Case of the Week 4-16-13: Iatrogenic Knee Pain | Modern Manual Therapy Blog

Case of the Week 4-16-13: Iatrogenic Knee Pain

I am currently treating a knee case which I thought should have responded very rapidly, read on to find out why she did not and what I did about it.

Her case seemed simple enough, I had seen her the previous year for chronic TMD and HA for only 3 visits prior to complete resolution. She displayed no fear avoidance. She returned this year complaining of chronic knee discomfort and feelings of instability with a history of patellar dislocation years ago. She displayed the normal ankle and hip restrictions along with difficulty with SL stance on that side. Her eval was as follows:

Subjective: Pt reports having R > L knee pain since she was in high school. She also reports Hx of dislocated R patella 20 years ago. Since then, Sx have been intermittent, rated 1-7/10 but worse with jumping, and any ADL that requires knee movement. Sx better with ice, stretch, wearing OTC knee brace on R.

Objective: fair sitting posture
key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension


flexion DN
extension DN
Rotation Left DN mild Right DN, mod
tibial IR Left FN Right DN

Flexion Left FN Right FN
Extension Left DN, mild Right DN mod
Int Rot Left DN, mild Right DN, mod
Ext Rot Left FN Right FN

(measured in supine)
Flexion Left FN Right FN
Extension Left FN Right FN

Dorsiflexion Left FN Right DN, mild
Plantarflexion Left FN Right FN

Myofascia: moderate restrictions in R lateral upper and lower LE patterns
Special tests: SLS on L FN, on R DN with eyes open and closed
Assessment: Signs and Sx consistent with PFS on R with accompanying hip and ankle mobility dysfunction

It seemed that she had the standard patterns of what most with knee pain/instability have
  • restrictions in the ipsilateral hip/ankle
  • difficulty with single limb stance tests and movements
I gave her the explanations of this, that she should see some improvement within 4-6 visits, and initiated some manual treatment. The first two visits Tx were
  • IASTM to the upper and lower lateral LE patterns to improve hip mobility, tibial IR, and ankle mobility
  • hip long axis distraction, ankle distraction and mobilization with movements to improve ankle df
  • instruction on gluteus medius strengthening exercises, education on avoidance of using her knee brace (which was really more like a loose sleeve)
For 2-3 visits, I expected some improvement in knee pain and perceptions of stability with the above treatments, like the majority of simple knee cases. Her ROM improved rapidly, but there were no subjective changes.. AT ALL. I decided to try some WB MWM, tibial IR, varus/valgus forces, also ankle MWM. She was barely able to single leg squat more than 5 degrees before feeling "cracking and unstable." 

She then tells me that the the specialist she saw in high school told her she should avoid bending her knee to avoid further degeneration and that she would need a knee replacement someday - to a TEENAGER! After getting home, she actually called again to make sure, because it seemed at the time like a ridiculous thing to order avoiding bending of the knee, but he confirmed, no bending! I remembered what she said on her first visit "I would NEVER think about doing lunges or squats." Essentially she had very high fear avoidance of knee bending, or at least, what she considered knee bending. I asked the following questions
  • Do you bend your knee getting in and out of the car?
  • Do you bend your knee while you are sitting in a chair?
  • Aren't you bending your knee right now? (she was sitting while we were speaking)
The answer to all of these questions was "yes." The light was starting to flicker. I then explained how joints need to move to be healthy, and how the idea of bending her knee would equate to damage was just doom and gloom. She then asked about the position of her patella and "going in and out of the track." I told her that was normal and then moved her uninvolved patella in all directions passively. That made her a bit nervous, but she saw that it was ok for her patella to move.

I also gave her the kisses of time speech, how many asymptomatic joints display on scans.. etc. I explained to her that her perceptions of instability and discomfort were protective mechanisms of her CNS and that she was moving her knee in NWB positions, some WB positions (in and out of chairs, the car) and the use of a mirror box. I held the mirror box over her right side (invovled side) had her gaze into it as she performed double leg squats. She was able to squat with at least 45 degrees of knee bending after only 2-3 reps. Her knee still "cracked" a bit, but she no longer felt discomfort.

I then had her lie supine and passively mobilized her left patella's reflection so it looked like I was mobilizing her right patella. She was amazed that she even let me do it. She ended up borrowing the mirror box and was going to practice squatting with her husband several times/day at home. I follow up with her later today and will update on her progress!

The longer I practice, the more irritated I get at the advice and word selection of other health care professionals.


  1. Erson,

    This is a very interesting case. It reminds me of times where I have began treating the patient and after several visits, the patient is not responding as expected. After follow up discussion, I find that I missed something during the initial evaluation and interview. It can be helpful to ask the patient what they believe to be the cause of their problem or what they have been told is the cause of their problem during their initial interview. This often proves very enlightening and can open the door towards a discussion to assist the patient with restructuring their understanding of their problem. Peter O'Sullivan really emphasized the importance of both clinician and patient beliefs in his IFOMPT keynote; I couldn't agree more.

  2. I agree, I did miss this, but she also would not have thought this is why she was afraid to bend her knee. I really liked the recent video online of O'Sullivan treating the LBP patient and getting him to move with education.

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