Diagnosis and Management of a Patient With Knee Pain Using the Movement System Impairment Classification System- A Case Report

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.

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.

• Sitting with her knee flexed for more than 10 minutes

• Standing for more than 30 minutes

• Descending stairs

• Participating in water aerobics.

• Hypertension

• Past complaint

• Lumbar spine included low back pain, with radiating pain into her left posterior thigh and foot.

Physical Examination

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.

• Sitting: Tibial Lateral rotation UCM

• Stairs: Tibial Lateral rotation UCM

• Gait: Tibial Lateral rotation UCM

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

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.