[

CASE REPORT

MARCIE HARRIS-HAYES, PT, DPT, OCSI>?HB;O7$I7>HC7DD"PT, PhD, FAPTA

87H87H7@$DEHJED"PT, PhD, FAPTA=H;J9>;D8$I7BI?9>"PT, PhD4

Diagnosis and Management of a Patient

With Knee Pain Using the Movement
System Impairment Classication System

nee pain is one of the most common musculoskeletal complaints

reported by individuals in physical therapy outpatient
facilities.1,24,43 Based on various reports, the prevalence of knee
pain is between 10% and 50%.2,8,11,12,36,38,51,55 Conservative care
of knee pain is recommended over surgical intervention; however,
there are numerous conservative treatment strategies. Conservative
treatment techniques described in the literature include quadriceps

strengthening,9,10,31 taping or bracing,10,16,41

hamstring stretching,9 hip strengthening,34,53 and use of foot orthotics.17 The
TIJK:O:;I?=D0 Case report.
T879A=HEKD:0 Selecting the most effective
conservative treatment for knee pain continues to
be a challenge. An understanding of the underlying
movement system impairment that is thought to
contribute to the knee pain may assist in determining the most effective treatment. Our case report
describes the treatment and outcomes of a patient
with the proposed movement system impairment
(MSI) diagnosis of tibiofemoral rotation.

T97I;:;I9H?FJ?ED0 The patient was a

50-year-old female with a 3-month history of left
anteromedial knee pain. Her knee pain was aggravated with sitting, standing, and descending stairs.
A standardized clinical examination was performed
and the MSI diagnosis of tibiofemoral rotation was
determined. The patient consistently reported
an increase in pain with activities that produced
abnormal motions or alignments of the lower
extremity in the frontal and transverse planes. The
patient was educated to modify symptom-provoking functional activities by restricting the abnormal
motions and alignments of the lower extremity.
Exercises were prescribed to address impairments
of muscle length, muscle strength, and motor

dilemma for clinicians is that no specic

treatment strategy has been shown to be
most effective.5 One approach that may
control proposed to contribute to the tibiofemoral
rotation. Tape also was applied to the knee in an
attempt to restrict tibiofemoral rotation.

TEKJ9EC;I0 The patient reported a cessation

of pain and an improvement in her functional
activities that occurred with correction of her knee
alignment and movement pattern. Pain intensity
was 2/10 at 1 week. At 10 weeks, pain intensity
was 0/10 and the patient reported no limitations
in sitting, standing, or descending stairs. The
patients score on the activities of daily living scale
increased from 73% at the initial visit to 86% at
10 weeks and 96% at 1 year after therapy was
discontinued.
T:?I9KII?ED0 This case report presented a
patient with knee pain and an MSI diagnosis of
tibiofemoral rotation. Diagnosis-specic treatment
resulted in a cessation of the patients pain and an
improved ability to perform functional activities.
TB;L;BE<;L?:;D9;0 Therapy, level 4.
J Orthop Sports Phys Ther 2008;38(4):203-213.
doi:10.2519/jospt.2008.2584
TA;OMEH:I0 classication, functional
activities, rehabilitation

improve treatment effectiveness is to

identify the movement impairment that
contributes to the pain problem and then
focus treatment strategies on the identied movement impairment.
Movement impairments of the lower
extremity in the transverse and frontal
planes have been proposed to contribute to knee pain29,30,56 and knee injuries.7,14,22,27,39,47-50 Movement impairments
may appear as abnormal alignment and
impaired movement of the lower extremity during the performance of test items
and functional activities. Abnormal alignment, such as knee valgus, knee varus, or
rotation of the tibia relative to the femur
have been shown to be associated with
anterior knee pain14,27 and the progression of osteoarthritis.7,47,48 Salsich and
Perman45 reported that tibiofemoral rotation was the largest predictor of patellofemoral contact area in individuals with
patellofemoral pain. Two independent
investigators compared the tibiofemoral
joint alignment of subjects with anterior
knee pain to controls and found that in
the subjects with anterior knee pain,
the tibia was in greater lateral rotation
relative to the femur.14,27 In a study of cadavers, Lee et al29,30 demonstrated that
rotation between the tibia and femur
resulted in a change in the contact pressures of the patellofemoral joint, which
may contribute to patellofemoral pain
problems.19,40 Recently, investigators have
reported that increased hip medial rota-

Assistant Professor, Program in Physical Therapy, Washington University Medical School, St Louis, MO. 2 Professor, Program in Physical Therapy, Washington University Medical
School, St Louis, MO. 3 Associate Professor, Program in Physical Therapy, Washington University Medical School, St Louis, MO. 4 Associate Professor, Department of Physical
Therapy, Saint Louis University, St Louis, MO. Address all correspondence to Marcie Harris Hayes, 4444 Forest Park Blvd, Box 8502, Program in Physical Therapy, Washington
University School of Medicine, St Louis, MO 63108. E-Mail:harrisma@wustl.edu
journal of orthopaedic & sports physical therapy | volume 38 | number 4 | april 2008 | 203

[
J78B;'
CI?:_W]dei_iWdZ
 :[iYh_fj_ed

CASE REPORT

Movement System Impairment (MSI) Diagnoses Associated With Knee Pain

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Tibiofemoral rotation
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tibiofemoral joint,
transverse or frontal plane

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rotation (WB or NWB)

