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Case presentation

By: Yashika Gupta


4th year
Demographic data

• NAME-XYZ
• AGE/SEX- 60/MALE
• ADDRESS- SHRESHTH VIHAR
• CONTACT NO. – 981*******
• OCCUPATION – HOMEMAKER
• DOMINANCE- RIGHT
• Date of assessment- 13.12.2018
• CHIEF COMPLAINT- PAIN IN KNEE WHILE STRAIGHTENING AND
BENDING , WALKING AND CLIMBING STAIRS.
PRESENT MEDICAL HISTORY
PATIENT REPORTED OF HAVING PAIN IN BOTH THE KNEES
ESPECIALLY OVER THE MEDIAL JOINT LINE OF THE KNEE
WITH PAIN IN BILATERAL PATELLA WHICH STARTED FOUR
YEARS BACK AND HAS INCREASED SIGNIFICANTLY SINCE
PAST TWO MONTHS . HE CONSULTED THE ORTHOPAEDICIAN
WHO ADVICED HIM FOR PHYSIOTHERAPY.
1. PAIN HISTORY
PAIN ASSESSMENT
MECHANISM OF INJURY – NO MECHANISM OF
INJURY IS FOUND.
ONSET – GRADUAL
DURATION – CHRONIC (4 YEARS)
SITE/ LOCATION – PAIN AT THE MEDIAL ASPECT OF
THE KNEE[BILATERALLY]
• Radiation- No radiation

• TYPE OF PAIN – DULL ACHING PAIN THAT INCREASES WITH MOVEMENT OF THE KNEE

• CHARACTER / NATURE OF PAIN – CONSTANT THAT AGGRAVATES WITH THE MOVEMENT OR


WEIGHT BEARING ON KNEES.

• AGGRAVATING FACTORS - STRAIGHTENING THE BENT KNEE, STAIR CLIMBING WALKING.

• RELIEVING FACTORS – AFTER TAKING REST IN SUPINE LYING POSITION ,NSAIDS.

• DIURNAL VARIATION – MORE STIFFNESS AND PAIN FELT IN THE MORNING THAT SLIGHTLY
REDUCES WITH MOVEMENT AS THE DAY PROGRESSES.

• SEVERITY – LEVEL 7 ( PAIN WITH ACTIVITIES OF DAILY LIVING)

• INTENSITY OF PAIN – MEASURED THROUGH VAS ( VISUAL ANALOGUE SCALE)


• AT ACTIVITY- 8
• AT REST- 3
• Stiffness – Present , More in the morning as compared to throughout the day.

• ANY PARASTHESIA /HEAVINESS- HEAVINESS IN B/L LEGS


• ASSOCIATED PROBLEMS- TYPE2 DIABETES MELLITUS.
• SEASONAL VARIATION- PAIN AND STIFFNESS INCREASES IN WINTERS.
• RADIATION – NOT PRESENT
• PAST MEDICAL HISTORY – PATIENT HAD HISTORY OF PAIN IN BOTH KNEES WHICH
STARTED IN 2015 WAS WAS DIAGNOSED AS OSTEOARTHRITIS OF KNEE.

• Surgical history – NoT RELEVANT

• Personal history – NO HISTORY OF ANY ADVERSE SOCIAL HABITS

• Family history- NONE


• SOCIOECONOMIC STATUS – GOOD

• PHYSIOTHERAPY HISTORY – STARTED TAKING TREATMENT IN 2015, TOOK


ON AND OFF TREATMENT SINCE THEN AND FOLLOWING HOME EXERCISE
PROTOCOL. HE.STARTED TAKING TREATMENT AT AMAR JYOTI IN 2018

• ASSOCIATED PROBLEMS – SUFFERING FROM TYPE 2 DIABETES MELLITUS


FOR WHICH HE IS TAKING MEDICATIONS [ GLYCOMET,ZIGLIM]
OBSERVATION
ATTITUDE OF LIMBS [ SITTING]
HEAD IN MIDLINE
LEFT SHOULDER SLIGHTLY ELEVATED
SHOULDERS ADDUCTED AND EXTENDED
ELBOWS AND WRIST EXTENDED WITH PALMS
SUPPORTED ON THE PLINTH.

