So, move to our final case

24 April of 2008

So, move to our final case. The bottom line here is that osteoarthritis is not necessarily a disease of older people. There are ways to modify it coming up. There are other ways to treat it that mimic more surgical procedures and may be preferable to use those instead of the surgical procedures.

Our last case – back to younger people – by that I mean a 22-year-old graduate student who had knee pain several weeks into the new semester. This was described as anterior knee pain, worst with prolonged sitting, climbing or descending stairs. She had occasional sense of catching, locking and giving way.

Physical exam showed slight lateral movement in the patella at the end of an active extension. This is what some would call a J-sign. Instead of the patella coming and tracking all the way in the middle of the trochlear groove, as it gets to the top it actually slides over to the sides. As if you have an upside-down J written on your knee. This is a finding that is not found in normal subjects. Patellofemoral crepitus was present. She had minimal medial translocation of her patella possible. It was hard to move it from side to side. And she had peripatellar tenderness. Her x-rays were normal, including A-P and skyline views. So this was a woman with anterior knee pain with some definite patellofemoral tracking problems who I thought needed attention to her altered biomechanics.

In spite of our best efforts, we are running out of time for our case so we’ll try to move through this one quickly. Because of her pronounced patellar tracking problems, and also lower extremity weakness in this person, we decided to try exercise and also to try patellar taping for her to see if it reduced her pain. In fact, when we taped the patella medially in this case, in clinic, we found that we reduced her pain by 50% for normal activities. So that made us think that patellar taping would be a good adjunct to the rest of the therapy. Patellar taping is a bit controversial. There is a growing body of research and literature on it now and most clinicians will use it if it seems to work on their patient. It does reduce lateral movement of the patella during exercise, although the clinical assessment of the patella hasn’t been shown to be extremely reliable, we know that patellar tracking or lateral displacement does occur because it’s very reliably measured on x-ray. Patellar tracking, as we said before, is not a consistent predictor of pain but done properly it has been shown to reduce pain with exercise and stepping by at least 90% and is a good adjunct.

This is what patellar taping looks like. Usually the patella is taped medially. It’s done in clinic. We do to allow effective strengthening of the quadriceps without continuing to irritate tissues and get effusion, which inhibit the VMO. People can also be taught to do their own taping outside of clinic. We use taping not just taping but to strengthen exercises. Another example, here she is not going to sit in the chair. The chair is just behind her in case she decides she needs to use it quickly. So this is functional strengthening. Very often use side stair stepping. What you see here is very good posture. The hips are level as they go up and down. They are using the knee. We’d use taping in that. We have found that foot orthoses can change patellar alignment and since she has that problem we are also going to use a foot orthosis with her. You can see here, without foot orthosis and good shoes. So again, minimal attention at the foot can often produce dramatic results at the knee. Her exercise program is one that you generally wish a young person to adopt and maintain for their lifetime. Some stretching. We are also going to teach her some patellar mobilization that she can do on her own at home, because her patella did seem to be tight. We are going to teach her quadriceps stretching exercises. This is a lot more effective and more comfortable and people don’t get hamstring cramps when they stretch their quadriceps like this.

We expect her to do better and to develop life-long habit of exercise and fitness. So sometimes coming to the healthcare professional for a problem can be an opportunity to help people develop some good habits that will prevent problems later.

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