complex case - Manipulation under Anaesthetic (MUA)

[seoirsemac]

Just looking for some opinions on this!
Pt referred to me following MUA of knee.
Brief history- Pt injured her knee during exercise class doing star jumps, carried on, in pain the following day. was referred to physio 3 months ago who was unable to detect any injury, given exercises and reassurance as pt was anxious +++. Pt had subsequent mti and arthroscopy which showed no injury. Over coming months pt developed fixed flexion deformity which required the Mua. Under general anaesthetic knee extended fully with no force required. Was placed in plaster for two weeks. As soon as plaster removed knee returned to flexion. pt has been wearing knee brace and walking with elbow crutches.
Ligaments- intact
Active mvts-- -30 knee extension
120 knee flexion
Passively- -10 extension
Muscle strength quads- 3/5, hamstrings 4/5
Pt very nervous muscles shaking while carrying out muscle strength tests.
this 23 yr old girl is currently on anti-depressant medication.

Any suggestions on how to handle the situation

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[BillOst]

More info please.
Is there pain on passive/active/resisted extension? If so -where? Is the problem one knee only? Any history of similar symptoms? Have you googled the meds for reports of contra's?

Cheers

Bill

[meganarch]

Have you considered the possibility of complex regional pain syndrome (AKA reflex sympathetic dystrophy) as a contributing factor to her ongoing pain?
M

[Tony Mitchell]

Refer her to a psychologist for an assessment. Note I say assessment and not treatment. There would appear to be no physical or organic condition, so physiotherapy is contra-indicated. There may or may not be a psychological condition and that is why an assessment is indicated. The types of tests in my experience that are useful in cases like these turn out to be the TOMM, PAI etc.
Is the young lady litigious? Does she currently have a legal case regarding the alleged injury?

[MrPhysio+]

I agree with all replies. If you have no previous experience with counselling or understanding of secondary gain behaviours, a psych referral for the patient is needed. You could try to find out what her fears are regarding the knee pathology. Was the patient on antidepressants before the knee injury?
I recently had a patient with a knee injury from high level combat sport, and both the surgeon and I felt that cruciate, meniscal, and collateral ligament damage had occurred. The patient did not respond to the usual physio, or even 'unusual' physio. A subsequent MRI was normal. Management chosen was conservative, with rest, knee brace, then strengthening physio. The case of the severe pain and loss of movement may be due to a combination of bruising, oedema, and meniscal irritation, plus muscle guarding effects.
After rest, the patient is doing well, and expects to restartv training for competion later next month.
If skin discolouration , abnormal hot/cold/ hypersensitivity etc is occurring, consider CRPS (chronic regional pain syndrome).
If this is confirmed, she will need emotional support, and time, as there is no reliably consistent treatment.
Good luck
MrPhysio

[marj]

I have worked with clients with "hysterical" conditions, which are typically neurological. If it is psychogenic, I was advised by the psych experts that physiotherapy is appropriate and that our role is to provide an environment in which they can recover with dignity. It is not appropriate to state it is a psychogenic condition or confront them, but you could gently suggest some counselling may help with her anxiety and depression and help her knee secondarily.

If CRPD, it is appropriate to educate re the influence of stress and anxiety on the immune and pain systems. Marj

[ShelleyAT]

I fear you are on an impossible course with this young woman I have had a few of these in my time (I have just retired) Unfortunately They have usually turned out to be complex anxiety problems and sadly a form of attention seeking. In my experience they do get better eventually but very stressful for the therapist as well as the patient. If the knee moves fully under anaesthetic and no abnormality has been found with extensive investigations it is reasonable to assume that the problem lies deep in the mind. I would try some deep relaxation techniques and some gentle passive flexion. Enormous amounts of encouragement will be necessary

Good luck

[Physiobase]

I think you are right there Shelley. Like you I have seen these type of patients here and there, mainly young females and often the result of being put in the plaster cast. I used to break my back and mind trying to restore range, perhaps to the point of over treating the area and perhaps therefore over-focusing on the issue. This all may well have fed into the problem if it is one of a central nature.

Perhaps reassuring the client that this can be a normal response and to review it every 3-4 weeks might be an interesting approach? 8o

[seoirsemac]

Thank you all for your suggestions. One of my seniors has suggested trying a joint session with her using craniosacral therapy. Anyone tried this technique in this case

[Physiobase]

Craniosacral therapy might well be of use if the client is open to it.

[neurospast]

I have read with interest your ideas and I must admit the likelyhood of the problem being a regional pain syndrome and some psychogical and central problem (like to my opinion all injuries) But I was wondering if a muscular injury would have come up in the examinations as performed because as far as I can see it would not. One muscle could easily mimic internal knee problems (like the small oblique which pulls the fascia posterior in order to prevent pinching or another muscle which wouldn't liked to be extended) because it seems to me that in case of a muscle injury (or nerve pinching) the manipulation under anestaetics would have the same result: an increase in the range of movement. Her anxiety would not help to find out if it is a muscular problem because of her anxiety which would be less if she understood the problem. So it might be a good idea to tell her a story and stick to it. With sherrington techniques you could have a look if the range of movement would increase ( avoiding co contraction of antagonists).