BOTH SIDE HIPS AND KNEES FLEXED SUPPORTED


OVER THE EDGE OF THE PLINTH WITH FEET
PLANTERFLEXED.
DEFORMITY – GENU VARUM

OEDEMA- NON PITTING EDEMA PRESENT


OVER MEDIAL JOINT LINE OF BILATERAL
KNEE JOINT LT>RT AND PIITTING EDEMA
PRESRENT IN LOWER LEG ADJACENT TO
MEDIAL MALLEOLUS OF RIGHT LEG

MUSCLE WASTING- NOT PRESENT

TROPICAL CHANGES - NONE

SCAR-NOT PRESENT

EXTERNAL APPLIANCES/ORTHOSIS –
PATIENT USES CANE FOR AMBULATION.
• Posture
• Anterior View

RIGHT HIP EXTERNALLY ROTATED


GENU VARUM [KNEES]
• Lateral view
Decrease in Lumbar lordosis
• POSTERIOR VIEW

HEAD ROTATED SLIGHTLY TO THE LEFT.


LEFT SHOULDER SLIGHTLY ELEVATED
GENU VARUM
GAIT OBSERVATION
WADDLING GAIT
palpation
• WARMTH – NORMAL AT THE SITE OF PAIN.

• OEDEMA –NON PITTING OEDEMA AT MEDIAL JOINT LINE OF BOTH KNEES AND PITTING
EDEMA AT RIGHT LOWER LEG AROUND MEDIAL MALLEOLUS.

• TENDERNESS – GRADE 2 TENDERNESS (MILD TENDERNESS WITH GRIMACE AND FLINCH)


ON THE MEDIAL JOINT LINE OF THE LEFT KNEE. AND GRADE 1 AT MEDIAL JOINT LINE OF
RIGHT KNEE.

• SPASM – NOT PRRESENT

• CREPITUS -NOT PRESENT


On examination
• MOTOR ASSESSMENT

ROM ( RANGE OF MOTION )


RIGHT RANGE OF MOTION
LEFT
END FEEL PROM AROM JOINT /MOVEMENT AROM PROM END FEEL
RIGHT LEFT
SOFT 0-110 deg 0-90 deg Hip flex. 0-90deg 0-110 deg SOFT

FIRM 0-17deg 0-17 deg Hip exten. 0-17 deg 0-17 deg FIRM

FIRM 0-45 deg 0-40deg Hip abduct. 0-40 deg 0-45 deg FIRM

FIRM 0-22 deg 0-20 deg Hip adduc. 0-20 deg 0-20 deg FIRM

FIRM 0-53 deg 0-50 deg Inter.Rot 0-45 deg 0-50 deg FIRM
FIRM 0-30 deg 0-25 deg External rotation 0-27 deg 0-30 deg FIRM

SOFT 0-100 deg 0-90 deg Knee flex. 0-100 deg 0-110 deg SOFT
HARD 130-0 deg 125-0 deg Knee extn 130-0 deg 135-0 deg HARD
FIRM 0-22deg 0-19deg Ankle dorsi. 0-19deg 0-22deg FIRM
FIRM 0-45deg 0-40deg Ankle plant. 0-40deg 0-45deg FIRM
Manual muscle testing(MMT)
JOINT RIGHT LEFT
HIP FLEXION (3+) 3+
HIP EXTENSION 3 3
HIP ABDUCTION (3+) (3+)

INTERNAL ROTATION (4) (4)


EXTERNAL ROTATION (4) (4)
KNEE FLEXION (4) (4)
KNEE EXTENSION (4) (4)
ANKLE DORSIFLEXTION (4) (4)
ANKLE PLANTARFLEXTION (4) (4)
HIP ADDUCTION 3 3
INVERSION 4+ 4+
EVERSION 4+ 4+
HAMSTRING –POSITIVE PRESENT
(90-90 STRAIGHT LEG TEST) MUSCLE LENGTH TESTING
ILIOPSOAS – NO TIGHTNESS PRESENT
(THOMA‘S TEST)
TENSOR FASCIAE LATAE - NO TIGHTNESS PRESENT
TENDOACHILLES TIGHTNESS - PRESENT (OBER‘S TEST)
Joint Play
 PATELLOFEMORAL JOINT-
 MEDIO-LATERAL GLIDE= GRADE 2
 SUPERO-INFERIOR GLIDE = GRADE 1

