Case study of the treatment and rehabilitation of a general knee injury
Patient x visited our City Centre clinic with a long standing knee injury.Patient x was 46 years old and had had the knee problem for just under 3 years. The patient said there was no major incident that caused the problem initially , it just came on gradually. He reported the injury to the GP who suggested a course of anti inflamatories and he was told to rest it as much as possible.
Patient x followed the GP’s advice and took the course of anti inflamatories and rested from irritating activities but, after 3 months it had not improved but was actually getting worse.
The patient revisited the GP, who this time suggested a course of physiotherapy , that he could arrange via the NHS. After 6 weeks the physiotherapy appointment arrived and Patient x attended physiotherapy , which involved some home excercises and attending a knee class for 4 sessions. At the end of the treatment this caused increased irritation to the knee and the physiotherapist suggested seeing an orthopaedic surgeon.
The patient visited the orthopaedic surgeon and after an examination he suggested having a MRI scan. After waiting 2 months the scan was carried out and it showed no major abnormality with the knee joint, just a general level of degenerative changes commensurate with the patients age.The orthopaedic surgeon suggested an arthroscopy, (a small camera which is inserted inside the knee under general anesthetic to check the inside of the knee for problems). This was carried out 6 weeks later and it was confirmed that there was a small medial cartilage tear and some mild degenerative changes. This seemed to improve the knee initially but after a couple of months it regressed to its original level of pain and irritation.
SUBJECTIVE EXAMINATION
Patient x reports a level of pain and stiffness on a morning when first getting up out of bed , this "eases off " after around 1 hour once he is up and moving around. The irritation increases in the morning, lasts longer and there may be some swelling and a feeling of heat in the knee if the patient has done some increased activity , such as walking the dog, etc.The patient reports a minor ache at all times which is worse in cold weather and lying in bed at night. The patient likes go on walks in the countryside and in the hills but is unable to do this, he can just about manage to walk his dog. He would like to get back to walking in the countryside but understands he will have to manage his knee.
OBJECTIVE EXAMINATION
The patient could not achieve active terminal extension of the Right leg ( get his leg straight compared to the other leg ).He had reduced knee flexion by 25% on the Right leg( could fully bend his leg compared to the Left leg ).He had 35% muscle wastage of the Quads and a small quads lag. There was an active Grade 1 effusion ( swelling of the knee ). He had reduced proprioceptive control of the limb by 25% ( loss of balance compared to the Left leg ).He presented with an asymetrical gait with longer at the mid stance phase and reduced toe off on the Right side. The patient had major biomechanical anomalies.
TREATMENT AND REHABILITATION
The goals of the injury management strategy is to :
1) Reduce the pain and irritation on a daily basis
2) Increase the activity level and manage the reaction
3) Prolong the longevity of the knee
How these GOALs are achieved are detailed below, initially the patient has a 4 to 6 week intense protocol, which will reduce all the pain and irritation to a minimal level.At 6 weeks the patient commences an increased activity protocol,on a gradual basis, this gradual basis allows the knee to adapt to the increased mechanical load without producing pain and irritation.An ongoing maintenance protocol is introduced after week 6 for the next 6 months.
FIRST PROTOCOL ( 0-6 WEEKS )
1) Terminal extension must be achieved ( you must be able to get leg straight yourself). You are given a series of prescribed exercises which must be done for a specific time and a specific routine.
2) The knee cap must be mobilised two times per week by a clinican to ensure the knee cap is mobile.
3) Any swelling must reabsorb via icing x20 mins on the hour every hour practically possible starting immediately.
4) The inflammation must reabsorb via prescribed oral anti – inflamatories .
5) Deep soft tissue massage must be performed twice per week as this releases the tight tissues and removes “ trigger sites “ which allows maximum facilitation of the thigh muscles.
6) A routine Biomechanical Assessment is carried out and a generic device prescribed to ensure correct loading of the knee when standing,walking ,etc
7) REST FROM ALL IRRITATING ACTIVITIES ,this allows the knee to settle and enables us to obtain a “ true picture “of the level of pain and irritation.
SECOND PROTOCOL (6-10 WEEKS )
1) Inner range quads control must be achieved to facilitate normal patellar tracking .You are given a series of percsribed excercises. Which must be done for a specific time and a specific routine..
2) Introduction of static cycling sessions x2/3 per week for 15 minutes per session and gradually increase cardiovascular activity upto a maximum of 40 minutes using X Trainer, static bike, rower and stepper.
3) Introduce proprioceptive sessions to facilitate normal knee function
MAINTANENCE PROTOCOL (10 WEEKS - 6 MONTHS)
1) Continuation of ALL prescribed exercise twice per week
2) Deep soft tissue massage once per month to ensure quality of tissues
3) The knee must be iced if it becomes irritable due to increased activity level
OUTCOME OF TREATMENT AND REHABILITATION
After the treatment and rehabilitation, Patient x has a much improved quality of life. Specifically , he could walk his dog on a daily basis with minimal/no pain or irritation during or after the activity. Furthermore, he could go walking in the countryside for around 3 hours alternate weekends with only minor irritation during and after activity.The morning stiffness and irritation reduced by 70%.This improvement was maintained with adherence to the Maintenence Protocol.
