A stubborn Dad

[Njorl]

Hi fellow members,

I am a recently qualified Physio keen to diagnose everything in sight, will curb that though because my family are getting sick of me hee!

I just wanted some thought regarding a problem my dad has with his knee.

He's age 58 and 14 stone 5 ft 10 inches Occ: plumber

His job involves alot of kneeling and alot of getting up and down from the floor. He is a keen walker (though always on flat) and does about 5 miles a day.

I want to help treat him but he is adamant that surgery is the only thing to help him.

His problem seems to be mechanical, so there is no pain at rest, and he feels a sharp shooting pain medial to the patella during walking and stairs, but cannot feel pain in self palpation of this area. There is swelling also and he feels an ache inside the joint going into the back of the knee. He especially feel the 'shooting pain' coming down the stairs. Walking as he still is everyday aggravates and causes swelling, but he has altered his walking pattern to avoid pain.

So I am jus wondering if this sounds like the typical problems associated with patellofemoral syndrome and if so the best Rx for this.

I was thinking stretch ITB, taping VMO exercises but anybody know of additional things that may help.

I was thinking of recommending a visit to a podiatrist to analyse gait as I feel to inexperienced to do a good job of this, but I know he has inflexible flat feet and is hip flexed in walking.

He seems to have no hip extension with walking or when asked to do actively in standing.
There is no Hx of LBP just stiff in upper T.spine.

Any advice would be really great,

Thanks Njorl

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[physiofixme]

Hi

Sounds like patellofemoral to me. Taping, VMO strengthening and itb stretching are definately all a must. With the itb, teach him to stretch but make sure you do some deep tissue massage over his itb as well. The other area to focus on is strengthening his PGM (posterior gluteus medius) as this works in conjunction with VMO. Getting a gait analysis from a podiatrist is worthwhile but bear in mind they see things from a foot perspective......they'll focus on the foot mechanics being the problem for what is happening further up. I'd be inclined to look at his pelvic stability as well. If he has no hip extension when walking then he probably has no glute strength so you may want to give him some exercises to increase that and maybe stretches for his hip flexors.

Start with exercises that are simple (ie. squats - with knee taped so he doesn't get pain) and i'd do PGM in side lying and his glute strength in prone. Then progress to more functional exercises like step downs off a step (still with knee taped if painful) focusing on proximal control while stepping down. Do some swiss ball stuff for glutes or cable work in standing if he/you have access to gym equipment. Hope this helps.

[physiotrav]

Hi,
I first do some tests to make sure it is patellofemoral syndrome like McConnels test, and medial patella glides etc;to make sure it is patellofemoral syndrome and not something else.
I agree with the above reply: strengthen glut med and stretch ITB and rec fem, and correct gait pattern (don't allow compensation as will lead to pain in other leg after time)

[nasde]

I'd clear the hamstrings and calf - they are often tight and a cause of pain at the back of knee joint. I'd do that with any soft tissue technique to the patient in prone. Good in general for most knees i find, and then stretching for calf and hamstring.

do all the Patello-fem stuff too.

[milo]

How long has your dad had this problem?

Does going down stairs with the bad leg leading or lagging cause pain?
Bad leg leading - may indicated tib/fem joint, meniscal issues as the knee is extended and weight is taken through it.
Bad leg lagging - may indicate patella mal-tracking causing the pain as it struggles to eccentrically load the weight.

[Njorl]

Hi Thanks for your reply,

My Dad said that when he climbs into his works van he pulls himself up with the steering wheel as hurts if puts weight through from that height and I think must lack strength also. He has very limited plantarflexion and looks generally stiff and tight from sustained postures and activities for amny years. Thanks for reply.

[schischka]

Hi there....

I guess when we hear "pain up or down stairs" we think patellofemoral. But I believe you need to try and really reproduce his pain with special knee tests. It sounds like it is bothering him alot and if he has constant pain and he feels it deep and behind his knee, I'd tend to think more knee joint dysfunction (?meniscus/?OA). Another good point someone made is to get a good history!!

If you are confident it's patellofemoral, I'd agree with the other replies regarding management.

All the best as you nut out your patients

[jwilso]

what about his weight. 14 stones is a lot for a 5ft 10 person to carry around