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;ZkYWj_edWdZceZ_YWj_ede\\kdYj_edWbWYj_l_j_[ij^Wj
contribute to impaired motion between the femur and
tibia
7ZZh[iickiYb[_cXWbWdY[iYedjh_Xkj_d]jeCI?
diagnosis
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Tibiofemoral hypomobility
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with rest
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@e_djYWfikb[WdZb_]Wc[dji

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?cfhel[HEC"ijh[d]j^"WdZYedZ_j_ed_d]m_j^ekj
increasing pain and swelling
<ehfWj_[djim_j^E70YWkj_edW]W_dij[nY[ii_l[ijh[d]j^ening of quadriceps and hamstrings in patients with
knee malalignment or laxity46

Knee extension
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of quadriceps muscle

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infrapatellar tendon

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stairs and tness activities) to improve the contribution of hip extensors and thus reduce requirement on
quadriceps
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improvement of hip extensor performance
=[djb[ijh[jY^_d]e\gkWZh_Y[fi
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Knee hyperextension
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of hamstrings

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or posterior joint line of the
tibiofemoral joint or peripatellar
pain

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walking and standing) to decrease knee hyperextension
7ZZh[iickiYb[_cXWbWdY[iYedjh_Xkj_d]jeCI?"ikY^
as improvement of quadriceps and gluteal muscle
performance

Patellar tracking
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tracking of the patella
in the trochlear groove

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performance
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Stretching to short structures
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Ikf[h_eh]b_Z[h[gk_h[iijh[jY^_d]e\gkWZh_Y[fi
Taping of patella may be indicated16,35

Tibiofemoral accessory
hypermobility
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tibiofemoral joint

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associated with instability

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corner/complex

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D[kheckiYkbWhh[jhW_d_d]15,23

Tissue impairment
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to perform a movement
examination as in cases of
acute trauma or postsurgery

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trauma or surgery

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associated with trauma or surgery

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involved structure
Stage 1: tissue protection to reduce stress to injured
structure
Stage 2: gradual progression of activities to gradually
increase stress to structure without causing new injury
Stage 3: tissue stress progression to prepare tissue for
return to normal activities

Abbreviations: ACL, anterior cruciate ligament; LR, lateral rotation; MR, medial rotation; MSI, movement system impairment; NWB, nonweight bearing;
OA, osteoarthritis; PCL, posterior cruciate ligament; ROM, range of motion; TFL, tensor fascia latae; WB, weight bearing.

tion and hip adduction may inuence the

forces occurring across the knee.20,39,49,50 If
a movement impairment of the lower ex-

tremity is associated with knee pain and

knee injuries, then treatment directed at
correction of the movement impairment

may be useful.
Directing treatment programs toward
the correction of an identied move-

204 | april 2008 | volume 38 | number 4 | journal of orthopaedic & sports physical therapy

ment impairment has previously been

described.21,34,39 In a prospective study,
Hewett et al21 demonstrated that participation in an anterior cruciate ligament (ACL) injury prevention training
program to correct knee valgus resulted
in a reduced incidence of ACL injury in
female soccer players. Pollard et al39 used
a similar treatment program in female
soccer players and demonstrated that,
after training, the movement impairment
of hip medial rotation during a landing
task was reduced. In a case report, Mascal et al34 described successful treatment
directed at correcting the identied lower extremity movement impairment of
2 individuals with patellofemoral pain.
Identifying the movement impairment
of the lower extremity associated with
the individuals pain or injury and directing treatment to correct the movement impairment may result in improved
outcomes.

Purpose
In this report, we report on the examination and treatment of an individual
with knee pain that is consistent with a
proposed movement system impairment
(MSI)44 diagnosis of tibiofemoral rotation. Individuals with this proposed MSI
diagnosis of tibiofemoral rotation would
report knee pain associated with impaired motion and abnormal alignment
of the tibiofemoral joint in the transverse
or frontal plane. Most commonly, the impaired motion manifests as knee valgus,
which is often the result of abnormal hip
motion. The diagnosis is based on identifying a consistent pattern of movement
that is associated with the patients pain
complaint and, when corrected, decreases
or eliminates the pain. Emphasis of treatment is placed on educating the patient
about the movement impairment and
modifying the performance of functional
activities to prevent the impaired pattern
of lower extremity motion during functional activities. In addition, therapeutic
exercise is prescribed to address impairments of muscle performance or exibility presumed to be associated with the

impaired movement. TABLE 1 provides

the proposed MSI diagnoses associated
with knee pain.

CASE DESCRIPTION
Patient History

he patient was a 50-year-old

woman (height, 1.73 m; body mass,
106.6 kg) referred to a Universitybased outpatient physical therapy facility. Informed consent was obtained and
the rights of the patient were protected.
The patient reported having had bilateral knee pain for 3 months. Her pain
began following activities related to
moving into a new home, such as, packing and carrying household items. She
reported a gradual onset of pain and did
not recall a specic injurious event. One
month prior to her initial visit to our facility, she saw an orthopedic physician
who diagnosed the underlying condition
as patellofemoral chondrosis. The physician prescribed Vioxx (25 mg daily)
and advised to use ice packs. According to the radiologists report, radiographs did not reveal any osseous, joint
space, or soft tissue abnormalities in the
tibiofemoral or patellofemoral joints of
either knee.
The rst author performed the initial evaluation and provided treatment
for both lower extremities. To be concise, only the ndings related to the
knee that was most painful will be reported. The patient reported intermittent aching pain located in the medial
and anterior aspects of the left knee. An
11-point numerical rating scale6,13,26,42,52
(0 representing the absence of pain and
10 representing the worst pain imaginable) was used to grade the pain severity
experienced during the previous week.
She reported her average pain intensity
as 5/10 and worst pain intensity as 6/10.
The pain was reported to increase when
she sat with her knee exed for more than
10 minutes and when she stood for more
than 30 minutes. She also reported that
her pain increased when she descended
stairs and participated in water aerobics.

