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A 16-year-old female competitive volleyball player with a 2-year history of intermittent anterior right knee pain and swelling is referred to physical therapy for evaluation and treatment. Six weeks ago, she had a fat pad debridement surgery and has been going to physical therapy sessions since then at another outpatient physical therapy facility. Each time she returns to volleyball, her pain and swelling return. The activities required for volleyball include running, cutting, jumping and pivoting; each of these increases her pain. During the 2 years prior to surgery, her pain was in the medial aspect of her knee. However, since surgery, she experiences the pain on both the medial and lateral sides of the knee. In the last 4 weeks, she has been experiencing pain and swelling similar to that she had prior to surgery. With either an increase in practice or game frequency, the anterior knee pain increases to 8/10 from a baseline of 1/10 on a visual analog scale (VAS). With a couple days of rest, her pain and swelling are eliminated. She has tried multiple treatments (e.g., ice, heat, compression, over-the-counter nonsteroidal anti-inflammatories), which provide symptomatic relief for short duration and are only effective if she is not playing volleyball. Although she has been in formal physical therapy for the last 6 weeks, primarily performing knee-strengthening exercises, her pain and swelling have not been effectively reduced. Her goal is to return to volleyball symptom-free now that the season has started. Her physician has not placed any restrictions on her activity.

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Based on her health condition, what do you anticipate may be the contributors to activity limitations?

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What are the examination priorities?

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What are the most appropriate physical therapy interventions?

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What precautions should be taken during physical therapy interventions?

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FAT PAD: Area of highly vascularized adipose tissue directly beneath the patellar ligament that can become a source of anterior knee pain; its role is thought to help lubricate and cushion the patellar ligament from stress

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LATERAL BUTTRESS EFFECT: Effect of the higher lateral patellar trochlea on the anterior surface of the distal femur; the higher lateral trochlea resists the natural lateral translation of the patella during knee flexion and extension

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PATELLOFEMORAL PAIN: Also known as anterior knee pain; one of the most common forms of chronic pain in or around the anterior knee and usually has insidious onset

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REGIONAL INTERDEPENDENCE: Theory that dysfunction either proximal, distal, or both from the knee joint may cause localized pain in and around the anterior knee

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SCREW-HOME MECHANISM: Obligate lateral tibial rotation that occurs during the last few degrees of knee extension as the tibia glides along the longer medial femoral condyle

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  1. Describe patellofemoral pain.

  2. Identify methods to assess for regional interdependence.

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