STARES 3 – Treatment for patient with knee pain

SITUATION
I had been referred a patient suffering from knee pain. The referral mentioned “patello-femoral syndrome” and through my subjective and objective assessment I found she had lateral mal-tracking of the patella. I also found she had very pronated feet when walking with low arches. Her lateral thigh structures were very tight and her vastus medialis oblique (VMO) was barely activating. Her quadriceps were weak with an obvious quads lag. Her pain was at the worst when she had to go up and down stairs. When a medial glide was applied to the patella it was not as painful to go up and down stairs. There were a number of factors contributing to this knee pain.

TASK
My task was to provide a treatment session for this patient, targeting the knee pain and lateral tracking of the patella.

ACTION
My first part of the treatment was education. It is important for the patient to understand what is going on and what the treatment plan is. I explained that the knee pain would be a result of the mal-tracking patella, which is sitting too far to one side (and therefore not sitting in the groove). I explained it could be mal-tracking as a result of the tight lateral structures pulling it one way and the weak medial structures (particularly VMO) could not pull it back to midline.
The second part of my treatment was aimed at decreasing the tension of the lateral structures. I used massage and advised her on the use of heat and stretches at home.
My final part of the treatment was exercises aimed at increasing the quadriceps and VMO strength. I prescribed step exercises which are very good for quad strength and can be modified slightly to target VMO. I used strapping tape to put a medial glide on the patella to relieve pain temporarily. The aim was to reduce pain to allow the patient to make a start on the exercises at home.
I also sent a referral to the podiatrist regarding the pronated feet to see if orthotics to raise the arches were possible. I feel it would take some of the pressure off the knee (which could be a contributing facto in the knee pain).

RESULT
I completed this treatment session in the allocated time and the patient understood how each treatment component could help to decrease her knee pain. The treatment had an immediate effect on the pain, and strapping provided temporary relief from the pain completely.

EVALUATION
I feel this was a god treatment session as it had an immediate effect on decreasing the knee pain and the patient knew what to do at home to continue this pain relief. I think a good treatment session gives the patient something to do at home to self-manage their pain, rather than waiting until their next physio appointment. It also encourages them to actively participate in the treatment, rather than having it purely passive (which has been shown to have a poor outcome). By prescribing exercises for this patient to do at home it will be a lot more effective than only being seen by a physio once a week. The fact there was an immediate decrease in the pain will encourage the patient to be compliant with the home exercise program as she knows this treatment really can help.
By referring her to the podiatrist I was taking a multidisciplinary approach, which will benefit the patient. Overall I feel it was a well-rounded approach that decreased the pain during the session but also focussed on how we would decrease the pain permanently.
There were a few improvements I would have made in this session. When demonstrating the step exercises I tried to explain too much first when I should have just shown her. Actions speak louder than words! I think I may have temporarily confused the patient with the exercise.
Also, I chose to use a plastic massage device over her clothes, rather than using cream directly on the skin. I feel massaging with cream may have been more effective (I can put more pressure through my forearm than the plastic device in my hand). The patient was wearing long pants that could not be rolled high enough to reveal the thigh. I did not think she would be comfortable taking her trousers off and being covered with a towel, however I should have given her the option instead of assuming what she would prefer.

STRATEGIES
1. Save time trying to explain a complicated exercise to a patient and just demonstrate it instead.
2. Don’t assume what the patient is comfortable with or not, always ask them what they would prefer.