Case of the Week 3-5-12: The Wobbly Knee

I recently evaluated a female in the clinic for knee pain and instability s/p a biopsy to her VMO area on the left.

History: Pt is a 24 yo female previously seen for HA and TMD with good outcome. She returned with complaints of left anterior and medial knee pain 8 months after having a biopsy of around her left VMO.  She later noticed knee pain and instability within 3-4 weeks after and complained to her doctor of a "bump" in the area that was biopsied. Functionally, she was limited in stairs and walking. She was told to live with it and she asked for a referral to see me. There was also significant discoloration around the area.

Objective:

• hip IR  
• Left mod loss/hard 
• Right WNL/firm
• hip ER WNL bilaterally
• hip ext 
• Left 0/hard
• Right WNL/firm
• Hip abduction 
• Left 3/5
• Right 5/5
• Hip ext
• Left 3/5
• Right 5/5
• Myofascia: mod restrictions in L ITB, with mod tenderness, L VMO mod restrictions in lengthening and transverse play, mod tenderness - restriction about the size 1.5" in diameter, oval in shape
• single leg stepdown shows mod medial knee tracking with instability medially, laterally, and anteriorly/posteriorly

Assessment: Signs and Sx consistent with PFS with accompanying muscle imbalance of the left thigh. This is causing medial knee tracking, inhibition of the gluteals, and resultant soft tissue dysfunction of the ITB and VMO s/p biopsy.

Treatment: Day 1-2 was IASTM to the VMO and ITB, which was moderately painful, despite being used to IASTM from her previous upper quarter treatments. Afterward, hip mobility improved in IR and extension, SL stepdown still moderately tracked medially.

Day 3-4: Walking and ascending stairs no longer painful, descending stairs still painful, but improved. Continued IASTM, added left hip distraction and MWM. The VMO restrictions and ITB were much less tender. The size of the VMO restrictions was reduced at least 50%, ITB still mod restricted.

Added corrective exercise single leg stepdown, which showed trendelenburg drop of the right hip immediately during stepdown. Also instructed on single leg stance anti-rotational exercise with arm press for dynamic stability and core work with a theraband. This was more difficult on the involved side and no problem on the uninvolved side. 

Day 5: No pain in any ADLs, but still had moderate difficulty with stepdowns. Verbal and tactile cuing was needed to prevent Trendelenburg drop, but she was able to do it with concentraction and having her hands on her hips, watching her elbow level. Anti-rotational exercise in SLS is no longer difficult, progressed to anti-rotation with a theraband with step ups. Min restrictions in ITB, tissue WNL for VMO. Gluteus medius and maximus now test 5/5.

While I have not seen her yet for her 6th visit, which is later this week, I have no doubt she will be pain free in all ADLs. She may have some continued difficulty in SL stepdown, however, this will come with time and training. As she is not a high level athlete, she is completely pain free now in ADLs and will be ready for discharge at next visit.

Edit: Came in today for 6th, visit, SL stepdown on the left has minimal to no valgus in the left knee. Also, the discoloration/hyper-pigmentation area is significantly lighter after the IASTM, previously this was unchanging. Discharged until she has a surgery on her left wrist in 6-8 weeks.

Discussion: Biopsy around the VMO area caused scar tissue and eventual inhibition of this muscle long enough to cause instabilty. The common muscle imbalance of restricted ITB and hip joint in a capsular pattern. So, the familar presentation with a different, slightly traumatic onset.