Qualitative Assessment of Single Leg Loading-as discussed at BOA
13 year old county netballer with Patellofemoral Pain
PC. Vague distributed anteriorly located left knee pain. Ache with occasional sharp pain. No giving-way but feels a sense of ‘slipping’. No locking, no swelling.
Thoughts: This sounds like PFP but must also remember it could be patella tendon, fat pad, Sinding-Larsen-Johansson(SLJ) and/or Osgood-Schlatters.
Aggravated. Landing from a jump in netball. Stair descent after netball for the rest of the day but not into the next day. Kneeling fine.
24 hour. No pain/stiffness on waking. Fine until pays netball. Pain on stairs for 1-2 hours post netball.
Thoughts. The fact that the pain does not extend into the next day suggests very little inflammation. No stiffness on waking makes it less likely to be tendon, and also that kneeling is fine makes it less likely to be fat pad, (SLJ) or Osgood-Schlatters.
Eased. Doesn’t hurt when on holiday ad not playing netball.
Thoughts. This indicates there is something around the netball. Need To explore volume of load more.
HPC. Insidious onset 9 months ago, and steadily getting worse in terms of intensity of pain. On questioning, she has grown 10 cm in the last 18 months, and also got into the county netball squad 9 months ago which added in x2 more training sessions a week. She has not had any treatment so far but has had an MRI.
Thoughts. Growth of this volume will alter the relative length of soft tissues, alter proprioception, and the trochlea shape can alter in this final growth spurt.
Need to ask about total training across a week.
MRI. Normal chondral surfaces but shallow inclination of lateral side of trochlea. Normal patella tendon length and tibial tuberosity position, (TTTG). Tendon, fat pad, and growth plates all normal.
Thoughts. Great news re growth plates/ joint surfaces, tendon and fat pad. The shallow slope subtly compromises the lateral stability of the PFJ However, the TTTG and tendon length being normal suggest that it should be possible to have a stable PFJ.
SH On a sports scholarship to her school. Anxious re ability to keep playing as feels her scholarship is at risk. Plays Centre for school team and WA for county. X2 training and x1 match per week for school, x2 training and x1 match per week for county. Also enjoys running so runs for a cross-country club at weekend.
Thoughts. Accumulatively this is a lot! X6 netball plus her cross country means no days off. Her position for the school involves more movement than her position for the county. Cross country aerobic so not particularly giving her very useful fitness for her netball. The scholarship is heightening her anxiety about the situation which may be altering pain processing.
On Examination-Main Findings.
Observation. No effusion, no fat pad oedema. Good muscle definition. Very prominent ITB’s bilaterally. Medialising femurs.
Thoughts. Is this an anteverted femoral neck, lengthened hip external rotators, lazy posture, or the foot driving the limb into medial collapse?
Craig’s Test. Neutral hip, i.e. not anteverted.
Gluts Assessment. Good static resisted hip abduction and external rotation at 20 and 90 degrees of hip flexion.
Hop test. Poor landing technique. Dropping into adduction and medial rotation, with inadequate hip and knee flexion. Able to correct with instruction.
Thoughts. Proximally her femoral neck appears in a good position and her strength appears good. However, she is not using this strength and is dropping into a large valgus moment, which overloads the lateral PFJ. This combined with her poor lateral trcochlea means two risk factors are coming together.
Muscle Length. All normal except 1.TFL/ Gmax, which are very tight. No passive adduction available on modified Thomas test. N2. Soleus tight so in knee flexion there is little dorsiflexion.
Thoughts. This may be due to the growth spurt. The TFL/GMax tightness is pulling on the ITB which given the poor lateral trochlea will lateralize the patella. The tight soleus encourages excessive pronation on landing and encourages whole limb medial collapse.
PFP due to:
Growth revealing poor lateral trcochlea shape.
Growth and? habit leading to poor landing technique.
Sluggish control of femoral adduction and medial rotation.
Proximal tightness leading to lateralizing of patella via ITB.
Tight calf encouraging excessive pronation.
TRAINING LOAD EXCESSIVE.
Temporarily stop cross country to have a day off per week.
Liaise with school about her changing to WA temporarily.
Soleus, TFL and GMax stretches to be performed x3 a week, x3 sets of 30 secs.
Proprioceptive training with bias on landing technique.
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Felipe Hardt 29-11-2016
Great discussion! Diferential diagnosis! I'll read all your cases, congrats!!! Do you have a Reference that teach you to open your thoughts, or just your clinical practice? Regards! Felipe Hardt,M D
Hi Felipe, I'm very pleased you like these case studies. Critical thinking is a big part of this and reflecting on practice. Have a look at this blog on reflective practice in my PFP practice which is referenced: rel="nofollow">
Thank you. It is a mixture of metacognition, ie understanding how you think, and as part of that understanding the difference between inductive and hypothetico-deductive thinking. Reflection is key and I use that a lot. You might enjoy my blog on reflection which has lots of references in it. Here is the link: http://clairepatella.com/a-behind-the-scenes-look-at-reflective-practice-in-my-patellofemoral-pain-practice-an-open-and-honest-account/
Ali Kennett 26-10-2017
Hi Claire, Fantastic blog and case studies as always. I find it very useful to see your thought process written out in full. I always learn something on every one! Many thanks, Ali
Hi Ali Thats so great to hear! I'll keeping doing more then! BW Claire