What would you be thinking in this case study?
I always thought it was cool when someone else shared their experiences, stories, and cases. It made everything that was learned more meaningful, more tangible, and more memorable. This is why I thought I’d take a different route on the mindfulness tour bus and share a fun case study that came into the office earlier this year.
I’ll break it down into the hard facts, share the things that I’ve performed, lay out the outcomes, give possible diagnoses, and offer insight as to what my thought process was when diagnosing the condition. Ready to go? Let’s do it!
HISTORY - Here’s the facts:
Sport: Crossfit
Right side dominant 25 YO female with left knee pain
Complained of pulling sensation underneath and deep to kneecap; uncomfortable pressure with achiness and soreness
There was no known etiology
The athlete had increased her running activities the past month and admitted that she had slacked off on her mobility work
Reported swelling in the calves immediately after working out and resolved within 2-3 days
No prior history of chief complaint
Symptoms have been present for the past 1.5 months and has progressively increased
It felt better with ice and mobility work such as stretches and foam rolling
It felt worse when squatting down “into the hole,” sleeping, running, extensive workouts
Rated it a 7-8 out of 10 (numerical rating scale)
EXAMINATION - Here’s what I performed:
Vitals (blood pressure, temperature, heart rate, O2 saturation)
Neurovascular assessment (DTR’s, myotomes, dermatomes, distal pulses, capillary refill)
Inspection (Asymmetry, scars, edema, ecchymosis, deformities)
Palpation
Range of motion (ankle, knee, hip, lumbar spine)
Movement assessment (SFMA top tier)
Orthopedic evaluation
Other (random things I’ve learned from seminars, other clinicians, etc. that I like to put into the mix)
FINDINGS - Here are the outcomes:
Vitals
Within normal limits (WNL)
Neurovascular assessment
WNL
Inspection
Patient walking with a slight antalgic gait favoring ipsilateral side
Palpatory findings
Tenderness to palpation along the posterior lateral joint line
Tonicity along the hamstrings, quadriceps, adductors, gracilis, popliteus
Range of motion
Ankle - dorsiflexion limited compared to contralateral side
Knee - end range flexion limited compared to contralateral side
Hip - internal rotation limited compared to contralateral side
Lumbar spine - WNL
Movement assessment
Multi-segmental flexion limited - lower body > upper body
Multi-segmental extension limited - upper body = lower body
Multi-segmental rotation limited - lower body > upper body
Orthopedic evaluation
(-) - Hip impingement tests
(-) - Ankle ligamentous tests
(-) - Knee ligamentous tests
(-) - Thessaly’s test
(-) - Dial’s sign; however, slightly increased external rotation ~10 degrees max (if that) on the ipsilateral side without pain/discomfort
(-) - McMurray’s test; however, there was discomfort with end range flexion and external tibial rotation along the posterior lateral joint line area
(+) - Posteriolateral joint line tenderness/pain
Other
Left anterior inferior chain (adopted from Postural Restoration Institute)
Manual Muscle Test (MMT) to check for tibiofemoral subluxation
5/5 Vastus lateralis, vastus medialis, vastus intermedius
-4/5 left popliteus
DIFFERENTIAL DIAGNOSES - Here’s what I was thinking it could be:
Posterior meniscal pathology
Posterior lateral corner instability issue (a global term used to describe disruption in the structures of the posteriolateral knee; could be a combination of the lateral collateral ligament, popliteus tendon, popliteofibular ligament, or other posteriolateral structures)
Tibial-femoral subluxation (not like those “halfway dislocations” we think when we hear the word subluxation, but it’s more of chiropractic jargon to describe an “articulation that is not tracking optionally”)
DEDUCTIVE REASONING - Here’s how I narrowed it down:
Posterior Meniscal Pathology -
Palpated the posterior meniscus
(+) finding - tenderness, pain, and/or recreation of symptoms
Assessed end range of motion
(+) finding - pain and/or recreation of symptoms in FLEXION
Orthopedic tests
(-) finding - however, McMurray’s tests revealed some discomfort with end range flexion and external tibial rotation along the posterior lateral joint line area
VERDICT - POSSIBLE
VERDICT - UNLIKELY
Posterior Lateral Corner Issue -
Palpating posterior aspect of the knee proximal and distal to joint line
(+) finding - tenderness, pain, and/or recreation of symptoms
Orthopedic tests
(-) finding - however, Dial’s sign revealed slight increase in external tibial rotation compared to contralateral side
Tibiofemoral Subluxation -
Palpated the posteriolateral joint line
(+) finding - tenderness, pain, and/or recreation of symptoms
MMT
(+) finding - -4/5 left popliteus
VERDICT - POSSIBLE
Since Dial’s sign was not absolutely positive, there was no traumatic mechanism of injury, and tenderness to palpation was isolated to the joint line itself, a PLC (in my mind) wasn’t highly suggestive; therefore, it dropped tiers on the differential diagnoses list.
This left only a posterior meniscal pathology to size up against a tibiofemoral subluxation - similar to old western movies where the heroic cowboy and feared gang leader faced each other nervously during a gun draw.
I mentioned to the patient that these were the two things I was thinking could be going on, and that I really couldn’t be absolute diagnosing a meniscal pathology unless supplemental images (ie. MRI) were performed to see if there was any compromise to that structure. For personal reasons and possible vocational restrictions, the patient did not want to get imaging and was hoping that conservative treatment could do the trick.
Luckily, I had an alternative plan. I mentioned to her that I could treat the suspected tibiofemoral subluxation. I suggested to her that after treatment, we would reassess and compare the results with the original outcomes. If treatment alleviated some of her symptoms, then I know that the subluxation had an influence on what she was currently suffering. Otherwise, if the treatment aimed at re-establishing joint congruency was not helpful, then my beliefs would shift more towards, and would be highly suggestive of, a posterior meniscal pathology. The athlete agreed to try this conservative option…
So guess what happened after treatment?
Well after treating the patient with the use of soft tissue maneuvers (ie. Active Release Technique), extraspinal adjustments (aka. adjusting the knee), and adding tissue activation methods (aka. joint stability exercises), the patient was able to establish 90% improvement where pain drastically dropped, ROM dramatically increased, and functional movements like squatting and lunging surprisingly improved!
What seemed to be a meniscal pathology was actually a tibiofemoral subluxation. After those functional movements were tested, I re-evaluated joint line tenderness, end range flexion, and McMurray’s test to find out that they too were minimized! Now, how cool was that?!
Here’s the take home message:
Don’t be in a haste to identify and diagnose meniscal pathologies, as it may not actually be what you think. Broaden your perspective and remember that the articulating structures may not be congruent (aka. centrated), leading to less than optional arthokinematics, therefore presenting itself as pseudo-meniscal symptoms. Being able to differentiate these conditions can save those you serve undue stress, wasted energy, and precious time.
Thanks for being curious and taking the time to read this! Hope it added value to your life and equips you to become better than you were yesterday!
Dr. Joe Jaime, DC, DACBSP®, ATC, CSCS®, FRC®ms, CES
BONUS: I try to reflect on the cases that come through, to see how I can improve my evaluation and treatment game, so here’s some of my afterthoughts …
Here’s what I think I should’ve done to be more thorough:
Ask more history about the swelling post-activity
Circumferential leg measurement
Nerve Tension test
MMT hamstings and gastrocnemius-soleus complex
Isolated tibial internal/external rotation assessment (ROM)