I recently treated a 63-year-old patient who presented left side knee pain and swelling. During her assessment, she told me she had had arthroscopic surgery for a torn meniscus more than a year ago. The knee was swollen and she told me she “did not trust it” when getting out of a sitting position. I told her to walk around the clinic. Her gait was both antalgic (trying to avoid weight on the involved leg) and wobbly (gluteus medius lurch). Her right leg also exhibited steppage gait (the knee flexes higher to enable to the foot to clear the ground). Her gait was exhausting to her, and she quickly became winded. An avid tennis player, she could not understand why she was still in so much pain more than a year after the surgery. And, after weeks of physical therapy. When she returned to her surgeon to complain, his answer was: “Can you live with it?”
How does the clinician help this patient? In traditional kinesiolgy, or the study of muscle movement, the therapist must take movement, muscle action, and biomechanics, into consideration. Let's do just that, and discuss some of the factors involved. Since the patient is in her sixties, osteoarthritis in the knee is a given. Arthroscopic surgeries are not always successful, and scar tissue is always left behind. These are two items that work against rehabilitation, and help cause the excessive swelling. Yet knowing all of this, what about her gait? This patient is not walking correctly, and every time she is weight-bearing, she is placing forces on the hips and knees. If the therapist treats the arthritis with say, ice and massage, will she recover?
If this patient's faulty movement is not corrected, the knee will not heal, and a slow snow-balling affect begins. Let's break down the gait issues mentioned earlier. Steppage gait is produced when the ankle dorsiflexors are not working. The toe scrapes the ground, so the patient over-flexes the knee to get it high enough to clear the ground. A gluteus medius lurch is produced by weak gluteus medius; the patient “wobbles,” struggling to thrust her hip to take the next step. This is no way to walk or live. Can she live with it? No!
Successful treatment involves correcting the imbalances in the body, alleviating irritation to the joints. When I told this patient this, she said, “No one has ever said that to me before.” I found that ironic after eight weeks of post-surgery rehabilitation. We began focusing on strengthening this patient's dorsiflexors and hip abductors, flexors, and extenders. Her uninvolved knee and hip were stretched to restore lost range of motion due to compensation. My first step was to correct her wobbled walk. Doing so provided stability to the joints, especially the badly irritated left knee. Also, knee extension stretches helped eliminate posterior knee capsule scar tissue. My next move was to show the patient daily exercises she would do on her own, including cryotherapy twice daily. On a weekly basis, I watched her gait improve until the wobbling became unnoticeable. With the gait issues corrected, her left knee functioned better, and was not irritated upon weight-bearing activities.
This patient was once ready to give up her tennis, but now she has returned to the game she loves. Using a multifaceted approach in kinesiolgy, and a specific mind-set in treatment, patients can be helped, even if their doctor does not believe it.
Want to learn more? Timothy Agnew will be teaching CFTE Kinesiolgy for Manual Therapies at the Downeast school of massage September 25-26, 2010. Learn how to solve your patient’s pain with a dynamic variety of solid treatment plans. To register, contact the school or Register On-Line.