A few weeks ago, one of my colleagues developed some knee pain with running. He reported that it was "clicking" and had pain along lateral tibiofemoral joint line. Having review repeated motions in the past with him, I recommended what to assess and what likely was contributing to his pain (he also reported a history of LBP on and off L>R). Over the next couple weeks he would occasionally do his exercises, report some relief and then report that it "just wouldn't get better." Having finally gotten some free time in the clinic, I thought I would take a look at his knee.
As many of you know, I always start at the spine in my evaluations. Even though a lot about this case screamed knee/meniscus, I still go to the spine. While flexion and extension of the lumbar spine were generally pretty good, he had a slight loss of loading L lumbar spine with sideglides. Additionally, he had loss of terminal knee ext and tibial IR mobility on the involved side. His primary report of frustration was that his knee felt "swollen/painful" with deep squats, so I made this my asterisk sign.
With the difficulty loading the L lumbar spine, I had my colleague begin with 20 repetitions of press ups biasing the L side (I frequently go to this if it is an end-range deficit in mobility). I then reassessed the squat ("a little better"). Another 20 repetitions ("better"). Another 20 repetitions ("almost 100%"). At this point, I had found my colleague's directional preference. For fun, I re-checked terminal knee ext and tibial IR mobility at the end as well - both were nearly normal. While many think of repeated motions of the spine as possibly addressing pain distal to the spine, it also can have a significant impact on mobility of distal joints. If there's one thing to take from this case, it's to always check the spine!
-Dr. Chris Fox, PT, DPT, OCS
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