REHABILITATION STRATEGY FOR ACTIVITY-RELATED BILATERAL KNEE PAIN
PATIENT PROFILE
Age: 61 years
Gender: Male
Occupation: Retired desk worker
Body weight: 102kg
Previous Activity Level: Regular walking and cycling
Primary Goal: Pain-free walking and cycling with restored confidence.
CHIEF COMPLAINTS
Bilateral knee pain for the past 6 months, more severe on the right side, associated with difficulty in walking and cycling, and early morning stiffness.
HISTORY
- Six months ago, the patient gradually developed pain in both knees without any specific trauma. The pain initially occurred after prolonged standing and walking, but over time began to interfere with daily activities such as cycling and lower-body exercises.
- He consulted an orthopaedic doctor, and investigations did not reveal any significant abnormalities. Pain medications provided temporary relief, but symptoms returned after discontinuation. He then began physiotherapy and exercise programs, which helped reduce pain but did not fully resolve his symptoms.
- Currently, he experiences intermittent flare-ups of knee pain, especially after prolonged standing or activity. The patient believes his knee pain is due to age-related joint damage and cartilage wear, which has caused concern about long-term mobility and independence. His main goal is to walk and cycle pain-free and regain confidence in physical activity, and also he wants to reduce his weight. So he approached us to relieve pain and improve overall function.
Physical Activity Status
Previously active with regular walking and cycling; Currently limited due to knee pain, as he avoids prolonged walking and lower limb strengthening exercises.
Sleep
6–7 hours per night, occasionally disturbed due to knee discomfort.
Stress Levels
Moderate stress related to functional limitation and fear of progression of knee problems.
PAIN ANALYSIS
Intensity:4/10 during daily activities, 6/10 after prolonged standing or walking
Aggravating factors: Prolonged standing, walking, cycling, stair climbing, standing after prolonged sitting
Relieving factors: Rest, medication.
Location: Diffuse pain in bilateral knees, right more than left
Irritability: Moderate
Sensitivity: Moderate
Fear of movement: Present during prolonged walking, squatting, and cycling.
Lifestyle impact: moderate impact as he reduced participation in walking, cycling, and lower-body strengthening activities.
PHYSICAL EXAMINATION:
Observational findings:
- No visible postural deformities
- No swelling or signs of inflammation
Range of Motion analysis:
Hip, knee, ankle – normal ROM
Mobility screening:
Forward bending: Full range, pain-free
Squat: Good depth with no asymmetry, pain-free
Stability screening:
| MUSCLE GROUP | RIGHT | LEFT |
|---|---|---|
| Hip flexor | Strong and painless | Strong and painless |
| Hip extensor | Strong and painless | Strong and painless |
| Hip abductor | Weak and painless | Strong and painless |
| Hip adductor | Strong and painless | Strong and painless |
| Knee flexor | Strong and painless | Strong and painless |
| Knee extensor | Strong and painless | Strong and painless |
Note: There is a mild strength deficit in the right hip abductors on break testing.
Special tests:
- Varus stress test: Negative
- Valgus stress test: Negative
- McMurray test: Negative
- Patellar grind test: Negative
INVESTIGATIONS:
- X-ray (knee): No significant structural abnormalities
- Blood investigations: Not indicated
DIFFERENTIAL DIAGNOSIS:
Meniscal pathology:
- No locking or giving way
- Negative McMurray test
- No joint line tenderness
Ligament injury:
- No instability episodes
- Negative stress tests
- No traumatic onset
Inflammatory arthritis:
- No prolonged morning stiffness
- No swelling or warmth
- No systemic symptoms
DIAGNOSIS:
1. Patient’s beliefs and expectations:
The patient aims to achieve pain-free walking and cycling. He wants to understand the cause of his knee pain and seeks reassurance regarding his condition.
2. Patient’s understanding of pain:
He perceives his pain as a sign of joint degeneration and is concerned about worsening mobility and long-term functional decline.
3. Psycho-social factor analysis:
Cognitive: Affected — worried about recurrence and progression of symptoms
Affective: Affected — frustration due to limitations in daily activities
Social: Mildly affected — reduced participation in recreational activities
4. Diagnosis with clear explanation:
BILATERAL NON-SPECIFIC KNEE PAIN – LOAD INDUCED
The pain appears to be influenced by multiple contributing factors, including:
- Reduced lower limb strength, especially hip abductors
- Prolonged standing and activity-related loading
- Fear of movement and activity avoidance
- Weight-related joint stress
- Inconsistent physical conditioning
- Limited understanding of pain mechanisms
Hence, the patient’s knee pain is not solely due to structural damage but is influenced by both physical and behavioural factors, making it well-suited for conservative physiotherapy management.
TREATMENT PLANNING:
Detailed Treatment Strategies
8 weeks (twice a week)
Goals:
- Reduce fear
- Improve tolerance to load
- Begin hip strengthening
- Restore basic aerobic capacity
Week 1 to 2 :
- Patient education on the non-threatening nature of knee pain and the importance of movement in the recovery.
- Advice on sleep hygiene, nutrition, hydration, and weight management.
- Graded exposure to strengthening within pain-free ranges to build confidence.
- Initiation of treadmill walking and stationary cycling.
Week 3 to 4 :
- Progressive strengthening focusing on quadriceps, hip abductors, and core stability.
- Education on load management and activity pacing.
- Functional exercises such as sit-to-stand,step-ups, hip thrust, calf raise, etc.
- Home exercise program reinforced.
Week 5 to 8
- Advanced strengthening and endurance training.
- Progression of walking and cycling intensity and duration.
- Preparation for independent self-management.
Home Programme
- Independent continuation of exercise program.
- Regular walking and cycling progression.
- Home-based resistance training at least 3 days per week.
- Lifestyle modification reinforcement.