The patient was asked to complete the

activities of daily living scale of the Knee
Outcome Survey (ADLS-KOS).25,32,33 The
ADLS-KOS is a reliable and valid measure of knee pain and function.25 Scores
range from 0 to 100, with 0 representing a complete loss of function and 100
representing no loss of function and no
pain. The patients score was 73% and
she stated that her goals were to (1) have
less knee pain, (2) be able to participate
in water aerobics, and (3) be able to descend stairs without pain.
The patient reported that she had no
prior episodes of knee pain. Her past
medical history included hypertension
and a diagnosis of degenerative disk disease with 2 bulging disks in the lumbar
spine. Previous pain related to the lumbar
spine included low back pain, with radiating pain into her left posterior thigh and
foot. She reported that the low back pain
and radiating pain had resolved after receiving treatment prior to the initial visit
at our facility. Daily doses of medications
included 100 mg of Atenolol for hypertension and 25 mg of Vioxx for knee pain.
For 17 years, the patient was employed
full time as a secretary in a hospital setting. Her primary duties included transcribing communications and other
computer-related activities. The device
she used for transcription required use
of a right foot pedal. Fitness activities in
which she participated included water
aerobics, swimming, and walking. Recreational hobbies included sewing, using a
machine that also required use of a right
foot pedal.

Physical Examination
Tests of Movement and Alignment The

examiner assessed a number of tests of

movement and alignment. Femoral alignment was assessed by observing the posterior vertical creases that are associated
with the insertion of the hamstrings. The
patient stood with the femur in medial
rotation; the medial hamstring insertion
was more prominent than the insertion
of the lateral hamstring. In single-limb
stance, the patient demonstrated exces-

journal of orthopaedic & sports physical therapy | volume 38 | number 4 | april 2008 | 205

CASE REPORT

<?=KH;'$7FWj_[djifh[\[hh[Zi_jj_d]feijkh[m^_b[meha_d]WiWi[Yh[jWho$H_]^j\eejYedjhebij^[f[ZWbje
her transcription device. Note position of her left lower extremity. The examiners nger is pointing to the tibial
tuberosity indicating lateral rotation of the tibia relative to the femur. (B) Correct sitting position to decrease the
amount of tibial lateral rotation of the left lower extremity.

sive femoral medial rotation; this was

determined by observing rotation of the
vertical creases in a clockwise direction.
With bilateral hip and knee exion (partial squat), she demonstrated increased
hip adduction and knee valgus, and reported that her pain increased compared
to standing. The patient was instructed to
perform the partial squat while limiting
hip adduction and knee valgus. She was
able to perform the movement correctly
and without pain. Tibial lateral rotation
was observed and pain was reproduced
when the patient performed active knee
exion in prone. When the lateral rotation was limited by physical assistance
from the examiner, the patient was able
to ex her knee painlessly.
Functional activities including sitting,
stair climbing, walking, and rising from a
seated position to standing were also assessed. Because the patient reported an
increase in pain when she sat for more
than 10 minutes, she was asked to simulate the position in which she sat while
working (<?=KH;'7). The patient demonstrated sitting with her right lower extremity extended to reach the pedal for

her transcription machine. The left knee

was positioned in tibial lateral rotation;
this was determined by visual observation of the tibial tubercle appearing to
be located lateral to the trochlear groove
of the femur and her foot pointing in
the lateral direction. She stated that she
sat in a similar position while she used
her sewing machine. She reported no
increase in her pain when she assumed
the position during the examination.
She reported that her pain increased
after prolonged sitting. The patient was
instructed how to modify her sitting position while at work and while using her
sewing machine by positioning her knee
over her foot and pointing her foot directly forward.
Stair ambulation was assessed using a simulated step up and step down.
The patients knee was in valgus as she
stepped both up and down. She reported
an increase in her knee pain during the
step up and down, compared to standing.
The patient was instructed to perform
the step up and step down while keeping
her knee over her second toe. The patient
was unable to perform the activities cor-

rectly, so the examiner provided manual

assistance. With manual assistance, the
patient was able to step up and step down
with less pain than when she performed
the activities without assistance.
Rising from a seated position and
walking were also assessed. The patient
demonstrated knee valgus when rising
from sitting to standing; however, she
reported no increase in her pain. When
she was walking, she demonstrated excessive femoral medial rotation during
early midstance.
Palpation The patient reported tenderness when the examiner palpated
along both the medial joint line of the
left tibiofemoral joint and the articular
surface of the odd facet of the patella.
Tenderness along the medial and lateral
tibiofemoral joint line is consistent with
the proposed MSI diagnosis of tibiofemoral rotation. Joint line tenderness may
also indicate a possible meniscal tear37;
however, the patient reported no complaints of locking or buckling and tests
for meniscal integrity were negative.37
Joint Flexibility and Muscle Performance Hip exor extensibility was

assessed using methods described by

Kendall et al.28 The patient demonstrated limitation in the length of the
iliopsoas and tensor fascia lata (TFL)
of the left lower extremity. For the measurement, the patient was positioned in
supine with her lumbar spine in neutral.
The patient was asked to hold her right
lower extremity to her chest to maintain
the neutral spine position during the
performance of the test. The examiner
then lowered the patients left lower extremity into extension while stabilizing
the pelvis by applying pressure on the
left anterior superior iliac spine (ASIS).
To test the length of the TFL, the knee
was exed to 90 and the lower extremity was lowered into hip extension while
maintaining the hip in neutral internal
rotation/external rotation and neutral
hip adduction/abduction. As the examiner lowered the limb into hip extension,
the tibia rotated laterally and the patient
reported that her pain was produced.

