Ben;
You have an interesting patient. I would agree with you that there is some over conditioning going on. Does the patient seem to not be able to handle the mileage? Is it a recent increase in volume of training?
You do not describe palpation at all, so that leads me to wonder........
I'm wondering what hip strength is also. I would guess he has weak hip Abductors and subsitutes this with a strong and tight TFL. Check out his IT Band flexibility with Ober's test (modified).
You also do not describe where in the knee or hip the pain is.
Hip flexors are painful and tight with Hip Int. rotation. It is possible that a slight avulsion of the psoas has occurred. Any imaging studies?
All in all, pain has to be reduced prior to exercising at that level. No training into the painful time frame. Active rest type of training is okay. Depending on the findings based on my questions above I would probably stretch IT Band, hip flexors, Rectus Fem. Strengthen weak muscles, probably Hip ABd.
Good luck and report more to us.
Patrick Zerr
www.apluspt.com
A+ Plus PT Exam prep package
-----Original Message-----
From: Ben Fisher <[log in to unmask]>
Sent: Apr 19, 2004 6:24 AM
To: [log in to unmask]
Subject: Knee & Hip pain?
Dear List
I have a patient I would be very grateful for your opinion on:
31 year old male who regularly cycles, runs and swims (cycle approx 100
miles a week) who has developed on/off knee pain over the last 8 months.
There is now also groin (?hip) pain on the same side that came on over last
3 weeks.
The nature of the pain is achey at both joints, but occassionally sharp at
the knee.
The pain tends to come on -end of day or after exercise, especially at
night when going to sleep (?inflammatory), and is proportionately worse
with the increased amount of exercise during the day.
This can cause considerable (2-3 hours) sleep disruption at its worst, none
at its best.
However, he is still able to do most sports with only very slight
discomfort (eg. 5 mile runs, 15 mile cycles etc) The most aggravating sport
for the hip is breast-stroke swimming, but he only does this very, very
occassionally.
For the knee, one sport doesnt seem to be worse than the other, simply the
amount of sport done.
About the only other thing of note is there can be occassional EOR
stiffness of knee when straightening the leg first thing am, or after sport
(once cooled down).
ON EXAMINATION, there is more or less full ROM but there is pain at both
EOR flexion and extension. Slight calf wasting on the affected leg.
There is no ligament laxity, and no positive meniscal tests (though there
is knee pain but NO laxity with anterior drawer test). PFJ tests are all OK.
He is very tight on the affected side, hamstrings, hip F etc
With regards to the hip, pain is strongly elicited with internal rotation
and slightly with the quadrant (flexion + adduction) <capsular pattern?>
He has tried stopping all sport for three weeks, and this helped but only
slightly, and on resumption the pain came back. He has a job that invloves
been on his feet for most of the day though.
I have been thinking along the lines of some over-use condition, and my
main questions would be-:
1) Is the EOR flexion/ extension pain typical of anything?
2) The hip is only recent onset but most problematic- is it known for
patients to adjust their biomechanics because of knee pain, only to
aggravate the hip somehow, because of the altered movement?
3) I have begun a programme of stretching tight structures and basic knee
strengthening (VMO slightly down) as well as proprioception (again just
slightly down). This is with a graduated return to sport to see what
happens. Any other thoughts?
Thank-you list
Regards
Ben Fisher
Junior physiotherapist, London
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