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Tricky Case - Knee Pain

Discussion in 'General Issues and Discussion Forum' started by St_Roars, Mar 4, 2011.

  1. St_Roars

    St_Roars Welcome New Poster

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    Hi all, this is my first post on the discussion forum.

    I recently had a 62 year old female present to the clinic under the Medicare EPC plan. Her primary concerns were lateral muscle compartment pain & anterior knee pain. Her medical history supplied by her GP included sinusitis, rhinitis, OA/RA - cervical & lumbar spine, depression & anxiety. This lady is quite active as a cleaner, also does gym-work & enjoys lots of walking & keeping active.

    The pain occurs almost all the time in both the front of the knee just behind the knee cap & the lateral muscle compartment, namely the peroneals which are quite tender to palpate.

    In stance & gait, pes planus foot type with rearfoot valgus is observed. There is significant HK build up @ medial 1st MPJ & IPJ. A functional hallux limitus is also present. Joint motions of the feet are mildly restricted & the patient does not appear to have any ongoing symptoms in her feet, other than general fatigue.

    Her current orthotics (about 2-3yrs old, patient wasnt sure) were made by Sidas technology & could be 'flattened' through the MLA area with the pressure of an index finger & provided almost 0% support & correction.

    The biomechanics & structures of the feet & lower legs led me to a diagnosis Patello-femoral syndrome (resulting from pes planus/rearfoot valgus/shock/incorrect patella tracking) & peroneal muscle overuse (resulting from pes planus/RF valgus).

    Due to the patient's active lifestyle, i put her on a self-myofascial rolling program to treat of the pain in her peroneals.

    In an attempt to provide her feet with more support & reduce the overuse of her peroneals, I reinforced the plantar aspect of the MLA area of the orthotic with a dense poron of 10mm thickness then ground it flush with the orthotic. A 3mm medial heel wedge was applied to the heel of the orthotic to bring it to neutral in stance, as the added MLA support was not enough for heel correction.

    The hope was to trial this for a short period of 3 weeks then return for possible new custom orthotics if the modifications were of benefit.

    I said to the patient to trial this for 3 weeks & return for a review, & that if there were any problems to call or return to the clinic.

    Fast forward to the present..... (the patient has NOT returned to the clinic, but has made informal complaints by telephone... it has been 10 weeks since initial appointment)

    My patient now has reduced pain in the lateral muscle compartment but shocking medial condyle knee pain, which has been diagnosed by both a physiotherpist & Orthopaedic Surgeon as Osteoarthritis. The physio & Orthopaed have both condemned the orthotic modifications as the cause of this problem. She stressed (via telephone) that this is not the same pain that the patient originally came in seeking treatment for.

    Im feeling terrible for this, as i had no idea that there was OA in her knees (as her symptoms seemed too anterior & presented as patello-femoral. The GP's initial Care Plan do not indicate OA in the knees either) & this is hardly the outcome i was seeking.... I have heard of a few articles on how raising the medial column of the foot can exacerbate OA symptoms in the medial knee but cant seem to find them, does anyone know of any? Im also open to other suggestions for future treatment... if she ever comes back that is?

    Thanks for your time... St.Roars
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    St Roars

    This is a salient example of treating without a firm diagnosis.

    You mention that the GP care plan mentions both osteoarthritis and rheumatoid arthritis as part of the patients' medical history. This would be sending warning signals to me straight away.

    Unfortunately you have made the mistake of treating based on a preliminary diagnosis which may or may not be accurate. This is where 'biomechanical' assessment alone is insufficient. It would have been prudent to organise at least basic weight bearing imaging of the knee, at least concurrent with a trial therapy.

    Nevertheless, I too have created the same problems for people from time to time by falling into this trap (treating obvious mechanical foot problems that would appear to be negatively influencing knee function).

    When a patient 'goes bad' these are the most challenging situations to deal with professionally. My advice, form experience, is to speak directly to the patient as soon as possible, apologise - but explain your rationale, and attempt to regain their confidence by seeing them as soon as possible and 'taking charge' of the situation. Organise and review the imaging. Seek more advice from the PT and orthopaedic surgeon. Re-evaluate your diagnosis and treatment plan.