206 | april 2008 | volume 38 | number 4 | journal of orthopaedic & sports physical therapy

The test was modied and manual assistance was provided to prevent lateral
rotation of the tibia. The patient reported that her pain was abolished with the
manual assistance. The examiner noted
that the nal hip position was approximately 20 of hip exion and concluded
that the TFL length was limited. The
test was then modied to test the iliopsoas. The examiner lowered the patients
left lower extremity into hip extension
with the hip abducted to accommodate
the limited length of the TFL. The examiner noted that the nal hip position
was approximately 10 of hip exion.
The knee then was extended to accommodate the length of the rectus femoris;
however, no additional hip extension
was noted. The examiner concluded that
the iliopsoas was limiting hip extension.
Measurements were not made with a
goniometer.
Ankle dorsiexion range of motion
(ROM) was 0 with the knee extended
and 15 with the knee exed; the ndings
are indicative of a short gastrocnemius.
Hip lateral rotation ROM appeared to
be limited; however, an accurate measurement was not possible because of
motion at the tibiofemoral joint. As has
been shown previously, when hip rotation ROM, is measured with the patient
in prone, the ROM measurement may
be exaggerated if the tibiofemoral joint
is not stabilized.18 Our patient demonstrated motion at the tibiofemoral joint
that could contribute to error in the measurement of hip rotation ROM. A second
tester was not available during the initial
examination and the examiner was unable to stabilize the knee to achieve an
accurate measure of hip rotation ROM.
The patient had full knee extension but
knee exion was limited slightly by soft
tissue approximation.
Muscle performance was assessed using manual muscle testing as described
by Kendall.28 The patient demonstrated
decreased muscle performance of the hip
lateral rotators (3/5) and the iliopsoas
(4/5). The manual muscle test for the posterior bers of the gluteus medius could

J78B;(

Results of the Physical Examination

J[ij?j[c

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e\J_X_e\[cehWbHejWj_ed

FWj_[dji<_dZ_d]i

Alignment

BHe\j_X_W

Positive sign; no pain increase

CHe\\[ckh

Positive sign; no pain increase

CHe\\[ckhijWdY[b_cX

Positive sign; no pain increase

Single-limb stance
Hip exion of uninvolved limb and
stand with weight on involve limb

BHe\j_X_W[n[Zb_cX
Single limb stance
Knee exion of involved limb and
stand with weight on uninvolved limb

Positive sign

Bilateral hip and knee exion

(partial squat)

CHe\\[ckh

Positive sign; pain increase*

Hip exor length test

Shortened length of TFL

Positive sign; pain increase*

BHe\j_X_WWi^_f_i[nj[dZ[Z_d
neutral hip abduction/adduction
WdZ^_fBH%CH

Positive sign; no pain increase

Manual muscle test

Weak posterior gluteus medius

Not tested

Weak hip lateral rotators

Positive sign; no pain increase

Knee exion in prone

BHe\j_X_W

Positive sign; pain increase*

Knee extension in sitting

Shortened length of gastrocnemius

Positive sign; no pain increase

Sitting (specic to work)

CHe\\[ckhehBHe\j_X_W

Positive sign; no pain increase

Stairs

CHe\\[ckhehBHe\j_X_W

Positive sign; pain increase*

=W_j

CHe\\[ckhehBHe\j_X_W

Positive sign; no pain increase

H_i[\heci_jj_d]jeijWdZ_d]

CHe\\[ckhehBHe\j_X_W

Positive sign; no pain increase

Functional activity

Abbreviations: LR, lateral rotation; MR, medial rotation; MSI, movement system impairment;
TFL, tensor fascia lata.
* With correction, the patient reported a decrease in pain.

not be performed due to the limitation

in the length of the hip exors, iliopsoas,
and TFL. Strength of the hamstrings and
quadriceps was considered normal (5/5).
The examination ndings consistent with
the proposed MSI diagnosis of tibiofemoral rotation are summarized in J78B;(.

muscle performance and exibility impairments, presumed to be related to her

movement impairment, included shortness of TFL and gastrocnemius, as well
as poor performance of the hip lateral
rotators (J78B;().

