Case of the Week 8-27-14: Marathoner with Lateral Knee Pain

A former patient and former student now DPT referred a friend who has been training for a marathon with lateral knee pain recently. We are three sessions in and the knee pain is all but gone.

The eval was as follows:

Subjective: Pt reports starting running April 2013, had 4-5 times of lateral L knee pain “hot” last only 30 sec to 2 min then go away during the run. Within the last two weeks getting worse, lasts for longer periods of time. Able to run 17 miles on Saturday no pain. Worse this past Monday, ran two miles. Currently rates intermittent L knee pain as 8/10 – unable to continue.

Saturday worse older running shoes, 150-200 miles, normally replaces 250-300.

Monday wore new pair of the same shoes – 4 miles current

Objective:

SFMA

Cervical, Shoulder, MSR all FN

MSF, FN

MSE DN

MSE LE bias Left DN, min Right DN mod

MSR Left DN Right FN

hip IR Left DN Right FN

hip ext Left DN Right FN

SLS Left FN Right FN

Eyes closed Left DN Right DN

SLSquat Left FN Right FN

ODS FN

tibial IR Left FN Right FN

ankle df Left FN Right FN

Runs upright, L LE adducts during swing

Repeated motions screen negative for unilateral SGIS loss to the left, loss of extension.

Things that stood out about this case that fooled me in the first two visits:

he could go 18 miles without knee pain, and then two days later have lateral knee pain within a short run 4 miles

to me, this indicates this is not a running injury - as in it's not overloaded muscle, tendinosis, as pain is intermittent, comes and goes during a run

remarkably symmetrical SFMA, I was expecting ankle df loss, tibial IR loss
expected loss of hip IR/extension on the involved side
SL squat and hop were also very symmetrical and stable

The first treatment

education on increasing cadence and slight lean forward at the ankles to accommodate for current loss of hip extension, symmetrical arm swing during running
IASTM to left QL, lateral and posterior thigh patterns, lumbar paraspinals
instruction on self hip IR mobilizations with EDGE Mobility Band
education on de-stressing and rest

last 18 mile run woke up on a Saturday refreshed
last 4 mile painful run ran after a sedentary sitting job - nervous system not primed to move

gave dynamic warmup

Follow up 2 (2 weeks later)

reports two days after last visit ran 18 miles, first ¼ mile 4/10, then no pain until 8 miles. Then from 8-11 miles, 5/10 pain, constant. Then lingering pain til 13, then no pain the last 5 miles. Felt great after, recovered better than ever
gait analysis in slow motion revealed loss of pronation on the left
did some PRI testing, positive for left AIC, gave 90-90 with emphasis on left hamstring and adductor
after 4 reps was pronating better in both walking and running
other treatment as above, hip mobility improved, but still DN

Follow up 3 (2 weeks later)

hip motion all FN
reports knee pain "all but gone" only hurt for first 4 steps then gone for 18 miles, last 2 miles states "broke down" and had R hamstring pain then all muscles in both LEs were very sore
I told him that sounded like a hydration issue, he reported always carrying enough water
however - the night before drove 10 hours and also had several beers the day before last - possible mild dehydration?
I just finished the Shoe Fit Course, and measured his feet, left foot was 11, right foot 11.5, patient already realized and wore 12.5 bilaterally, toe break and shoe stability appropriate
this is where the case turns amateur hour

during The Gait Guys course, they mentioned having a loss of ankle dorsiflexion and "The PT has your patient doing calf stretching" - missing great toe extension/first ray mobility
I scoffed thinking - "Pfffff, I wouldn't miss that!"
however, his overall symmetry, good ODS, SL stance, squat, hop, ankle df, and tibial IR made me miss his left great toe having 50% loss of dorsiflexion - D'OH!
of course that would make him supinate, have a loss of plantarflexion, and possibly contribute to lateral knee pain

Treatment Follow up 3

IASTM to dorsum and plantar aspects of first ray, arch
reset of repeated toe flexion, instruction for HEP
great toe extension near FN by the end of the visit, patient pronating better than ever

He is following up now via email, but overall feels great making sure to stay hydrated and having enough electrolytes etc. There will be one more "tune-up" visit prior to his marathon at the end of September.

Keeping it Eclectic....