Management of a difficult knee problem

Chronic disabling patellofemoral (PF) pain and instability can have significant effects on patient function and lifestyle. Although the management of PF pain has improved greatly, there is still a category of patient who tends to have recalcitrant symptoms, which are difficult to manage. The patient often bounces from practitioner to practitioner, physiotherapist as well as surgeon, for some relief of symptoms. However, often the underlying source of the pain is not well understood, so treatment can aggravate the symptoms. The following case report demonstrates the effectiveness of physiotherapy in managing a complex clinical case of a 40 year old patient with bilateral PF symptoms of severe right knee pain and a subluxing left patella, as well as left hip pain. Some background is given as to the source of the right knee pain with magnetic resonance imaging (MRI) supporting the diagnosis and treatment progression. The initial MRI demonstrated marked redundancy of the patellar tendon, resulting in patella baja (infera). Two years and ten treatments later, the patient, who originally could barely walk, was playing tennis for the first time in 25 years. Her MRI showed a complete resolution of the patella baja (infera), indirectly implying an improvement in quadriceps tone, as well as, resolution of the subchondral bone marrow oedema at the lateral patellar facet. Physiotherapists should not give up on patients with chronic musculoskeletal conditions as much can be done for them. These patients need clinicians to persevere, because certainly, for both patient and therapist, the rewards are great.