?dj[hl[dj_ed
CI?:_W]dei_i
The ndings from the examination and
the patients report of pain were consistent with the proposed signs and symptoms for the MSI diagnosis of tibiofemoral
rotation. Palpation revealed tenderness
along the joint line. Tibiofemoral rotation was demonstrated across a number
of movement and alignment tests. Pain
consistently increased when tibiofemoral
rotation occurred and decreased when
tibiofemoral rotation was restricted. The

Treatment was provided 4 times over a

2-month period. The treatment program
included a combination of instruction in
(a) correct performance of functional activities, (b) home exercises, and (c) taping. Emphasis of treatment was placed on
training the patient to restrict tibiofemoral rotation during functional activities for 2 reasons. First, we believe that
repeated use of the patients preferred
movement and alignment strategies during functional activities contributed to

journal of orthopaedic & sports physical therapy | volume 38 | number 4 | april 2008 | 207

[
J78B;)

CASE REPORT

Instructions for Functional Activity

Modification Specific to the Proposed MSI
Diagnosis of Tibiofemoral Rotation

7Yj_l_jo

:e

:eDej

Alignment

Keep knees over foot

Allow the knees to roll in

(hip medial rotation)

Sitting

Position knees over the foot

Point foot outwardly

Standing

Keep weight distributed evenly over both feet

Sit to Stand

Slide to the front of the chair

Stand from the back of the chair

Keep knees over foot

Allow the knees to roll in

Ambulation

Squeeze buttock muscles to keep knees over the Allow the knees to roll in
foot. Squeeze the left seat when stepping on the
left foot

Stair ambulation

Squeeze buttock muscles to keep

the knees over the foot

Allow the knees to roll in

Abbreviation: MSI, movement system impairment.

the cumulative stress on the tissues, leading to tissue injury and pain. Second, the
patient reported problems with functional activities. Therefore, addressing functional activities rst may have facilitated
the patients adherence with the rest of
the rehabilitation program.
The exercises that were prescribed
emphasized correcting the specific
alignment and movement impairments
identied in the examination. The lower
extremity muscle length and strength impairments contributing to the tibiofemoral rotation also were addressed with the
prescribed exercises.

L_i_j'
During her initial visit, the patient was
given information about the diagnosis of
tibiofemoral rotation. The patient must
understand what factors might be contributing to her pain so she could recognize and correct faulty movement and
alignment strategies during her daily
activities. Specic instructions also were
provided regarding performance of functional activities (J78B; )). The activities
addressed included those that the patient
had reported as being painful, such as
prolonged sitting and descending stairs.
Walking and rising from a chair did not
evoke pain, but the patient did demonstrate signs of tibiofemoral rotation when

she performed the activities; therefore,

these activities also were addressed. The
patient was instructed in the proper positioning of the lower extremity; specically, she was told to keep her knees over
her foot and to not allow the knee to roll
in. She also was instructed to squeeze
her seat muscles during walking, in an
attempt to activate the hip lateral rotators and abductors, thereby to reduce the
amount of hip medial rotation and hip
adduction. After instruction, the patient
practiced each of the activities with specic modications (J78B;)).
During the initial visit, the patient
was given instructions for 6 exercises to
perform at home: (1) knee extension with
ankle dorsiexion in sitting, (2) hip lateral rotation with abduction in side lying,
(3) knee exion in prone, (4) hip lateral
rotation in prone, (5) hip lateral rotation isometrics with the knees exed in
prone, and (6) weight shifting in standing (7FF;D:?N7).
Knee extension with ankle dorsiexion was prescribed to improve the extensibility of the gastrocnemius muscle and
to decrease the amount of time the knee
was kept in a exed position during periods of prolonged sitting; this exercise was
to be performed with 6 repetitions, 3 to
4 times a day. Active hip lateral rotation
with abduction performed in side lying

and in prone was used to improve muscle

performance of the hip lateral rotators;
this exercise was to be performed with
10 repetitions, once or twice a day. She
was encouraged to increase the number
of repetitions as long as she was able to
perform the exercise properly. Active
knee exion and hip lateral rotation in
prone were prescribed to improve the
extensibility of the TFL and to increase
the recruitment of the tibial medial rotators. The patient was instructed to restrict tibial lateral rotation by pointing
her toes toward the opposite leg during
the performance of these 2 exercises and
to perform 10 repetitions of each exercise
once or twice a day.
In an effort to reduce hip medial rotation during the stance phase of walking,
she was instructed to perform the weightshifting activity frequently throughout
the day. She was instructed to shift her
weight onto the left foot and contract the
hip lateral rotators on the left side when
standing. The patient was told that she
should not experience an increase in pain
either during or after performance of her
exercises. She was told to discontinue
any exercise that produced an increase
in pain until she consulted her therapist.
The patient was given written instructions for proper performance of the exercises and a phone number to call if she
had any questions or concerns.

L_i_j(
During the patients second visit 1 week
after the rst visit, she reported a marked
decrease in pain with an average pain intensity of 2/10 and worst pain intensity
of 3/10 during the course of the week.
She reported that she had stopped taking Vioxx and that the functional activity
instruction were helpful in reducing her
pain. Proper performance of functional
activities, such as walking, was practiced
during the treatment session and the patients performance of the home exercise
program also was observed. Further instruction was provided to ensure proper
ankle dorsiexion during the seated knee
extension exercise. Further instruction

208 | april 2008 | volume 38 | number 4 | journal of orthopaedic & sports physical therapy

also was provided to increase the recruitment of (a) the hip lateral rotators during
the performance of hip lateral rotation
side lying and (b) the gluteals during the
weight shift exercise. Additional cues
were provided to improve the performance of the knee exion in prone and
hip lateral rotation in prone exercises.
The patient was encouraged to continue
with her program as instructed.

