Case prepared by: Rishab
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
HISTORY:
Patient has an ankle injury in March 2023
He fell while playing badminton and had a fracture in the lateral malleolus of the fibula (Right) – Hair line #
Rest for almost a month and start to do exercises prescribed by the family doctor.
Didn’t follow proper rehab
On and off going for playing badminton
Oct-2023 He went for playing almost 3-4 times a week and his ankle got severe pain again. Consulted with another doctor
Suggested to do rest until the pain subsides, and then physical therapy
Dec 2023, he joined the gym and started working out under his trainer
He focused on ankle strengthening mostly while doing exercises
Again, back to play 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 4- 5 days
Dec 2024, he started to feel pain in the same side knee
By the time the intensity of pain increased
No gym for the last 2 months
Stopped playing badminton 1 month back
Before ankle injury – Playing daily with high intensity – >1-2 hours
Before knee pain – Mostly go to play every day – ½ to 1 hour
Not playing nowadays.
Sleep – Disturbed sometimes (IT professional), Avg 6-7 hours
Stress – +ve but not so dominant
Physical activity status: Now walking daily 2-3km in the morning, doing some stretching, and playing badminton lightly sometimes.
Consulted with so many physios and doctors
No relief
Your objective on why he/she consulted us or the goal to meet us
Want to know the reason why knee pain is there
Want to get rid of pain
Return to play as same as before (High intensity) >1 to 1.5hour
Beliefs and expectations:
Since he had experience with a similar injury on the opposite side and underwent surgery, he felt that this injury was not serious enough to undergo surgery immediately. So, he thought of managing it without surgery, so he came to us for the non-surgical management of an ACL tear. He wants to prevent further injury, get fit, and play again.
Sleep – Slightly disturbed. He is trying to work on it.
Stress – He is a little stressed because of another injury.
Physical activity status – Before the injury, he played 2–3 times a week and worked out three times a week. After the injury, he started doing exercises on his own as he had previous treatment experience.
Goal/ Objective of his consultation with us:
- He wants to go for non-surgical rehabilitation.
- His motive is to play football again recreationally.
PAIN ANALYSIS:
Mild discomfort in the left knee while loading.
Fear of movement analysis
Partially positive because of past injury history. But he has a good attitude towards movements.
An important aspect of the history that we discovered is:
- No proper and consistent rehab, and RTS testing were done for the previous injury.
PHYSICAL EXAMINATION:
Partially positive because of past injury history. But he has a good attitude towards movements.
An important aspect of the history that we discovered is:
- No proper and consistent rehab, and RTS testing were done for the previous injury.
1) Observational findings
- Good muscular physique
- Muscle mass is very slightly reduced on the left lower limb.
- Mild swelling present on left knee, medial side.
2) Muscle mass circumference
- Good muscular physique
- Muscle mass is very slightly reduced on the left lower limb.
- Mild swelling present on left knee, medial side.
PAIN ANALYSIS:
Goal/ Objective of his consultation with us:
| 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.