PREFERRED PRACTICE PATTERN
4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation3
A 21-year-old, 6′5″, 190 pound, Division II male collegiate basketball player, with no previous history of knee and/or patellofemoral pathology, reports to the athletic training/sports medicine facility complaining of bilateral anterior knee pain. He states the pain began approximately 2 weeks ago, with the highest incidence of pain occurring in the morning after a weight-training session. About 3 days ago, the pain became constant and has impacted his training. He reported that as part of his off-season conditioning, he has increased strength training (e.g., squats, leg extensions, etc.) and plyometric activities (e.g., box jumps, bounding, etc.) aimed toward increasing power output and vertical jump height. His training over the previous 6 weeks focused on the lower extremity, with 30 to 45 minutes per day of cardiovascular training (e.g., running, cycling) to supplement the 4 days per week of Olympic lifting techniques and plyometric training. He admitted he does not focus on pretraining dynamic warm-ups and performs limited postactivity stretching, but did use ice post activity a few times to manage his pain. The patient presents with no obvious deformity or signs of Osgood–Schlatter disease; no obvious laxity or instability at the patellofemoral joint. Manual muscle testing (eccentric break test) WNL for knee and hip with exception of 4/5 grading: bilateral hip flexion, internal rotation, external rotation, and knee extension. He has a positive Thomas test and positive Ely test, suggesting muscular tightness in his iliopsoas and rectus femoris bilaterally. During gait analysis, he presents with an early heel rise during terminal stance, suggesting tight gastroc-soleus (Achilles tendon). Kinetic chain dysfunction from muscular tightness was further evident during an observed body-weight squat. Radiologic findings include X-rays (negative) and musculoskeletal diagnostic ultrasound (positive for inflammation).
Traumatic injuries to the anterior knee. (From LeBlond RF, DeGowin RL, Brown DD. DeGowin’s Diagnostic Examination. 9th ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
No displaced patellar fracture seen best on the lateral view. (From Simon RR, Sherman SC, Koenigsknecht SJ. Emergency Orthopedics: The Extremities. Fig. 15-26, bottom photo only, p. 405. Copyright 2007. New York, NY: McGraw-Hill.)
Patellar tendon defect. (A) Long-axis sonogram of the proximal patellar ligament showing a hypoechoic tendon defect near the origin of the patellar tendon (arrow). The remainder of the tendon appears ...