Telehealth Cases Study - Running Injury

Subjective:

  • 44-year-old woman
  • Longstanding history of knee pain
  • Increased running load during COVID-19 lockdown, reports gaining 6kg of body weight in this time
  • Notable incident of pain 12 months ago, reported sudden onset of pain running up a hill, felt pain in left quadricep and had difficulty extending knee
  • Had an MRI scan, was diagnosed with left moderate chondromalacia patellae with notable chondral defects, subarticular cystic formation and prominent underlying marrow oedema. There was also a moderate knee joint effusion and Baker’s cyst measuring 6.6cm.
  • The patient was told by a surgeon to “never run again”
  • The patient’s pain is aggravated by running on undulating surfaces/hills, and extending the knee from a flexed position

ANSWERS:

  • What does she do for work? Works in an office
  • Does she have night pain? Only if she has done something to aggravate her pain. She otherwise sleeps well
  • Has she tried anything that has effectively reduced her pain? Ibuprofen and ice have been effective in providing short term pain relief
  • What are her goals? To be able to run 10km without pain 

Objective Assessment: 

  • Observation: no obvious swelling or skin discolouration
  • Generally strong with muscle testing
  • Mild weakness and pain with chair side planks (Copenhagen)
  • Pain and weakness with a weighted single leg heel raise
  • Lacking power when hopping on left leg
  • Running assessment:
    • Anterior pelvic tilt greater on the left versus the right, and landing further in front of centre of mass on the left leg compared to the right
    • Lands in a forefoot stance, lands with a good degree of knee flexion on impact.
    • Good hip extension observes in terminal swing
    • Mild pelvic drop noted when landing on left leg

ANSWER:

Functional strength assessment: single leg bridge – right = 18, left = 12; single leg sit to stand – right = 12, left = 6; single leg heel raise with weight – right = 10, left = 1 (test ceased due to pain) 

Passive knee range of motion: right = 0-135 degrees, left = 0-130 degrees

Self palpation: tender on medial of aspect of knee inferior to the joint line, patient reports feeling some swelling in the area when compared to the right knee

ANSWER:

  • Provide education on adaption to loading, sensible load progressions, acceptable and not acceptable pain
  • Reassurance and encouragement that running is possible and is actually good for the body and the knee joint
  • Set goals: running 5km 1-2 times a week in 6 weeks time, running 10km 1-2 times a week in 12 weeks time
  • Exercise prescription: side plank exercise, isometric heel raise holds with weight, banded crab walk
  • Create running plan: starting running 3 times a week for a maximum of 2km per run

Follow up appointment: two weeks later the patient is tolerating running well. She still has pain with knee extension in basic activities at home but the pain does not last long. The exercises are going well but continue to be challenging. At this time side plank/copenhagen exercises and long lever bridges on a chair are added to the patients exercise program. The patient is now encouraged to push 2 runs a week to 2.5-3km.

ANSWER:

  • Evaluate current running program, plan gradual progressions to achieve run distance goals
  • Review exercise technique and dosages, progress program intensity by adding plyometric exercises to develop power
  • Re-assess running pattern for technical improvements as a result of the strength interverntions

Next follow up appointment: The patient is now running mostly pain free. She is running 3.5km per run and is recovering well. She notes her cardiovascular fitness is now more a limiting factor than her knee. In an assessment of her running pattern there is still some noted over-striding, but she is now able to maintain good core and pelvic position.

ANSWER:

  • Progress running program:
    • Attempt to incorporate more higher intensity efforts to facilitate increased cardiovascular fitness.
    • Create guidelines for independent progression of running program, i.e.adding 0.5km distance every 1-2 weeks
  • Progress exercise program through increased resistance/level of difficulty on the prescribed exercises

Answer:

The patient is now able to run 10km once a week without pain. All functional tests have improved, and her left side testing is within 10% of her results on the right side. She has no pain at rest or during the night and reports noting significant increases her muscle strength. She has lost the 6kg she gained during COVID-19 lockdown.