Aquatic physiotherapy for patellofemoral pain – a case study from Aqua-Physio.

Aquatic physiotherapy can be an excellent tool in the management of patellofemoral pain. Here is a recent case study where dry land treatment was incorporated with aquatic therapy.

Our case patient (PB) had a previous history of right sided patellofemoral pain and six years’ prior had undergone lateral release surgery to try and correct lateral tilt and maltracking of his patella. He is a keen amateur cyclist, a sport which he maintains to a good level and he had recently completed L’Etape Du Tour a gruelling amateur cycling event replicating one of the Tour De France stages. Not long after completing this event he described an innocuous flick with his foot to move a ball situated on the floor and the onset of his anterior knee pain.

On assessment his patella was excessively mobile laterally with poor vastus medialis obliquus muscle bulk and function, which is a muscle on the inside of the knee that helps to provide support to the patella from laterally tracking. He had weak lateral hip and trunk stabiliser muscles and showed internal rotation of his femur on loaded tasks such as a single leg dip, a classic movement pattern seen with this particular type of problem. An MRI scan had been completed which showed significant degeneration in his lateral patellofemoral joint and fat pad swelling. This was in addition to a shallow trochlea groove which would be reducing the structural stability for the patella and placing further emphasis on his biomechanical faults. Clinically he had a picture of lateral patellofemoral pain and a recent fat pad injection had already been trialled which was unsuccessful in changing his symptoms, indicating more of a patellofemoral joint dysfunction rather than fat pad pain. Expert clinical opinion was also sought through Claire Robertson who clarified the important clinical findings and gave practical solutions of how to proceed with PB’s dry land treatment.

Mechanical overload to the knee is often the key driver to the onset of patellofemoral pain. This may be due to a biomechanical issue which causes overload to the joint, or simply an increase in loading due to external factors such as recent increased sporting activity. As we often find clinically PB showed a combination of both biomechanical issues and a surge in activity levels with his recent cycling event. One benefit of exercising in water for this type of pathology is the ability to load the lower limbs without causing further mechanical overload and to begin working on the biomechanical faults in a relatively pain free environment.

PB used our aquatic therapy pool to exercise his trunk and lateral stabilising muscles using a host of different techniques utilising the properties of water to challenge him in ways he had not expected. It is interesting in this case how someone can cycle over mountains yet have some quite specific leg weaknesses. He was pleasantly surprised that with time in the water he could exercise through full functional knee movement without pain, thus giving an opportunity to correct his dysfunctional technique. Even light cycling had been painful up until this point and PB was becoming increasingly frustrated at his inability to exercise and felt he was losing his hard earned fitness levels. This highlights another great benefit of aquatic therapy for the treatment of anterior knee pain where fear avoidance or increased anxiety regarding exercise has been highlighted as one of the main causes of a poor long term prognosis and can potentially become a secondary pain driver.

Coupled with a progressive dry land exercise regime and some simple patellofemoral self-taping techniques PB has successfully returned to his long distance cycling. He is maintaining his exercises on dry land and is planning another attempt at L’Etape Du Tour this summer.

Here are a few words of his own regarding his treatment in the pool:

“Due to my limitations with respect to my knee injury I was not making much progress. So I decided to explore the avenue of Aqua Physio. I was as astounded on my first session how quickly we realised that my poor movement and poor core muscles was impacting my knee. Just trying to do some basic walking in the pool was challenging and I was constantly off balance. The first obvious advantage was that I could lose balance without injury. Also stability the water gave me, minimised impact to my knee. Over a period of several weeks I started to engage more of my core muscles which offered stability to my knee. I felt that I could I challenge my knee more. However, the greatest win for me was how incredibly quickly the flexibility in my knee improved.”

Written by Philip Morel, Physiotherapist

Aqua-Physio is a state of the art aquatic therapy pool based in Lower Morden, Surrey. Visit their website: http://www.aqua-physio.co.uk