HIPS: Two Different Knee Evaluations

January 27, 2013

In my latest attempt at some humor, and a chance to educate, I bring you my newest series.. This series “Hips: One Four Letter Word You Must Use” will take you through my thoughts over the last several months on the importance of the hips in exercise, fitness, rehabilitation, and sports enhancement. It truly is a topic that I have grasped full-on and really believe that if our hips are weak, we WILL get injured. And most often it is not our hips that get injured in this process! Please join me in this journey as we will explore the hip complex and its importance to the rest of our body!

I have a strong belief that the hips play major roles in all knee pain. But the initial evaluation is not always the place to immediately address the hips. I’m going to describe two of my recent evaluations and I think you’ll see what I mean.

My first patient is a 14 year old girls’ soccer player experiencing mild-moderate bilateral knee pain. She has begun conditioning for her sport which has caused the pain to flare up. Because she does not have any significant mechanism of injury noted, I quickly assess the knee and move on. She has chronic knee pain with no recognized MOI therefore most likely her knee pain is simply the outlet rather than the cause of the pain. So we must move to the source of the pain instead of focusing on it. As Perry Nickelston says, quit chasing the pain. Instead, we must work on finding that source. In this girl’s case, her knee pain is likely stemming from a couple of different sources. First of all, she is internally rotated at the hips and is experiencing delayed or nonexistent glute firing. Additionally, she presents with severe pronation of her feet. Right now we’re going to attack this from multiple angles.PatelloFemoral Pain Syndrome We’ll attack her knee pain using ice post-treatment. We’ll begin glute activation exercises to get them to fire correctly and work to improve her hip strength. And we’re addressing her pronation first using RockTape and eventually through the use of an orthotic to correct the pronation. Multifactorial problems all coming out as “knee pain.”

My second patient is also a 14 year old girls’ soccer player however she is experiencing moderate-severe knee pain. Mechanism of injury is falling on stairs and landing on anterior knee. She has pain at and around patella as well as swelling. Also complained of pain to posterior knee. My immediate thought was a posterior cruciate ligament (PCL) sprain as those tests were positive and tests for the anterior cruciate ligament (ACL) were inconclusive. I believe those tests were inconclusive due to the possibility of the PCL sprain AND because the MOI was not right for an ACL sprain. She has complained of and reported multiple incidences of “giving out” since the initial injury. Due to her pain and the trauma, I did no kind of muscle testing and at this time have no done any kind of postural or movement assessment. I would guess she probably has hip weakness, but at this time that is not of concern. We must first address the knee trauma. Right now, she was taped with RockTape for edema and is nonweightbearing utilizing bilateral crutches. We’ll continue to treat her pain with ice and rest while we get further medical evaluation.

I think the take-home message here is the recognition of the type of injury that is present. In case #1, she had chronic pain that is due to biomechanical flaws elsewhere along the kinetic chain (both proximal and distal to pain site). We’ll address these biomechanical flaws to hopefully alleviate the knee pain. In case #2, she had direct trauma to the knee. The biomechanical flaws, while possibly present, are irrelevant at this time. You can see there are two different evaluations based on mechanisms of injury.

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