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Hi

An interesting case recently 'unfolded' under my care.
28 year old marathon runner/ cricketer. 6/12 onset of left knee pain. Physio diagnosed patella-femoral syndrome. Much conservative treatment constantly failed.

Saw pt who showed classic signs of a tracking patella with weakness of Vastus lateralis, left knee. Associated mild ITBFS.

Biomechanical evaluation revealed otherwise neautral gait both in walking and running - the 'text-book' patient. There was no LLD, tibial-torsion, pedal pathomechanics, tight AT, incorrect footwear or any other 'usual' culprits in the cause of this knee pain.

Strapping of the patella laterally and support strapping of the ITB and intensive rehab of the vastus lateralis under the guidance of a biokineticist showed slow improvement plus the inclusion of rest.

On the go ahead of the biokineticist, pt tok part in a game of cricket.
He felt good with the strapping and confident of the knee 'holding up', he came in to bowel and as he landed on his left foot, he and the rest of the field heard an audable crack.

Diagnosis: medial-lateral complete fracture of patella. Surgeon mentioned the clean line of the break and suggested the very real possibility of a stress fracture evident on the patella! surgeon also looked for any cartilagionous damage and found nothing.

Does this suggest that all knee pain should be scanned/ x-rayed/ MRI'd?

Any thoughts?

Kind regards

Brandon

 

Branden

My logic tells me that if a pt presents with pain for a period of time as yours did and had no "usual culprits" causing the problem and conservative forms of treatment not working then yes my next step would be to investigate further as you would with all difficult/complicated or intriguing cases to find out the possible DDx.The cogs start turning and you start thinking out of the box when all else fails.

Faye

 

Hi Faye

Thank you for your reply. And you are absolutely right, if all else fails, investigate more. The interesting thing with this patient was that from time of my initial consult with him until the time of his patella fracture was 9 days.
As usual, further investigation always follows failed conservative attempts. The physio was treating him for patella-femoral syndrome without success. My assessment showed weakness of the vastus lateralis muscle and began rehab of this muscle to cease medial tracking of the patella at knee flexion.

I am 'glad' this happened to this pt, as now the primary diagnosis was found (although in a horrible way) and recovery will be complete.

Under these 'unusually normal' circumstances (relating to the absence of pathomechanics), my thoughts are to investigate early in the assessment of the patient and not wait for such an injury to occur.

Thanks again for your input.

Regards

Brandon

 

Hi Branden

Dont be too hard on yourself....This is all part of the learning curve.If we dont experience these difficult cases we will nevr learn and grow and part of learning is retrospecting,investigating and asking questions.

Good luck

Regards

Faye

 

Hi Brandon

As a physio with a lot of experience working with soldiers and having a long term interest in LL biomechanics I found that a high percentage of AKP was attributable to the hypertonicity of the Rec Fem.
Mostly the pathology related to the infra patella teno-osseous junction.Once this was addressed with corrective exercises (aimed at lengthening Rec Fem) ,coupled with the removal of impacting activities the AKP was greatly reduced or abolished within a matter of weeks.

Colin Campbell