Recently, Erson saw a healthy young female athlete and martial artist with bilateral knee pain. Based on her findings it seemed like an obvious knee problem. However, there were two things he overlooked and he didn't start where he says you should. What do you think of this case?
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[00:01:25] I saw a recent 18-year-old healthy female athlete.
[00:01:30] She runs, mostly does martial arts and works out regularly.
[00:01:34] Her complaints were bilateral knee pain greater than left.
[00:01:38] And there are two things that really should have clued me in when I'll talk about later
[00:01:42] as to the intervention ended up working.
[00:01:44] And I really wasn't...
[00:01:46] I just let my biases kind of get the best of me and it can happen to all of us.
[00:01:51] Even though I talk about the thing that ended up helping her a lot, this is the
[00:01:54] thing that I ended up doing last after failing for a bunch of treatments.
[00:02:00] So I made the erroneous assumption based upon her lumbar flexion being full.
[00:02:05] She could easily palm the floor in lumbar extension, just being minorly limited, not
[00:02:09] deviating at all into your tilt and side bending did not deviate to the left indicating
[00:02:14] why she might have potentially greater knee pain on the right.
[00:02:19] What I did find the relevant findings for the extremities were that she had severely
[00:02:24] limited great toe extension on the right, moderately limited on the left, severely
[00:02:28] limited lateral tubular glide on the right, moderately limited on the left.
[00:02:34] And I thought, oh, it's just a simple kind of limitation in ankle dorsiflexion, which
[00:02:41] causes her knees to kind of buckle in where the limitations in great toe extension usually
[00:02:47] made her toe out quite a bit when she was walking, squatting and doing close kinetic
[00:02:50] chain activities.
[00:02:52] So I thought, oh, it's simple kind of patella femoral syndrome, you know, or what I call
[00:02:56] knee pain.
[00:02:57] That's what she came in as the diagnosis of anyway.
[00:03:01] But strangely enough, when I measured her dorsiflexion, and this doesn't happen too
[00:03:05] often, especially when you have moderate to severe lateral tubular glide restrictions,
[00:03:10] she had full dorsiflexion.
[00:03:11] She could easily bring her knee to the wall four to five inches away with her
[00:03:15] great toe being four to five inches away from the base of the wall.
[00:03:19] So I thought that was a lot unusual.
[00:03:20] Her tibial internal rotation was also with the normal limits bilateral, and I thought
[00:03:25] that she would have had a little bit of restriction on the right.
[00:03:29] Despite that, I tried to be on turn rotations and tried giving her the simple
[00:03:34] cue of going knees out during squats.
[00:03:36] So I was trying a mobilization and movement technique.
[00:03:39] At first, she said that made her knee, both her knees feel quite a bit better
[00:03:44] in squatting and upon return.
[00:03:48] But after five or six reps, they started getting a little irritated.
[00:03:51] So I tried medial glides, lateral glides, even anterior glides at the tibia
[00:03:54] because she said that the symptoms were right inferior to the pull of her patella.
[00:04:00] And that eventually just irritated her knees.
[00:04:02] So I thought let's try strength.
[00:04:05] I pulled out the active force to her hip flexion, abduction and extension
[00:04:11] were all significantly stronger than I thought there would be especially abduction.
[00:04:16] I thought that that would be, you know, in the weaker side because most people with knee pain
[00:04:19] tend to have glute-mean weakness.
[00:04:21] But she was really strong and actually even stronger on the right side of the left.
[00:04:26] I'm not sure if it was because of the other PT that she's been going to,
[00:04:29] even though she said that they were not doing any strength training.
[00:04:32] It possibly to all the martial arts that she's been doing
[00:04:35] and the fact that she already had very good balance.
[00:04:38] The other PT was only focusing on balance training.
[00:04:40] I'm not sure why because she does martial arts.
[00:04:45] But anyway, after about 45 minutes of trying various treatments
[00:04:49] and eventually irritating her knees and went back to the lumbar spine
[00:04:52] thinking well she had a little bit of lumbar extension limitation.
[00:04:56] So I had her do some repeated lumbar extension and standing.
[00:04:59] Little pain at end range with some isometrics that improved.
[00:05:04] So I thought I'm going to just try to calm that down a little bit,
[00:05:07] got her in prone, measure her hip extension.
[00:05:09] Hip extension severely limited on the right, moderately limited on the left.
[00:05:12] Potentially that's why she had difficulties going up from a squat position.
[00:05:18] Again, those are the two things that should have clued me in.
[00:05:21] It should have clued me in that I should have went to the spine first.
[00:05:25] So I did some hold relax to the hips mostly on the right,
[00:05:31] a little bit on the left that improved hip extension to FN
[00:05:35] or within normal limits.
[00:05:36] Then some simple PT-A glides and soft tissue work
[00:05:40] to kind of free up the lumbar spine in the middle lower thoracic spine.
[00:05:45] After this her lumbar extension improved quite a bit.
[00:05:47] I thought she was only minimally limited,
[00:05:49] but it turns out that she's one of those people who is very lax
[00:05:52] and used to be able to, she also used to be a gymnast,
[00:05:54] used to be able to do those kind of like gymnast bridges
[00:05:57] where you know your bend of her backward and bring your hands to the floor.
[00:06:02] So after doing several more sets of repeated extension standing
[00:06:08] now her squats coming up were pain free.
[00:06:12] Because remember it wasn't squats going down,
[00:06:14] if it really was more of like the patella femoral syndrome
[00:06:17] or what I call air quotes knee pain.
[00:06:20] If that was an issue,
[00:06:22] you typically see the knee pain with the closed kinetic chain
[00:06:24] on the decent phase not the ascent phase.
[00:06:27] So in this case it's more lumbogenic or at least
[00:06:32] you know lumbar spine and hips have something to do with it
[00:06:34] but more of the fact that she can squat but not come up.
[00:06:38] And repeated lumbar extension was the only really thing I gave her
[00:06:42] other than you know avoiding prolonged sitting
[00:06:45] and doing some hip extension strengthening
[00:06:51] and some you know adding in some deadlifts to her strengthening program.
[00:06:55] So let me know what you think about this.
[00:06:57] I haven't followed up with her,
[00:06:58] but her mom tells me that she is feeling quite a bit better
[00:07:02] and squats and exercise and martial arts are now easier
[00:07:05] and rising from sitting is easier.
[00:07:07] Especially now that she's also limiting her static sitting positions
[00:07:12] or static positions for greater than 20 minutes
[00:07:14] which is something typically I do for most lumbar cases.
[00:07:21] So if you guys find this case interesting
[00:07:24] or if you have any comments or questions
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[00:07:39] and as always you guys have a great day.