History of Presenting Symptoms:
Client ‘B’ is an 18 year old girl with a 3 year history of bilateral knee pain that began without incident 3 years ago. Client B’s knee pain was reducing her ability to participate in her chosen sport of dancing to the point where she had ceased dancing. She was also having trouble with participating in school sport and her knee pain was affecting her ability to engage socially as long walks through the national park were causing pain.
Client B has seen multiple different clinicians including surgeons, movement coaches, podiatrists and physiotherapist but has found little benefit. Throughout the course of her journey she has been prescribed orthotics, medications and been diagnosed with hypermobility syndrome.
Client B was troubled with walking up and down stairs, standing for long periods and first thing in the morning.
Client B has struggled to find anything that impacts her symptoms positively. In a bid to reduce her pain Client B has been reducing her physical activity in order to not to exacerbate her symptoms. Unfortunately, Client B had found that her pain was getting worse, finding that now only small levels of physical activity were necessary to aggravate her pain. Client B was unsure as to whether her knees would ever improve as she felt that she had exhausted all treatment options.
I first saw Client B in July 2019. She was understandably quite frustrated with her current situation. From Client B’s history it was obvious that she was in a boom/bust cycle which is quite typical of a person who experiences persistent pain. Client B would do something that would aggravate her knee pain and then take several days of rest to recover from it. This approach leads to a detraining effect on the local muscles around the affected joint and well as ramping up her pain levels a phenomenon known as wind up. She was tender globally with palpation around her knee joint. Her squat was very hip dominant, avoiding flexing her knees. Her single leg calf and quad strength were quite weak for someone of her age. Her single leg balance was also quite poor.
Client B and I started with discussing what is new in the pain sciences research. We talked about how pain doesn’t mean damage and that pain is more about threat rather than tissue damage. We used some recent research (Drew, 2015) to work out some realistic timeframes for Client B to get back to dancing. We then discussed what Client B’s rehab looked like. We started off with some simple movement activities to get Client B’s neural system to dampen down its response. We also started by using some strengthening work around her ankles and hips, both very important regions when managing knee pain. We discussed using a pacing approach, focusing on regular, small amounts of physical activity three per week rather than a large amount of activity that would knock her out of action for the rest of the week.
Client B is now 9 months down in her rehab plan and we have caught up 1/month in that time. She is now able to walk for 50 minutes interspaced with 10 minutes of jogging with her goal to be able to complete 30 minutes of running. She is able to complete a full squat without pain, the first time in 3 years. She is able to complete 25 single leg calf raises, is doing single leg Tr-X squats and weighted Bulgarian split squats. Client B is able to box jump 400mm and single leg box jump 300mm, both massive achievements from where she has been.
The major learning outcome of Client B’s presentation is that sometimes things take time. Sitting back and recognising a long history of pain can lead to a large amount of deconditioning. As a physio we would love to provide a quick fix however this approach can lead a person in pain down a rabbit hole of doctor shopping looking at what magic fix there is. Sometimes there isn’t and a holistic approach is needed.
Drew, M. K. (2015). Loads and risks following troughs.