The Hidden Cause of Knee Pain: Exploring Muscular Deficiencies
Patient profile
Age and gender – 33-years-old male
Occupation – Working in a software company
Complaints – Right side knee pain (Past 2 months)
HISTORY:
Present history:
In October 2024, he started to feel pain in his Right Knee.
By that time, the intensity of the pain had increased.
No gym for the last 2 months
He stopped playing badminton 1 month back
Before knee pain – Mostly go to play every day – ½ to 1 hour
Past medical history:
The patient had an ankle injury in March 2023
He had a fall while playing badminton and had a fracture in the lateral malleolus of the fibula (Right) – Hairline Fracture.
Rest for almost a month and start to do exercises prescribed by the family doctor.
The doctor just prescribed quadriceps activation, calf stretch, calf raise, and making circles in SLR exercises. He followed for almost 6-8 weeks.
Later, he started playing badminton on and off, but he had a fear of getting injured again or his condition worsening.
Oct-2023 He went for playing almost 3-4 times a week, and his ankle got severe pain again. Consulted with another doctor.
He was advised to rest until the pain subsided, and then he consulted with the physiotherapist.
In December 2023, he joined the gym and started working out under his trainer.
He focused on ankle strengthening mostly while doing exercises.
Again, back to playing badminton in July 2024 with moderate intensity (½ to 1 hour,4-5 days/week)
As well as going to the gym for a workout but without any guidance/coach
Following the push, pull, leg, core, and mobility – Weekly for 4- 5 days
Believe and expectation:
Consulted with so many physios and doctors. No relief
He wanted to play badminton like he was playing before his ankle injury (Playing daily with high intensity – >1-2 hours)
- Sleep – Disturbed sometimes (IT professional), Average 6-7 hours
- Stress – Yes, it was there because he loves to be physically active and play badminton. But he can’t do that now, and his activities of daily living were affected by the pain.
- Physical activity status: Now walking daily 2-3km in the morning, doing some stretching exercises.
Objective for his consultation with us/ Goal:
Want to get rid of the pain and wants to know the reason why he has pain.
Return to play the same as before (High intensity) >1 to 1.5 hours
PAIN ANALYSIS:
- Intensity – Loading dependent, on average 4/10
- Aggravating factor – Climbing up/down, Running, long-standing, sitting with flexed knee, and Moderate to high-intensity badminton
- Relieving factor – Rest, hot, medicine
- Location – Deep inside the anterior patellar (Inline), sometimes below and medial side of the patella
- Duration – The past 2 months become severe
- Type of pain – Nociceptive
- Character – Mechanical pain
- Irritability – Low to Moderate explain (While playing he started to have pain but he tried to push himself sometimes and ended up with a bit more severe pain) Load related – Sometimes the pain will be there till 4-7 hours
- Sensitivity – Moderate to high (Once structure becomes loaded it takes time for pain to subside) Capacity was not sufficient to bear the load
- Lifestyle factor affected due to pain – Yes affected
- Fear of movement analysis – Partially positive because of past pain history, he has a good attitude towards movement.
What we discover or important aspect of the history:
- Still not clear about his condition, why pain is coming. Maybe the suspected knee joint may be overloaded.
- Lack of guidance in rehab for previous injury.
- No consistency/Progressiveness in treatment
PHYSICAL EXAMINATION:
1) Observational findings – Bulky guy, good muscle mass, good attentive and listening skills, no swelling, redness, atrophy at present at and surrounding the right knee
2) Mobility/ROM screening – The 5-inch ankle mobility test was performed, revealing a restriction in right ankle dorsiflexion, with a 1-inch deficit compared to the left side.
3) Strength test – isometric brake test of hip abductor comes weak and painful on the right side compared to the left one.
| Movements | Left | Right | Limb Symmetry Index |
|---|---|---|---|
| Body weight Single leg sit to stand (On chair) | 21 | 7 (not able to perform more due to pain) RIR – 5-6 | 33% |
| Body weight Single leg glute bridging | 58 sec | 37 sec (Hamstring activation was more he felt) | 64% |
| Side plank leg lift | 40 sec | 29 sec | 72% |
| Single leg hamstring bridging | 12 reps | 10 reps | 83% |
| Body weight Single leg calf raises | 22 reps | 21 reps | 95% |
4) Special tests- All the other ligaments-related special tests were negative
There are some special tests out there like Clarke’s test positive but this test doesn’t have strong clinical testing value.
INVESTIGATION:
- Blood test/ MRI/USG/NCS – NO
- X-ray – Normal
DIFFERENTIAL DIAGNOSIS:
Any ligament injury:
- No history of trauma, Twisting of the knee
- Sharp, intermittent pain, often worse with twisting and deep squatting, which is not present
- May have clicking, locking, or catching sensations which are not present
Osteoarthritis –
- >45 years of age
- There is no morning stiffness, which improves with activity
- There are no reports of effusion and crepitus
- The patient is younger and active, so there are fewer chances for degenerative changes
- X-ray normal
- Loading is a key factor in all diagnosis. Not this specific one
DIAGNOSIS:
1) What is the patient’s perception of pain
He had a good understanding of pain. But after seeing people playing badminton, he could not resist himself and tried to play. It shows his love for the game. So, he does not have the knowledge of loading when to push and stop.
2) Psycho-social factor analysis
| Aspect | Level | Impact |
|---|---|---|
| Cognitive | Low | Not affected much |
| Affective | Low | Not affected much |
| Social | Low | Not affected much |
DIAGNOSIS WITH CLEAR EXPLANATION
Basically, the patient had a history of an ankle injury. By that time, there was no proper weight bearing on that side, which led to restricted mobility in the ankle. The strength test shows insufficient ability to produce force in the quadriceps and glute muscles. The pain location and the aggravating factors also confirm that he is having pain in loading. So the diagnosis is Patellofemoral pain syndrome.
(Patellofemoral Pain Syndrome (PFPS) lacks a definitive diagnostic test. We can come to a conclusion by the history and clinical assessment)
TREATMENT PLANNING:
When a patient comes with patellofemoral pain syndrome, research shows it takes 4-6 months to recover from the pain and return to functional activity without difficulty.
But in 40% of cases, it tends to reoccur. Some patients may have pain till 2 years.
In this case, I have planned to go for a total of 18 sessions over the time period of 3-6 months. The main goal for the treatment was to improve ankle and hip mobility initially, work on strengthening grated exposure to loading the knee joint, and make him return to sports.
| Time Frame | Target | Exercises |
|---|---|---|
| First week | Mobility with Isometric loading | ATG split squat, pigeon stretch, supine scorpion, 90-90 hip mobility, etc. with isometric strengthening of quads and glutes |
| 2nd – 3rd week | Isometric progression along with Isotonic loading | Progress mobility exercises with graded exposure to strengthening of quads, glutes, all lower body, and trunk, focusing mostly on unilateral exercises |
| 4th – 5th week | Progressively develop volume in isotonic loading | Started introducing squats, RDL, and hip thrust |
| 6th week | Started low-level impactful activities | Progressive strengthening with mild agility and plyometric start |
| 7th week | Performed RTS to check limb symmetry index | Timed 6-metre Single Leg Hop, Single Leg Lateral Hop, Muscle strength testing |
| 8th – 9th week | Graded exposure to badminton | Mild to moderate intensity |
| End of 12th week | Started to play badminton | Moderate to intensive intensity with strong education about load management and the importance of strength training |
Always keep in mind every session is assessment.
Happy learning.