 |
 |
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