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.

PMH. Nothing.

DH Nil

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.

Overall Impression:

Pain due to:

            Inflamed fat pad and PFJ with bone marrow lesions.

.

Plan:

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.

65 year old male runner with left anteriorly located knee pain.

PC. Deep ache antero-lateral PFJ. Occasional sharp pain. ‘Loss of confidence’ in knee.

Thoughts. The age of this patient increases the likelihood of OA but must not presume this is the source of the pain. Loss of confidence may be from pain, and or instability and instability may be from the joint or from reduced dynamic control.

 

Aggravating Factors:

Pain increases for 2 days after running.

Twisting on a fixed foot to the right can create sharp pain.

Kneeling

Stair descent creates pain during the movement.

Thoughts: Pain lasting this long after running indicates either an inflammatory reaction and/or increase in bone marrow oedema.

Twisting to the right could indicate tibiofemoral pathology or lateral PFJ as the femur medialises.

Kneeling compresses the PFJ but also stresses many other structures eg tibiofemoral jt, fat pad, and streteches quads and patella tendons.

Stair descent increases load on PFJ.

 

Ease.

Rest.

Thoughts: Fits with decrease in either inflammation or bone marrow oedema, (also referred to as bone marrow lesion).

 

24 hour pattern.

Pain at night. No extra stiffness in the am in the knee.

Thoughts: Night pain suggests one/combination of:

            Red Flag, (on questioning, no weight loss or history of Ca. No feeling of malaise).

            Inflammation-but I would expect increased stiffness in joint on waking.

            Bone marrow oedema. This characteristically can increase pain at night.

 

HPC.

Gradual onset over last 3 months. No fall or trauma. He has been doing sprint intervals as part of his running training for variety over the last 6 months.

Thoughts. No trauma makes ligament injury very unlikely. Distance runner and therefore cannot exclude insufficiency fracture. Degenerate meniscal tear unlikely given location of pain. PFJ/lateral tibiofemoral joint OA most likely with this age and history.

Running faster means using greater hip adduction and increases load on the PFJ. It also requires more strength in both the quads and gluts.

 

PMH.

Nil. V healthy. Low but healthy BMI.

SH

Retired. Wife died last year.

Runs 3×10 km per week. Describes his running as, ‘sanity time’.

Thoughts.

Running incredibly important to this patient and contributes significantly to his mental well-being.

 

MRI.

Grade IV lateral PFJ chondral damage with associated bone marrow lesion, (BML) Otherwise healthy.

Thoughts. BML likely source of pain, not the cartilage-remember cartilage is aneural.

 

O/E.

Observation.

Good muscle bulk with symmetry right to left.

Standing with left knee in 10 degrees of flexion. Unable to correct when asked.

Highly visible ITB

No effusion

Thoughts. Good muscle definition fits with running levels, but doesn’t mean there is sufficient phasic activity to cope with sprint intervals. Phasic activity also declines rapidly with age.

Lack of effusion reassuring.

Really need to look at fixed flexion deformity and its cause. PFJ never gets a rest from loading in a knee that won’t go straight. Highly visible ITB suggests high tone/ overactivity in proximal contractile origins. Need to explore further.

 

ROM.

10 to full flexion passively, 0 to full flexion actively. Extension tight.

Thoughts. Not a complete block to extension and therefore should respond to stretching/ mobilizing.

 

Muscle length Assessment.

Modified Thomas test=20 degrees hip flexion.

TFL via ITB tight in 10 degrees hip adduction.

Thoughts: Loss of hip flexion will increase amount of time spent in knee flexion, and correlates with increasing BML, (see Teng et al., 2015).

Tight TFL means in smaller degrees of hip adduction the patella will tilt and or lateralize, (more of a problem with fast running).

 

Gluteal Assessment.

Static Gluteus medius good on plinth but functionally pelvis drops with landing from a hop.

Thoughts: Insufficient phasic capacity to counteract sudden increased force on pelvis. Once again more of an issue running at greater speeds.

 

Single Leg Squat.

Very painful in lateral PFJ, with pseudo giving-way. Complete abolition with medial glide manually performed.

Thoughts: Off loading lateral PFJ with Q brace will help off load BML and allow it to settle. (see Callaghan’s work, 2015). This pseudo gving-way is pain driven and on questioning is the element that has led to a loss of confidence in the knee.

 

Impression.

Source of pain, BML lateral PFJ.

Cause: increased load on lateral PFJ from;

            Intrinsically, tight TFL, tight hip flexors and insufficient gluteal phasic activity.

            Extrinsically, running especially sprint intervals.

 

Plan:

Q brace to be worn all day every day as a treatment for 6 weeks.

Mobilise terminal extension and teach pt how to stretch at home.

Hip flexor stretches.

Once pain settling, start some small hops to work on stable pelvis, for better neuromuscular use of GMed in weight bearing. Progress this to ensure adequate phasic performance in gluteus medius in frontal plane.

Aquarunning for 6 weeks whilst joint is de-loaded to give BML chance to settle. Really important to keep this man active. If aquarunning not available, then cross-trainer wearing Q brace, not on consecutive days.

Long-term exploration of need for sprint intervals. Look at better ways to have variety with lower PFJ stress.

Teach pt to self-tape to off-load lateral PFJ for running.