History and Presenting Symptoms
The patient is a 48-year-old real estate broker, who is also the president of the local Chamber of Commerce. She reports pain in the front of her right knee, over the past several months, especially when playing tennis. She denies any specific injury, and has no obvious swelling or discoloration. She reports that she takes ibuprofen for relief, but is worried that she has to take this drug in order to play tennis.
Exam Findings
Vitals. This active, middle-aged woman weighs 140 lbs, which, at 5’5’’, results in a body mass index (BMI) of 23—she is not overweight. She is a non-smoker, and her blood pressure and pulse rate are both at the lower end of normal range.
Posture and gait. Standing postural evaluation finds generally good alignment throughout her pelvis and spine. She has a mild bilateral knee valgus and moderate calcaneal eversion and hyperpronation on the right side. Measurement finds a standing Q-angle of 28° on the right and 24° on the left (20° is normal for women).
Chiropractic evaluation. Motion palpation identifies a limitation in lumbosacral motion, with moderate tenderness and loss of endrange mobility to the right at L5/S1. A compensatory subluxation is also noted at T10/T11. Neurologic testing is negative.
Primary complaint. Examination of the right knee finds no ligament instability, but there is a positive patellar grinding test. All knee ranges of motion are full and pain free, bilaterally. Manual muscle testing finds no evidence of muscle weakness.
Imaging
No X-rays or other forms of musculoskeletal imaging were requested.
Clinical Impression
Patello-femoral arthralgia (previously chondromalacia patellae) on the right, associated with an elevated Q-angle and foot pronation. This is accompanied by lumbosacral joint motion restriction and compensatory lower thoracic subluxation.
Treatment Plan
Adjustments. Specific, corrective adjustments for the lumbosacral joint and the lower thoracic region were provided as needed. Manipulation of the right knee into external rotation was performed to decrease the internal rotation associated with hyperpronation and her elevated Q-angle.
Support. Custom-made stabilizing orthotics were provided to support the arches and decrease the Q-angles. Two pairs of stabilizing orthotics were ordered, one designed specifically for her tennis shoes and the other for her job-related dress shoes.
Rehabilitation. Due to her active lifestyle, no specific rehabilitation exercises were provided. She continued with her frequent tennis playing.
Response to Care
The spinal and knee adjustments were well tolerated, and she reported a rapid decrease in symptoms. Once she began wearing her orthotics regularly, she noted a substantial decrease in knee irritation with use, and a firmer foot plant during tennis playing. Within two weeks of receiving her orthotics, she related that she had successfully completed a round-robin tournament with absolutely no knee pain or limitation. She was released to a self-directed maintenance program after a total of eight treatment sessions over two months.
Discussion
Several interesting factors are present in this case. This high-powered businesswoman used her tennis games as both a form of business interaction and a recreational relaxation. As her knee began to bother her more, she was driven to using anti-inflammatory drugs. She was wearing supportive shoes, but the underlying biomechanical problem had not been sufficiently addressed.
When women are physically active, their naturally higher Q-angles are frequently a source of patello-femoral pain. This condition was previously called chondromalacia patellae, but it has been recognized that it is actually a biomechanical “tracking” disorder of the kneecap in the femoral groove. The best treatment is a conservative approach, with a combination of chiropractic adjustments, flexible stabilizing orthotic support, and—when indicated—rehabilitative strengthening sessions using elastic exercise tubing.
Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program. He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System. He has been in private practice in Massachusetts for 29 years. He can be reached by e-mail at [email protected].