L_i_j)
The third visit took place approximately
5 weeks after the initial evaluation. The
patient reported that she had 1 episode of
increased knee pain (7/10) since the last
visit. The episode began the morning after swimming for approximately 20 minutes and the pain persisted for 2 days. She
used ice packs and ibuprofen to control
her pain during this episode. At the time
of her third visit, her pain had returned to
the level she had reported on her second
visit and she was no longer using the ice
or ibuprofen.
She reported that her pain increased
after descending 4 ights of stairs. The
examiner decided to tape the patients
knee in an attempt to increase the control of tibiofemoral rotation during stair
ambulation (<?=KH;(). The taping technique was developed by one of our clinicians but has not been described in the
literature. The tape was applied while
the patient was standing. Cover-Roll was
applied rst to protect the skin. Three
strips of the Leukosport tape were applied diagonally along the limb from the
mid portion of the anterolateral thigh
posteriorly behind the popliteal crease
to the mid portion of the anteromedial
tibia. Three strips of tape also were applied diagonally along the limb from the
mid portion of the anteromedial thigh
posteriorly to the mid portion of the anterolateral tibia. Finally, small strips of
tape were applied from the patella to the
posteromedial aspect of the knee. Prior
to application of the tape, the patient
was asked to perform a step-down from
a 20.3-cm-high step. When she stepped
down, she reported pain of 4/10. When

<?=KH;($(A) Anterior view of taping method to reduce tibiofemoral rotation. (B) Posterior view of taping method
to reduce tibiofemoral rotation.

the patient repeated the step-down task

after the tape had been applied, her pain
was 0/10. The patient was instructed to
wear the tape as long as it was comfortable, but to remove the tape after 3 days
to prevent problems with her skin. The
patient also was given written information regarding precautions of tape and
its removal.

L_i_j*
Ten weeks after her initial visit, the patient reported that she had not experienced any pain during the previous 2
weeks. She had worn the tape for 3 days
before removing it. The relief of pain
experienced when the tape was on persisted after the tape was removed, so that
she was now able to descend 4 ights of
stairs and sit through an entire movie
without pain.
During this visit, the patient demonstrated improved lower extremity alignment and movement, and no pain during
performance of single-limb stance, partial squat, stair ambulation, and rising
from a sitting position. She also demonstrated proper sitting position for work

and sewing. She did not demonstrate improvement with walking; she still demonstrated excessive femoral medial rotation
during stance. Muscle performance and
exibility also were reassessed. The
patient demonstrated a 4+/5 manual
muscle grade for the hip lateral rotators.
There was no pain during the test for TFL
exibility. Flexibility of the TFL appeared
to have improved, as compared to the initial visit; however, goniometric measurements were not taken.
The patient reported performing
some of her activities on a daily basis, because those were easy to perform
throughout her workday. Activities that
she performed daily included knee extension with ankle dorsiexion in sitting,
weight-shifting activity in stance, and
modications of her functional activities. She reported that she performed the
other exercises approximately 30% of
the time. The performance of her home
program was observed. She could perform each exercise independently, except
for hip lateral rotation in the side-lying
position. Because she still had difficulty
recruiting the hip lateral rotators, the

journal of orthopaedic & sports physical therapy | volume 38 | number 4 | april 2008 | 209

[
exercise was modied. The patient was
instructed to perform hip abduction in
prone and to position her femur in slight
lateral rotation. The patient was encouraged to continue with her home program
and to contact her therapist if she had
any questions. The patient required no
further visits.

CASE REPORT
J78B;*

]
Patient Outcomes

 
L_i_j

FW_d
7l[hW][?dj[di_jo 

Mehij?dj[di_jo 

I_jj_d]

IjWdZ_d]

7:BI#AEI

Visit 1, day 1

5/10

6/10

10 min

30 min

73%

Visit 2, day 7

2/10

3/10

20 min

30 min

76%

Visit 3, week 5

2/10

7/10

Not limited

Not limited

F^ed[<ebbem#kf

Visit 4, week 10

0/10

0/10

Not limited

Not limited

86%

One year after discharge, the patient was

contacted by telephone and a questionnaire designed to assess long-term outcomes was mailed to her.

Mailing and phone follow-up, 1 y

0/10

0/10

Not limited

Not limited

96%

EKJ9EC;I

he patient was seen 4 times over

the span of 2 months. Overall, the
patient reported a cessation of pain
and an improvement in her functional
activities (J78B;*). Her average pain intensity rating was 5/10 at initial visit,
2/10 at 1 week, 2/10 at 5 weeks, 0/10 at
10 weeks, and 0/10 at 1 year. At 10 weeks
and at 1 year the patient reported no difculty with sitting, standing, ascending/
descending stairs, or participating in
water aerobics. The patient also demonstrated an increase in the scores of the
ADLS-KOS, compared to scores at the
initial visit.25,33 She had a score of 73% at
the time of her initial visit, 86% at the
time of her nal visit, and 96% at 1 year
after her initial visit.

:?I9KII?ED

e have reported on the examination, diagnosis, and treatment

of an individual with anteromedial knee pain. A standardized examination, including tests of alignment and
movement, was performed and a MSI
diagnosis was assigned. The signs and
the subjects report of pain were consistent with the proposed MSI diagnosis of
tibiofemoral rotation. Emphasis of treatment was placed on having the patient
correct the identied movement and
alignment impairments while performing her daily activities. Exercises also

Abbreviation: ADLS-KOS, activities of daily living scale of the Knee Outcomes Survey.
* Pain intensity based on an 11-point verbal numerical rating scale.6,52,52 Zero represents the absence of
pain and 10 represents worst pain imaginable.6

Represents the length of time patient can sit without an increase in her pain.

