60-year-old retired female with 6 week history of severe knee pain.

PC

Right sided lateral knee pain. 8 out of 10 at worst.

Knee feels unstable and some ‘giving-way’ associated with sharp pain. Slightly swollen all round. No locking. Tearful. Has just retired and was really looking forwards to active retirement. Fearful she will not have the retirement she had anticipated.

Night pain

Thoughts: Giving way may be due to pain inhibition as pain of 8/10 likely to disrupt dynamic control.

The night pain requires further questioning. Are there any further red flags or could it signify bone oedema which frequently presents as night pain?

Aggravating Factors.

Stair descent virtually impossible

Walking downhill

Getting out of a low chair.

Kneeling impossible due to pain.

Crouching possible due to pain.

Thoughts.

This sounds very much like the PFJ. Pain on stair descent in my experience tends to be more associated with joint surface problems.

HPC

No problems until 6 weeks ago. Retirement present to herself was a trek up Kilimanjaro with her husband. The pain on the descent was so severe she had to do some of the descent backwards. On return to the UK she had a rheumatology opinion. The consultant requested an MRI which showed, (Grade IV degenerate change and associated bone marrow oedema in the lateral facet of the PFJ.). Told nothing much that she could do and that she needed to review her retirement aspirations and accept she was heading towards a knee replacement. The patient is really upset and worried about the label of osteoarthritis she has been given.

Thoughts.

Grade IV degenerate change does not develop in 6 weeks, and in fact the degeneration on MRI probably would have looked identical two months ago. The new feature is likely to be the bone marrow oedema which is associated with pain, especially in the lateral PFJ, and would fit with the night pain. Until 6 weeks ago she was managing perfectly well.

The label of ‘degeneration, and, ’osteoarthritis’ are terribly catastrophic for this lady. The worry and anxiety about the future is as much as a problem to her as the pain itself. It is too premature to suggest gross changes in long term lifestyle and suggest this will end in TKR.

Can we turn this around through education for us to view that we have the ‘heads up’ about the joint and that with smart use and staying strong she can be as she was 8 weeks ago once the oedema has gone?

O/E.

Small effusion. Stiff patella. Lateral tilt.

Thoughts.

The effusion will further inhibit the quads and increase the feeling of instability.

The stiff patella especially tilted laterally will further increase load through the lateral PFJ. This is the very area we need to offload to allow the bone marrow oedema to dissipate.

Quads.

Poor firing of VMO and wasting through the vmo compared to the contralateral side.

Thoughts.

This may not have been an initial driver and may be as a result of the pain and swelling, but nevertheless leaves the joint unprotected and vulnerable in the long term.

Weight bearing assessment.

Right leg tibia externally rotated compared to left.

No single stance assessment possible as too sore but double stance mini-squat had bilateral femoral adduction and internal rotation. Gets out of a chair with this movement pattern too.

Thoughts.

What is externally rotating the tibia as this will increase lateral PFJ contact pressures? Movement patterning with adduction and IR increases lateral PFJ pressure.

Muscle length.

Two things of note are very tight right hip flexors on modified Thomas test, and tightness through ITB complex, (ie ITB and its proximal contractile origins).

Thoughts.

The hip flexor tightness will lead to a loss of hip extension and hence greater knee flexion in terminal stance. This will increase PFJ pressure.

The ITB complex tightness will be causing the tibial external rotation via its tibial attachment.

Plan.

1. Alleviate fear and explain that the bone oedema is reversible, and it is that not the worn cartilage that is the source of the pain. Ask her to view it as too much ‘pressure’ under the knee cap, and we can alter that. She needs to consider using walking poles in the future for hill walking especially the descents, and where possible avoid routes with very long, prolonged descents.
2. Movement re-education. Get her to become super aware of foot-knee-hip in a line for stairs, getting out of chairs and hill descent in particular.
3. Stretches for TFL and hip flexor.
4. Q brace to be worn asap for 6-8 weeks to off load lateral facet.
5. Pain free light quads to be built up avoiding high PFJ stress long term.
6. Little and often light self patella mobs to be taught to patient.