COTW 8-11-13: Simple Knee Pain | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

COTW 8-11-13: Simple Knee Pain

A husband of one of my wife's friends was climbing into bed with his daughter when he felt a pop and had a sharp pain in his knee. He came in shortly afterward to have it checked out. ITB? Read on to find out!

The eval is as follows:

Subjective: Pt reports onset of L knee pain and lateral numbness (loss of sensation) after climbing into his daughter's bunk bed and WB on L knee in kneeling position. Sx worsened at first and have since been unchanging for 2-3 weeks. He c/o “stiffness and achiness” in the knee and numbness that radiates into S1 dermatome. Sx are rated 3-4/10 and intermittent. Sx worse with closed chain knee flexion ADLs, when still, after prolonged sitting. Sx better when walking.

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


sidegliding Left DP min Right FN

repeated SGIS Left PDM in lumbar spine, centralizes L knee pain and numbness remains better as a result

Dermatome: S1 dermatome (lateral LE) on the L was 30% compared to the R which was 100% to light touch

Day 1 Discussion

So, yeah... that's about it. He wanted to come in directly to see me instead of his doctor, which is good, because he would had been told to rest, or gotten knee x-rays, etc...

Pre-test prior to repeated SGIS was self rating of light touch to his numb area and squatting, which was painful in the left knee.

The first thing I check in unilateral lower quarter issues is SGIS to the involved side, so, hips to the right, shoulders to the left was dysfunctional and painful (yes I'm mixing SFMA terminology with MDT). SGIS to the right was FN. Three sets of 10 reps of SGIS to the left, and his sensation had improved to 70% on the left compared to the right, and squatting was about 80% better. Several more sets and there was little change.

We switched to prone hips offset "roadkill" with L LE hip flexed and abducted to 90, knee flexed to 90 or so to load the left side in NWB. This was initially and uncomfortable yellow light. After 2-3 minutes, sensation and knee pain improved, so we progressed to roadkill on elbows, again initially a similar yellow light. In each position I sheared overpressure 2-3 sets of 10 reps to further enhance the left lumbar loading. Initially the overpressure was uncomfortable in the spine, but improved the knee pain and sensation. This was described to him as centralization and great news.

After 3-4 more sets of overpressures into sidegliding left in prone on elbows, he was able to perform pressups with the left LE in roadkill position. This was a yellow light for 3 reps, then green light for the other 7. He was instructed how to get off the plinth without twisting and rotating. His squat was pain free (in his left knee), his S1 sensation was now WNL compared to the R and walking felt "normal."

After this, he mentioned having hip issues for many years, and this is going to be looked at next visit, as long as he was able to keep his L "knee" reset with his SGIS and prone pressups in roadkill for HEP. He was also instructed to break up prolonged sitting at work as he uses a computer for 8/hours a day and the use of a lumbar roll when sitting. He was also recommended to alternate with a standing desk.

On a side note, I know I was supposed to review Explain Pain, 2nd Ed, but I had a busy weekend and only made it through half of it, plus comparing to the first is tough because they are SO similar, I was expecting more differences. Review coming but give me a few weeks!

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