Represents the length of time patient can stand without an increase in her pain.

Patient reported a lower score for the squat and kneeling than she did in the previous administration
of the scale. She stated that she did not know if it would hurt and she did not want to try.

were prescribed to address muscle performance and exibility impairments that

are presumed to contribute to tibiofemoral rotation. Movement impairment-specic treatment resulted in improvements
on a number of outcome variables, including a decrease in pain and improvement in functional activities.
Although the patient improved with
the treatment prescribed, we acknowledge that another approach may have
achieved similar outcomes. Strong evidence to support the existence of a causal
relationship cannot be established from
a case report. Other treatments that have
been shown to decrease symptoms in patients with knee pain include quadriceps
strengthening, 9,10,31 hamstring stretching,9 and use of foot orthotics.17 The use of
quadriceps strengthening is based on the
theory that the pain is a result of either
patellar malalignment or poor patellar
tracking. Upon examination, the patient
did not demonstrate any signs of patellar
malalignment or poor patellar tracking.
Therefore, quadriceps strengthening was
not prescribed. In addition, the patient
did not have short hamstrings; therefore,
hamstring stretching was not prescribed.
The patient did not demonstrate excessive pronation during stance or gait assessment, therefore, foot orthotics were
not prescribed.
Other factors may have contributed to

the patients outcomes. The effect of time

on symptom resolution must be considered. Based on the time needed to achieve
tissue healing, resolution of pain would
be expected to occur within 4 to 6 weeks.
The patient reported no noticeable decrease in her pain during the 3 months
prior to her initial visit. She reported a
decrease in the average intensity of her
pain from 5/10 to 2/10 within the rst
week of physical therapy. So, it is unlikely
that her symptom relief was due to time
alone. The concurrent use of medications
and ice may have provided the patient
with relief of pain. She reported having
used both Vioxx and ice during the month
prior to her rst visit and having experienced minimal relief. She discontinued
the use of Vioxx before her second visit to
physical therapy when she noticed a signicant decrease in her pain. Therefore,
it is unlikely that the resolution of pain
was due to the anti-inammatory effects
of either the medication or the ice.
Because the patient had not experienced complete resolution of her pain
with 5 weeks of treatment, the examiner
decided to use a taping technique that has
been developed in her clinic. The tape was
applied in an attempt to limit the amount
of rotation occurring at the tibiofemoral
joint. The patient reported that she experienced no pain when descending stairs
while the tape was in place. Anderson

210 | april 2008 | volume 38 | number 4 | journal of orthopaedic & sports physical therapy

et al3 performed a study on the knees of

cadavers in which a similar taping technique was used. They demonstrated that
taping can signicantly reduce rotation
of the tibiofemoral joint.3 Although the
intent of the taping was to minimize rotation at the tibiofemoral joint, it is possible that other mechanisms resulted in
the decrease in pain. The technique used
by the author included strips of tape applied to the patella in the medial direction as described by McConnell35; these
strips of tape were provided to prevent
excessive pull of the iliotibial band on the
patella. It is possible that the patellar taping may have provided the relief without
the strips of tape applied diagonally. We
plan to study the effectiveness of this taping method in future trials.
The patient demonstrated improvement in the strength of the hip lateral
rotators and slight improvement in the
extensibility of the TFL. A greater increase in muscle extensibility might be
expected given the length of time the
patient was seen; however, the patient
had a low level of adherence to her home
exercise program. Upon each return visit,
the patient required additional instruction for proper performance of each of
the exercises assigned the previous session. Low exercise adherence may have
limited the amount of improvement with
strength of the hip lateral rotators.
The patient did report that she consistently modied her functional activities,
particularly sitting alignment. She also
demonstrated improved performance
during the reassessment at her follow-up
visits. The fact that her pain decreased
within the rst week, despite poor performance of the exercises, suggests that
addressing the performance of the patients functional activities may have
been helpful in reducing the patients
pain complaints. By simply changing her
sitting position at work and modifying
other functional activities, she was able to
reduce her pain from an average intensity
of 5/10 to 2/10. We believe that addressing functional activities is important for
all patients; however, it may be particu-

larly helpful for patients that have difculty performing an exercise program.
Regarding the patient in this case, we
hypothesize that improved performance
of exercises may have resulted in a faster
resolution of pain.
A limitation of this case report is the
lack of specic criteria to indicate the
patients poor performance on the movement and alignment tests used in the
examination. Clinical measures to determine rotation between the tibia and
femur are challenging. Quantication
of tibiofemoral joint motion is difficult,
particularly when the patient is performing a motion such as walking. Despite
these limitations, observational movement analysis is a key component of the
physical therapy examination. We have
established methods to standardize the
test items; however, the reliability and
validity of the methods have not been
tested. We hope to develop future studies
to address this deciency.
We believe the association of the patients pain behavior with the identied
movement impairment is important to
making the diagnosis. If the patient has
an increase in pain and appears to demonstrate increased tibiofemoral rotation,
the examiner performs a secondary test.
The secondary test involves performing
the same test item with correction of the
observed tibiofemoral rotation movement impairment and then reassessing
the patients pain behavior. If the pain
improves with the corrected movement
compared to the impaired movement, the
examiner is more condent the impaired
movement may be contributing to the
pain problem. The method of performing secondary tests has been reported
previously.54

