60 year old female with PFJ OA
60 year old female executice with Patellofemoral Osteoarthritis
PC. Vague distributed antero-medially located right knee pain. Ache with occasional sharp pain. No giving-way but feels less confident in knee. No locking, aware of some swelling.
Thoughts: This sounds like PFJ but must also remember it could be tibiofemoral, fat pad, hip joint or L spine referral.
Aggravated. Stairs, heels.
24 hour. Very stiff knee on waking. Much better at weekends.
Thoughts. The stiffness on waking tells us there is an inflammatory component here.What is she doing differently at the weekends?-that needs to be established.
Eased. Doesn’t hurt when much on holiday and re-iterates better at weekend.
Thoughts. This indicates there is something around lifestyle. It may be physical, or it be cognitive-affective.
HPC. Insidious onset 10 months ago, and steadily getting worse in terms of intensity of pain.
Thoughts. No trauma so more likely at age 60 to be a degenerative problem.
SH. Works in London and uses escalator steps as her exercise during commute at both ends of the day. Loves to look smart and wear thin, high heels. Commutes in heels.
Thoughts. Although stairs to offer some fitness benefit, in this case because stairs load the PFJ x3-4 the downsides probably outweigh the positives. Furthermore the commute in thin heels that shift the centre of mass forwards towards the PFJ, and create more instability through the limb through being a thin heel challenge the PFJ more. Need to explore alternative footwear and exercise options. This helps to explain the difference between weekday and weekend pain.
On Examination-Main Findings.
Observation. Very small effusion but very large oedematous right fat pad. Poor muscle definition.
Thoughts. Effusion may be causing some quads inhibition and the fat pad swelling may be a cause of pain and also promoting the pro-inflammatory cycle, and possibly encouraging pro-fibrotic, chondrocytic catabolic activity which is highly undesirable.
Muscle Length: Modified Thomas test reveals really tight hip flexors bilaterally.
Thoughts. The tight hip flexor means a greater percentage of the gait cycle will be spend in knee flexion. This has been evidenced to increase the likelihood of bone marrow lesions in the PFJ. BML are a potential source of pain, but are also reversible.
Quads. Poor bulk with VM wasting.
Thoughts. The effusion may be inhibiting the VM. The loss of VM means the fibres are more vertical and hence poorer at medializing the patella. The loss of quads function may be contributing to the loss of confidence in her knee, ie decreased dynamic stability.
Proprioception. Poor control of single stance. Touching down with the other leg and needing a hand hold. No pain, but very unstable. Lots of uncontrolled limb rotation and excess movement around the fat pad.
Thoughts. The poor limb control will increase the patients risk of falling. She is also going to enhance this instability in her high thin heels. The excess limb rotation is causing micro trauma to the fat pad which in turn causes a macro problem.
MRI- Severe degeneration of the PFJ with associated effusion and fat pad oedema. Presence of multiple bone marrow lesions in the PFJ.
Pain due to:
Inflamed fat pad and PFJ with bone marrow lesions.
Long discussion re shoes! Compromised on wedged heels at work and commute in trainers.
Stop doing escalator stairs.
Start doing walks at weekend as long as no significant downhill. Ideally progress her exercise as her knee permits and she wants to.
Hip flexor stretches.
Ice massage to fat pad and fat pad offloading tape taught to patient.
Isometric quads at 20 degrees to avoid aggravating either PFJ or fat pad. Little and often initially to be progressed to alternate days with longer holds.