Treating the foot to cure the knee

I was treating a patient on my rural placement with chronic lateral knee pain (~ 6mths). The patient had hurt their knee going down some stairs and, being a fit person, decided to leave the injury to get better on its own. When the patient had finally decided to see the physio, they had a lot of wasting of their VMO and calf’s and his main complaint was pain when sitting with their knee flexed for long periods of time.

The patient had been seeing the previous PT student for 3 weeks, who had prescribed VMO strengthening exercises and applied McOnnells (med glide) taping, as well as STM of the ITB. The patient said that these treatments had offered him relief so for the first session with him I continued with the same treatments, and progressed his VMO exercise. Each week I concentrated on his VMO exercises (my theory was that his VMO had become so decondisioned that he needed some time to build its strength before his pain would improve). By the second time I saw the patient they had good length of ITB, good VMO activation, but their symptoms had not improved one bit. I was stumped and asked my supervisor for some guidance.

I explained to my supervisor all that I had done and was asked if I had checked what the patient’s hip and foot posture is like. I had analysed it when the patient was standing still and it looked normal. The supervisor advised me to have a look at those joints while the patient is walking. I did so and realised that the patient had poor control of pronation of the affected side foot. I then looked at his gasrtoc-soleus length and found that it was decreased significantly, and he mentioned that he had a Achilles rupture then surgical repair year ago. I addressed this by taping the foot to prevent over pronation and giving the patient a calf stretch program and the patient said instantly he no longer felt a pull in his knee.

The patient had not reported walking as causing his pain, and only once I had put the tape on his foot that he realise that he had a ‘pull’ of his knee when walking. Hence why I did not look at his walking. This taught me how important it is to analyse motor control during walking in a patient who has lower limb symptoms, even though that may not be the aggravating symptom. The body is a kinetic chain and an alteration in motor control at one point can effect other parts in the chain, particularly if it is injured. This experience made more observant of all my other patient’s movement patterns and actually helped me find things that were not obvious to the condition/symptoms the patient had presented with.