    Good luck

  3. Roars:

    I wouldn't lose any sleep over this. I've made medial knee pain worse many times due to exacerbation of medial knee OA with foot orthoses over the past 26 years and 12,000+ pairs of orthoses. Just tell the patient that this sometimes happens, the pain generally goes away very quickly once the orthosis is removed or adjusted and that this pain is actually a good thing so now you know that additional valgus wedging will need to be placed into the orthosis to make their knees more comfortable.

    No foot orthosis could cause medial knee OA in this short of a time, it is just a temporary exacerbation of the pre-existing medial compartment knee OA. No permanent damage has been done to your patient, no matter what the orthopaedist or physiotherapist has told the patient. If the orthopaedist and physiotherapist continue to insist that the orthoses caused the medial knee OA, then ask them to produce one piece of scientific research or even a case report that shows that foot orthoses are the primary cause of medial knee OA. Don't worry, they won't be able to. Varus-wedged foot orthoses often help medial knee pain in post-menopausal females, if the pain is due to medial collateral ligament strain or pes anserinus bursitis. Sometimes, foot orthoses are a trial and error process, especially in individuals with multiple pathologies in their feet and lower extremities.

    If you want to me more proactive with this in the future, you should learn how to palpate the medial knee joint margins for tenderness and osteophytes which may indicate early or advanced medial knee OA (I'm giving a workshop on knee exam at the seminar in Manchester in June). Also, people with more advanced knee OA often can't fully extend their knees to 180 degrees. It's alway good to know knee examination techniques and knee anatomy when you are making lots of orthoses because foot orthoses definitely can affect structures distant to the feet.

    Hope this helps.:drinks
  4. St_Roars

    St_Roars Welcome New Poster

    Thankyou both LL & Kevin for your replies, your insight has been valuable

    The problem at the moment is that the patient just wont come back in.... She was booked for a review appt 4 weeks after her initial consultation (was supposed to be 3 wks but she went on hoilday). After her trip, she called & cancelled her review & after speaking to her by phone & listening to her voice her concerns & trying to explain that the purpose of the review appt is to assess how the treatment has helped or 'troubleshoot' if it has not, she has not returned. I have tried my best to explain to her that i cant help her if she doesnt come in for a review, yet has continued to call & complain to our reception staff almost on a weekly basis, but refuses to come in when they have offered an appt.

    I have decided to write a letter to her Orthopaedic surgeon explaining my rationale for the original diagnosis of patello-femoral syndrome & endevour to have her return to the clinic. It is interesting to note though, when i spoke to this lady on the phone & asked her about the pain in her lateral/peroneal muscle compartment, she said that this pain had reduced since the orthotics were modified. So in effect, i have resolved one issue but exacerbated another

    My concern is that if i were to remodify the orthotics by removing the medial foot support (MLA/medial wedge) & use a small valgus heel wedge & give the MLA a low-arch profile, this will reduce pain in the medial compartment of the knee but cause the pain in the peroneals to return.... A catch-22 really, but I guess I will have to try

    Thanks again ;)
  5. I wouldn't write the letter to the orthopedist...just take a deep breath and let this one pass. If the patient comes back to you...you can fix it. If she doesn't come back.....you can chalk it up as an important lesson learned.
  6. Ian Linane

    Ian Linane Well-Known Member

    Hi St Roars
    I would agree with Kevin on this. Like others on the site I've had my early days share of pts and prescription not succeeding. There is a part of you wants to have another go for all kinds of reasons but the best is to leave it be. Any damage to reputation (if any at all!) is minimal and very short lived. If you move into justification at this point you run the risk of making it something bigger. You've had one unfortunate matter. Set it against a future life time of having learnt and getting right.
  7. Ian Drakard

    Ian Drakard Active Member

    Just echoing Kevin and Ian's advice

    The orthotics may have caused an aggravation of symptoms but would not have caused OA in this time. It is distressing to think of damage to reputation caused by a patient sounding off when they have not attended for the review at which you could have addressed the issues but I wouldn't loose sleep over this one.

    By all means think what you could do to avoid the issues in future (additional verbal discussion, written advice etc) but otherwise just chalk it up to experience.

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