 TIBIOFEMORAL JOINT-
o ANTERIOR GLIDE- GRADE 2
o POSTERIOR GLIDE –GRADE 2
Girth and Oedema Measurement

• Right Left
14CM ABOVE THE BASE OF PATELLA 49CM 49CM
MEDIAL MALLEOLUS LEVEL 29CM 28CM
14CM BELOW MEDIAL KNEE JOINT LINE 34CM 33CM
LIMB LENGTH
RIGHT LEFT

TRUE LIMB LENGTH


84cm 84cm
APPRENT LIMB LENGTH
89cm 89cm
• Posture - (PL – plumb line)
1.ANTERIOR ASPECT

Head HEAD IN MIDLINE . EYES AND


EARS ARE AT LEVELLED.
Neck/shoulder RIGHT SHOULDER SLIGHTLY
ELEVATED
HIPS/PELVIS ASIS ARE AT LEVEL
KNEES GENU VARUM . MEDIAL
CONDYLE ARE NOT
EQUIDISTANT
ANKLE MEDIAL MALLEOLI ARE NOT
EQUIDISTANT
• Posterior aspect

Head/NECK LEFT SHOULDER SLIGHTLY


ELEVATED
SPINE INFERIOR BORDER OF THE SCAPULA
ARE EQUIDISTANT FROM THE
SPINE.
HIPS/PELVIS BOTH PSIS ARE AT LEVEL . BOTH
HIPS EXTERNALLY ROTATED
KNEES GENU VARUM. RIGHT MEDIAL
FEMORAL CONDYLE IS HIGHER
THAN THE LEFT
ANKLE TOE OUTING OF 4.5 TOES[LEFT]
AND 2.5[RIGHT]
Lateral aspect

HEAD AND NECK PASSES THROUGH THE EARLOBE AND


ACROMION
SPINE DECREASE IN LUMBAR LORDOSIS

HIPS/PELVIS ASIS AND PSIS ARE AT LEVEL [NO TILTING] .


PASSES POSTERIOR THROUGH THE HIP
JOINT AXIS
KNEES PASSES POSTERIOR TO THE KNEE JOINT
AXIS
ANKLE PASSES ANTERIOR TO THE ANKLE JOINT
GAIT ANALYSIS
QUALITATIVE ANALYSIS
STANCE PHASE INTERPRETATION
HEEL STRIKE
SWING PHASE INTERPRETATION
FOOT FLAT
PRE SWING
MIDSTANCE
TERMINAL STANCE MID SWING

HEEL OFF TERMINAL SWING

TOE OFF
QUANTATIVE ANALYSIS
PARAMETERS FINDINGS NORMAL

BASE OF 15 cm 5-10 cm
SUPPORT
STEP LENGTH 24 cm 35-41cm

STRIDE LENGTH 34 cm 70-82 cm

DEGREE OF TOE Right-5 deg 6-7 deg


OUT Left-6 deg
Functional assessment

• Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)


• To assess pain, stiffness, and physical function in patients with hip and / or knee pain and
stiffness.
• The WOMAC consists of 24 items divided into 3 subscales:
• Pain (5 items): during walking, using stairs, in bed, sitting or lying, and standing
• Stiffness (2 items): after first waking and later in the day
• Physical Function (17 items): stair use, rising from sitting, standing, bending, walking, getting
in / out of a car, shopping, putting on / taking off socks, rising from bed, lying in bed, getting
in / out of bath, sitting, getting on / off toilet, heavy household duties, light household duties
• Interpretation of Scores
• Higher scores on the WOMAC indicate worse pain, stiffness, and functional limitations.
SCORING
• TOTAL SCORE = 56
• 56/96 INTO 100= 58% OF FUNCTIONAL LIMITATION
SPECIAL TESTS
CLARK TEST (PATELLAR GRIND)- POSITIVE ZOHLERS TEST- POSITIVE
• LIGAMENTS TESTING IS BEING DONE
TO RULE OUT ANY POSSIBLE INJURY
TO THE LIGAMENTS AS THEY
MAINTAIN THE INTEGREITY OF THE
KNEE JOINT
• VALGUS(MCL) , VARUS (LCL) ,
LACHMAN(ACL) , ANTERIOR[ACL] AND
POSTERIOR DRAWER (PCL) –
NEGATIVE

