Treating Muscoskeletal Pain: Part 2

Originally published by the Federation of Holistic Therapists in International Therapist, Issue 63.

In part one I discussed three case studies, emphasising the importance of taking a subjective history so that a conclusive hypothesis of the diagnosis can be established.

In the following case study, the patient’s diagnosis (in relation to her symptoms) is relatively simple, however in this case, it is the ’cause’ that needs to be discussed and analysed during the objective examination.

This is often where the difficulty lies in being a Sports Therapist. In the past, as a practising Sports Therapist myself, I would have initially treated the area presenting pain without taking into consideration any other relevant areas which might have been contributing to the complaint.

I am not saying that you have to be an Osteopath to identify the cause of the pain, rather that if you have a good understanding of the ‘functional’ anatomy of certain muscle groups, then it is possible to consolidate all of your objective tests and formulate a realistic plan of treatment.

The Patient

A 28-year-old female presents with bilateral anterior knee pain, in which the left knee is particularly painful. This has been present for the last 18 months and has progressively got worse over the last 5 weeks. It is aggravated by walking up and down stairs, running, sitting for long periods and driving. The patient currently works as a nanny so she is constantly bending down to pick up children, and is finding this simple task very difficult because of the pain. She would like to be able to run a marathon but presently can only run for about 500m before her pain comes on. It is a constant ache most of the time. She has been given quadriceps exercises by a personal trainer (e.g. squatting and leg extension), but this seems to make matters worse. She also participates in an exercise class on a weekly basis and this seems to exacerbate her symptoms too, especially after doing hip abduction exercises.

“Her knee pain is a weak link in the kinetic chain.”

This patient has consulted her GP, and was advised to take anti-inflammatory drugs and reduce any exercises that were irritating her knees. The GP also mentioned that due to the patient’s pain, she would not be able to participate in any running for the near future. The GP recommended a course of physiotherapy but she is still on the waiting list. There is no medical history to note.

In order to arrive at a diagnosis, let’s first look at what she is presenting with. She has bi-lateral anterior knee pain, which is exacerbated by going up and down stairs and sitting for long periods, etc.

In my experience the hypothesis of the diagnosis is that this patient has patella femoral syndrome (PFS) or simply anterior knee pain. The tissues (which I considered to be responsible for the pain) are around the patella-femoral joint, which is possibly mal-tracking and causing an inflammatory response. Her knee pain is a weak link in the kinetic chain. On examination the following tests were positive for the above diagnosis:

She also mentions a ‘band’ like sensation around her thigh. Examination results were as follows:

Patella tests (scoop, grinding, Clarks)
Passive knee flexion with overpressure on the patella caused pain
Standing and half squat

With the above clinical findings I confirmed that it was the patella-femoral joint that was responsible for her pain.

The problem with this hypothesis is that we are often expected by patients to treat the area of pain, which as you will see in this case study, will not be the main issue.There is much literature on the predisposing and pathological causes of PFS. The authors discuss overpronation, increased Q angle, patella alto, muscle imbalance, pelvis obliquity, leg length inequality, etc. My experience in treating PFS considers all of the above factors, but recently I have also had a lot of success with looking at pelvic stability – or rather instability, as is often the case.

The first plan of my assessment was to see if I could change her symptoms by performing a simple technique to the knee. This involved gliding the patella medially whilst the patient squatted, which immediately reduced her symptoms. This told me that something was causing the patella to track laterally.

“In my experience the hypothesis of the diagnosis is that this patient has patella femoral syndrome”

I assessed the tensor fascia latae (TFL)/ ilio tibial band (ITB) [see Fig. 1 ‘A’] with the OBER’S test and found it to have increased tension especially on the left side. Again another theory is that by ‘stripping’ the ITB it will release. However, this does not address why there is increased tension in this structure in the first place. It is more likely trying to stabilise the lateral thigh/ knee because structures or muscles are possibly less active. I then tested the functional ability of the Gluteus maximus (Gmax) / medius (Gmed). I would like to explain the functional anatomy of these muscles before I continue with the objective examination.

Gluteus Maximus

This is a large muscle with a multitude of attachments from the pelvis to the femur. We get taught in our studies that it is a powerful hip extensor but we might not understand its function during motion. For example, as we step upwards, the Gmax has an external rotation and an abduction influence on the femur which helps control the knee alignment, whilst powerful hip extending propels the body upwards. If the Gmax is weakened then the knee will be observed to deviate medially, which will then predispose the knee to pain.

Gluteus Medius

This muscle is the main stabiliser of the pelvis as well as an abductor of the hip. When you stand on one leg, the Gmed should be the main muscle responsible for pelvis stability. If it is weakened then the pelvis might be observed to tip down on the opposite side. This may appear as a trendelenberg gait in motion. If the Gmed has become weakened then possibly the TFL might become over active due to compensation and exert an increased force towards the knee.

The Treatment Plan

The treatment plan involved a simple re-education of the exercises my patient was already doing but with specific focus on the technique. Initially I had my client doing prone hip extension exercise to re-educate the firing of the Gmax. I asked the patient to simply squeeze the Gmax and lift the leg an inch off the floor and to repeat with the opposite leg.

The next exercise had the patient lying on her side: with knees and hips bent to about 45 degrees, the patient was instructed to keep the feet together, take the knees apart and when she could feel the pelvis rotate posteriorly, she was to hold this position for about 10-15 seconds. (This would be increased to 45-60 seconds over the next week.) This activates the posterior fibres of the Gmed.

“The treatment plan involved a simple re-education of the exercises my patient was already doing but with specific focus on the technique.”

The third exercise was a half squat using a small step. The patient was advised to bend the knee approximately 10-15 degrees with the patella being guided towards the second toe to control alignment of the joint. She would then squeeze the inner quad and was told to lock the knee into extension and hold for the count of 2 and repeat 10-12 reps on each leg for 2 sets. This exercise can commonly give some discomfort to the knee because of general gluteal weakness or incorrect technique, etc. I have on occasion taped the knee medially whilst performing this exercise and it has been shown to reduce the symptoms.

The above exercises have been indicated to strengthen some of the weakened soft tissue but I also advised the patient to lengthen the psoas muscle in order to complement the treatment paradigm.This patient over the subsequent three weeks had a progressive exercise programme consisting of squatting, lunging, stepping etc. She was also advised on stretching techniques, concentrating on the psoas, rectus femoris and hamstrings. In each follow-up session the patient showed a considerable reduction of symptoms and within four weeks was able to run 5km without any pain. This patient now has no difficulty with performing any of her daily tasks within her working environment.

Conclusion

It can be seen from this specific case study that a holistic approach to t objective examination is required. If this patient’s treatment had focussed mainly on her symptoms then I have no doubt that despite helping with the pain she was experiencing at the time, the long-term benefits would have been minimal.

John Gibbons BSc (OST), Dip Manip, Dip FTST, Dip IIST, Dip ITEC is an Osteopath, Sports Therapist, and Lecturer in Sports Medicine at the University of Oxford and St Mary’s University.

Pictures: Courtesy of Corpus Publishing (drawn by Amanda Williams)