk at sustaining a LAS. •When treating patients with an acute LAS, modifiable risk factors such as deficiencies in proprioception and ROM should be identified and if possible included in a prevention and/or rehabilitation programme to mitigate the risk for recurrent sprains. •Extrinsic risk factors(type of sport practised) although outside of the patient, may provide a significant increase in the risk at sustaining a LAS. *Prognostic factors Adequate attention should be directed towards the patient’s current level of pain, their workload and level of sports participation. These may all negatively influence recovery and increase the risk of future injury recurrence. *Diagnostic Regarding the clinical assessment of damage to the anterior talofibular ligament, the sensitivity (8️4%) and specificity (9️6%) of assessment using the anterior drawer are optimized if clinical assessment is delayed for between 4️ and 5️ days post injury. In case of a suspected fracture, the OAR should be applied. *Treatment •Rest Ice Compression Elevation (RICE) There is no evidence that RICE alone, or cryotherapy, or compression therapy alone has any positive influence on pain, swelling or patient function. •Non-steroidal anti-inflammatory drugs NSAIDs may be used by patients who have incurred an acute LAS for the primary purpose of reducing pain and swelling. However, care should be taken in NSAID usage as it is associated with complications and may suppress or delay the natural healing process. •Immobilization Use of functional support and exercise therapy is preferred as it provides better outcomes compared with immobilization. If immobilization is applied to treat pain or oedema, it should be for a maximum of 10 days after which functional treatment should be commenced. *Functional treatment •Functional support Use of functional support for 4–6 weeks is preferred over immobilization. The use of an ankle brace shows the greatest effects compared with other types of functional support. •Exercise Exercise therapy should be commenced after LAS to optimize recovery of joint functionality. Whether exercise therapy should be supervised or not remains unclear. •Manual mobilisation A combination with other treatment modalities, such as exercise therapy, enhances the efficacy of manual joint mobilization and is therefore advised. •Surgical therapy Despite good clinical outcomes of surgery after both chronic injuries and an acute complete lateral ligament rupture, functional treatment is still the preferred method as not all patients require surgical treatment. •Other therapies As no strong evidence exists on the effectiveness of these treatment modalities, they are not advised in the treatment of acute LAS. *Prevention •Functional support Both tape and brace have a role in the prevention of recurrent LAS (limited evidence). •Exercise therapy It is advised to start exercise therapy, especially in athletes, as soon as possible after the initial sprain to prevent recurrent LAS. Exercise therapy should be included into regular training activities as much as possible as home-based exercise. •Footwear No recommendations can be made concerning shoe wear. •Return to work To speed up return to work, a brace and immediate functional treatment in combination with a return to work schedule are advised. •Return to sports Supervised exercises focusing on a variety of exercises such as proprioception, strength, coordination and function will lead to a faster return to sport.