Palpation findings and special tests: The patient complains of mild discomfort (3/10) upon palpation to the medial femoral condyle and lateral tibial plateau. There are no other positive findings suggestive of any associated neurological impairments, nor was there any indication of acute meniscal or ligamentous tears. Excessive laxity was found for the affected knee during a varus stress test. Range of motion: Passive knee range of motion was 3 to 135 degrees (meaning lacking 3 degrees of knee extension). Her active range of motion was 5 to 130 degrees. Hip and ankle were normal. Performance-based tests: The patient completed the TUG in 7 seconds with mild difficulty when rising from the chair. She walked 490 meters on the 6-minute walk test without an assistive device. Patient reported outcomes: The patient completes the KOOS and scores 68/100 overall, with her lowest score in the sports/ recreation subscale (42/100) and her highest in the activities of daily living subscale (92/100). Strength: The patient has weakness of her right quadriceps as evidenced by measurements on an electrodynamometer. Her strength ratio (right side divided by left side) was 65%, indicating that her affected knee was 35% weaker than her unaffected limb. Observational gait analysis: When walking, the patient lands with the knee flexed approximately 10 degrees at initial contact, does not come to full extension during midstance, and has an antalgic gait pattern in which she reduces the stance time on the affected side. In the frontal plane, there is a varus thrust gait pattern during loading response on the right side. Patient goals: The patient reports her primary goals are to return to her running club, which meets twice a week to run 4 miles. She currently has too much pain to participate. She does not want to undergo a total knee arthroplasty (TKA) until it is absolutely necessary. Questions 1. How do the patient age, history, and goals differ from many other patients with knee OA? How might this affect her treatment plan? 2. What might be the primary intervention recommended for this patient? Resources ● Osteoarthritis Research Society International Recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis: https://www.oarsi.org/sites/default/files/docs/2013/manual.pdf. This site contains information about the performance-based tests that should be included when evaluating patients with hip or knee OA. It includes a description of the test, as well as the specific instructions for completing the test in a valid and reliable manner. ● American College of Rheumatology http://www.rheumatology.org The American College of Rheumatology is a nonprofit professional organization dedicated to improving the lives of those with rheumatic diseases, including osteoarthritis. A subsection of the American College of Rheumatology is the Association of Rheumatology Health Professionals (ARHP), which provides resources for allied health professionals, such as physical therapists, who treat patients with osteoarthritis. ● Arthritis Foundation http://www.arthritis.org The Arthritis Foundation is a national organization that has resources for patients, as well as healthcare providers, about the treatments for osteoarthritis.
3. What type of patient education could a physical therapist provide about her condition? 4. Given her gait abnormalities, what other treatments and devices may benefit this patient? Answers 1. Most patients with knee OA suffer from a degenerative and progressive condition where there is no identifiable cause. In this case, the patient is younger than most individuals with knee OA and has goals that may be higher than other patients with knee OA. She had an identifiable injury that preceded the onset of her condition, which is considered posttraumatic OA. Because of her younger age, treatments and education should be provided with an intent of not only reducing symptoms, but also delaying the need for TKA. The prosthetic components of a TKA are known to have a limited lifespan, so performing TKA in younger patients is typically done only in select cases. In addition, her goals are to return to running and she had little difficulty with activities of daily living. Therefore, her treatment may include a running or return to sport progression and not focus solely on lower level activities. It will be important to monitor joint effusion during any functional retraining. 2. Given her dramatic strength asymmetry, the focus of this patient’s treatment should be on improving strength of her quadriceps. Quadriceps strength is highly correlated with functional performance, and may even provide some protective effect against worsening of the disease symptoms. 3. Although this patient does not want to undergo a TKA, it is important to inform this patient that OA is a progressive condition for which there is no cure. Maintaining a physically active lifestyle, reducing body weight, and maintaining normal range of motion at the joint may help to prevent future functional decline. Even after she leaves physical therapy, she will likely require a home exercise program to manage the symptoms and impairments associated with knee OA. 4. This patient had laxity in the valgus direction and a noticeable varus thrust during gait. This patient may benefit from a knee brace to improve joint stability during weight-bearing activities, particularly if she is interested in returning to running. ● Orthopaedic Section of the American Physical Therapy Association http://www.orthopt.org The Orthopaedic Section of the American Physical Therapy Association has a variety of online material that provides updated and useful information for managing symptoms associated with musculoskeletal impairments. This information includes resources for clinicians about the latest research on effective treatments and information for patients on the benefits of physical therapy or self- managing their condition. ● Rehabilitation Measures http://www.rehabmeasures.org Rehabilitation Measures is a website that contains an exhaustive database of outcome measures. Many of these outcome measures have been discussed in this course. This website also provides information from research studies about the validity, reliability, and normative values for many of the instruments and tests listed on the website. ● American Academy of Orthopaedic Surgeons: Clinical Practice Guidelines https://www.aaos.org/guidelines The American Academy of Orthopaedic Surgeons provides clinical practice guidelines for a variety of conditions, including nonoperative management of patients with knee OA. These guidelines are derived from current, high-quality research studies that have focused on topics such as weight loss, physical therapy, and self-management. The information in these guidelines may help physical therapists choose the most appropriate course of action for patients with knee OA, as well as understand the treatment options that may be provided by other healthcare providers, including orthopaedic surgeons.
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Book Code: PTNC1023
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