6.PIRIFORMIS TIGHTNESS -
Present
Differential diagnosis

OSTEOARTHRITIS KNEE
PATELLOFEMORAL SYNDROME
Investigation
Probable diagnosis

OSTEOARTHRITIS OF KNEE COMPLEX [ TIBIOFEMORAL WITH


PATELLOFEMORAL JOINT INVOLVEMENT]
Problem list
- PAIN AND TENDERNESS IN THE B/L KNEE JOINT MORE OVER THE MEDIAL ASPECT.

- SWELLING IN THE KNEE JOINT [ MEDIAL JOINT LINE] AND RIGHT LOWER LEG[ ANKLE NEAR MEDIAL
MALLEOLI]

- DIFFICULTY IN WALKING AND BEARING WEIGHT .

- PAIN IN FLEXING AND EXTENDING THE KNEE JOINT.

- STIFFNESS IN THE B/L KNEE JOINT

- DIFFICULTY IN SITTING ON LOWER SURFACES.

- Tightness in muscles ( PIRIFORMIS , Hamstring and TA)


GOALS

• Short term goals


1. To reduce pain various activities(walking ,asc. Desc. Stairs, BENDING AND
straightening the knee)
2. To reduce the tenderness AND SWELLING on the medial aspect of the
knee AND OVER MEDIAL MALLEOLI
3. Reduction of stiffness IN B/L KNEE JOINT
4. TO INCREASE THE ACTIVE RANGE OF MOTION OF LOWER LIMB
5. TO INCREASE THE MUSCLE STRENGTH OF LOWER LIMB MUSCLES
6. TO REDUCE THE TIGHTNESS IN HAMSTRINGS,TA AND PIRIFORMIS
• Long term goals
1. AlleviatION OF PAIN
2. improvement of functional status.
3. Slow down the prOGRESSION of the disease.
TREATMENT
REDUCE THE DEGREE OF COMPRESSIVE FORCE
Avoid prolonged standing and walking
Posture training
Avoid squatting
Avoid unsupported climbing
Maintain body weight
• To reduce pain –
1. Hot fomentation B/L knees
2. IFT B/L knees (2 pole modulated for 15 min)
3. Ergonomic adaptation
of work or home environment
4. Hydrotherapy
• TO INCREASE FLEXIBILITY OF THE MUSCLES-
STRETCHING
(3 reps with 30sec hold)
- B/L hamstrings, TA AND piriformis

HOLD-RELAX CONTRACRT-RELAX of the tight muscles to relax


them and to inc ROM
 TO REDUCE OEDEMA
I. Ankle toe pumps with leg in elevation
II. Compression bandage (Uses compression garment)
III. Faradism under pressure
IV. Massage
To increase strength
I. Active movements
II. SLR’S in all directions(supine,side,prone)
III. VMO strenghening by:-
• SLR with lateral rotation
• Adductor squeeze
• Terminal extension using bolster
• Isometrics of quads and hams
• EXERCISES FOR GENU VARUM
• Lift one leg, bend it at the knee and then gently pull it down to the chest with
your arms.
• Lie flat on your back. Bend the knees and place a weight between the feet (start
at 10 pounds and then increase the weight and the number of repetitions as you
become stronger). Holding the weight in place by squeezing the legs together,
bend the knees until your heels touch the buttocks, then extend the legs.
• Yoga helps promote overall flexibility and alignment, positions like the forward
bend, Warrior poses and Cow Face are beneficial for bow leg correction. You may
want to use a yoga strap to bind the legs together.
• HOME REGIEME EXERCISES

• SLR’S USING WEIGHT CUFFS


• STATIC AND DYNAMIC QUADS AND HAMS
• GENU VARUM EXERCISES
• USE OF COMPRESSION GARMENT
• (2-3 Times a day , 10 repetitions each, progress with follow up ,
hot fermentation once or twice a day.)