9ED9BKI?ED

n this report, we describe the

evaluation and treatment of a patient
with anteromedial knee pain. The patients examination ndings and report
of pain were consistent with those proposed to constitute the MSI diagnosis of

tibiofemoral rotation. Treatment was described which emphasized the modication of alignment and movements of the
knee to limit tibiofemoral rotation during
performance of functional activities. The
patient also was instructed in an exercise
program to address muscle and motor
control impairments that were proposed
to contribute to the MSI diagnosis of
tibiofemoral rotation. The patient had reduced pain from 5/10 to 0/10 in 10 weeks
with no return of pain at 1 year. She also
had improvement of function represented by an improved ADLS-KOS from
73% at the initial visit, 86% at 10 weeks,
and to 96% at 1 year after end of therapy.
Further research to assess the effectiveness of treatment programs proposed to
improve specic movement impairments
of the knee is indicated. T
ACKNOWLEDGEMENTS: We would like to ac-

knowledge Jennifer Smith, PT, DPT for her

assistance in manuscript preparation.

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*-$ Sharma L, Lou C, Cahue S, Dunlop DD. The
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osteoarthritis: the mediating role of malalignment. Arthritis Rheum. 2000;43:568-575.
http://dx.doi.org/10.1002/1529&')'(&&&&)*)0)2+,.007?:#7DH')4)$&$9E1(#;
*.$I^WhcWB"Ied]@"<[bied:J"9W^k[I"I^Wc_yeh E, Dunlop DD. The role of knee alignment in
disease progression and functional decline in
knee osteoarthritis. JAMA. 2001;286:188-195.
*/$ Sigward SM, Powers CM. The inuence of gender on knee kinematics, kinetics and muscle
activation patterns during side-step cutting. Clin
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dx.doi.org/10.1016/j.clinbiomech.2005.08.001
+&$ Sigward SM, Powers CM. Loading characteristics of females exhibiting excessive valgus
moments during cutting. Clin Biomech (Bristol, Avon). 2007;22:827-833. http://dx.doi.
org/10.1016/j.clinbiomech.2007.04.003
+'$ Sobti A, Cooper C, Inskip H, Searle S, Coggon
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1997;32:76-83. http://dx.doi.org/10.1002/
(SICI)1097-0274(199707)32:1<76::AID7@?C/4)$&$9E1(#F

[
+($Ijhed]@"7i^jedH"9^Wdj:$FW_d_dj[di_joc[Wsurement in chronic low back pain. Clin J Pain.
1991;7:209-218.
+)$Job[hJ<"D_Y^ebWiI@"CkbbWd[oC@"CY>k]^
MP. The role of hip muscle function in the treatment of patellofemoral pain syndrome. Am J
Sports Med. 2006;34:630-636. http://dx.doi.
org/10.1177/0363546505281808
+*$LWd:_bb[dBH"IW^hcWddI7"Dehjed8@"
Caldwell CA, McDonnell MK, Bloom N. The effect

CASE REPORT

of modifying patient-preferred spinal movement

and alignment during symptom testing in patients with low back pain: a preliminary report.
Arch Phys Med Rehabil. 2003;84:313-322.
http://dx.doi.org/10.1053/apmr.2003.50010
++$M[XXH"8hWccW^J"BkdjC"Khm_dC"7bb_ied
T, Symmons D. Opportunities for prevention of
clinically signicant knee pain: results from a
population-based cross sectional survey. J Public Health (Oxf). 2004;26:277-284. http://dx.doi.

org/10.1093/pubmed/fdh162
+,$M_dibem@"OeZ[h;$FWj[bbe\[cehWbfW_d_d
female ballet dancers: correlation with iliotibial
band tightness and tibial external rotation. J
Orthop Sports Phys Ther. 1995;22:18-21.

CEH;?D<EHC7J?ED
WWW.JOSPT.ORG

7FF;D:?N

;N;H9?I;I<EHJ>;?D?J?7B>EC;FHE=H7C7D:FHE=H;II?ED
(Italics denote patient-specic cues given at time of treatment.)
L?I?J'
1. Knee extension with ankle dorsiexion in sitting
Do not allow the thigh to roll in

4. Hip lateral rotation in prone

Point toes to the inside (toward opposite leg)

6. Weight shifting in standing

(no picture available)
In standing shift your weight to the left foot
and squeeze the left seat muscle
Do not let your knee roll in
L?I?J(7D:)
Fh[l_eki[n[hY_i[ih[l_[m[Z
Ded[m[n[hY_i[iWZZ[Z
L?I?J*
Fh[l_eki[n[hY_i[ih[l_[m[Z
;n[hY_i[(0^_fbWj[hWbhejWj_edWdZWXZkYj_ed
in side lying change to hip abduction in prone

2. Hip lateral rotation with abduction in side lying

Squeeze seat muscles and gently roll knee
towards the ceiling

7. Hip abduction in prone

Roll the left thigh out slightly
5. Hip lateral rotation isometrics with knees
exed in prone
Squeeze seat muscles as you gently push your
feet together.

3. Knee exion in prone

Point toes to the inside (toward opposite leg)

H[fh_dj[Z\hecIW^hcWddI7$44 Diagnosis and

Treatment of Movement System Impairment
Syndromes, pages 424-440, copyright 2001, with
permission from Elsevier.

journal of orthopaedic & sports physical therapy | volume 38 | number 4 | april 2008 | 213