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connie.pt -> Patient with knee pain (November 25, 2005 4:44:00 PM)
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I evaluated a 59 year old woman today whose main c/o was left knee pain. I started about two weeks ago when she woke up one morning before she got out of bed. It was so painful that she went to her primary care Dr. that day. She recieved a cortisone shot. One week later the pain was so intense that she went to the ER. No tests other than xrays were taken that she knows of. She was referred to an orthopedic Dr, who sent her for PT, to include aquatic (pool) therapy. Dx on the Rx: knee pain.
Her medical history is unremarkable except for one area: significant bowel pathology that required an ostomy, so she has an ostomy bag.
(She told the ortho doc three times that she had an ostomy bag, and he still ordered pool therapy, so I'm thinking that maybe he wasn't paying attention?) She has to sleep on her back due to the ostomy bag.
She denied any knee trauma, hx of knee pain, tingling or numbness, or feeling ill. Movement makes it feel better, as does the resting position. The pain is constant, rated 4-8 out of 10. Pain meds don't help much at all. The area of pain is superior, medial and lateral to the patella and the joint line, as well as the joint line itself. She also c/o swelling and sometimes feeling hot in this area.
She is using a rolling walker for amb. Previous to this she was working out (going to "curves") and doing Thi-Chi. She is a retired teacher.
Her gait was slow, but not as antalgic as I expected. Even though she said weight bearing was painful, she was able to balance on the affected side (left side) longer than the right in SLS.
Testing revealed hip compression was more painful than tibial-femoral compression. Patello-femoral compression was negative. The left knee was about 2.5 cm larger than the right, and it felt warmer. Distally there was no swelling. She was tender to palpation over the VMO area, and the tibial-femoral joint circumferentially.
MMT: knee ext 4, knee flex 4.
She didn't c/o pain with this.
She did c/o pain with resisted hip flex and passive hip ext. The knee in extension produced pain in supine.
In the Thomas test position, the knee pain was reproduced. In fact, she wouldn't let her hip extend down past about negative 50 degrees. I flexed her hip up just out of the painful range, then flexed her knee fully, which produced no pain. (If it was her quad, I would have expected that to reproduce the pain.)
This is where I ran out of time for the eval.
Her primary care Dr. is referring her to another ortho doc. But I'm not sure this is an orthopedic problem. As far as I know they have ruled nothing out so far.
I asked her to come back for another visit, where I will do some further testing proximally and maybe some ROM exercises in a pain-free range. Unless I find further musculoskeletal findings next visit, I plan to put her on hold until further medical testing is done.
The factors that make me hesitant to treat her:
1. no specific Dx in the presence of
2. acute onset with no trauma
3. it seems nothing has been ruled out by medical testing.
4. X-rays were of her knee only as far as I know (vs the entire femur)
5. joint warmth
6. bowel pathology; I remember reading somewhere that joint pain can be associated with this somehow.
Can anyone offer some insight here?
Connie
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