History and Presenting Symptoms
The patient is a 41-year-old male, who describes persistent pain and occasional stiffness in his left knee, which is not associated with any specific activity. He reports several years of recurring episodes of medial knee pain that just comes and goes, with no swelling or inflammation. Previous evaluations, including a knee MRI, have resulted in a diagnosis of a torn meniscus. Surgery has been offered; but with no guarantee of significant pain reduction, he has declined to undergo arthroscopic repair.
Vitals: This male patient weighs 172 lbs., which, at 5’10’’, results in a BMI of 24; he is not overweight, but getting close. He is a long-time moderate cigarette smoker (10/day), and his blood pressure and pulse rate are at the upper end of the normal range.
Posture and gait: Standing postural evaluation finds generally good alignment, with a slight forward head carriage, but otherwise intact spinal curves and a balanced pelvis. He has a mild bilateral knee valgus, with moderate calcaneal eversion and hyperpronation on the left side. A tendency for the left foot to toe out (foot flare) is noted during gait screening.
Chiropractic evaluation: Motion palpation identifies a limitation in left sacroiliac (SI) movement, with definite tenderness and loss of endrange mobility. Several compensatory subluxations are identified throughout the lumbar region. Otherwise, all spinal orthopedic and neurological testing is negative.
Primary complaint: Examination of his left knee finds no ligament instability and no limitation, pain, or “click” on McMurray testing. Moderate pain and crepitus is found during Apley’s grinding test. All knee ranges of motion are full and pain-free, bilaterally. Manual muscle testing finds mild weakness in the left sartorius muscle, when compared to the right side.
No X-rays or other forms of musculoskeletal imaging were requested, since multiple X-rays and an MRI of the knee had previously been performed.
Biomechanical asymmetry of the lower extremities, with probable meniscal irritation at the left knee. This is accompanied by SI joint motion restriction and compensatory lumbar subluxations.
Adjustments. Specific, corrective adjustments for the SI joints and lumbar region were provided as needed. The left proximal tibia was adjusted into internal rotation, with additional medial pressure for the valgus malposition.
Stabilization. Custom-made, flexible orthotics were provided to support the arches, to decrease the medial pressure on his left knee, and to reduce the asymmetrical biomechanical forces being transmitted up the lower extremity to the pelvis and spine.
Rehabilitation. This patient performed daily exercises with elastic tubing to retrain and strengthen his left sartorius muscle for improved medial knee support. He also worked to strengthen internal rotation action of his left hip, to decrease the tendency to toe out. In addition, he was supplied with a dietary supplement for joint health that contained glucosamine and chondroitin sulfates.
Response to Care
The spinal and extremity adjustments were well tolerated, but knee pain recurred until he had been regularly performing his rehab exercises for two weeks. He reported no difficulty in wearing the orthotics in all of his shoes. Over the next two months, he described a noticeable improvement in his knee function, with an eventual complete cessation of the previous pain and stiffness. He was released from active problem care to a self-directed maintenance program after a total of 15 visits over three months.
This patient had received the “learned opinion” that, at some point, surgery would be the only answer for his chronic knee pain. Fortunately, he persisted in searching for alternatives. The combination of spinal and extremity adjustments, nutritional supplementation, and better support for the medial knee from improved muscle function and custom-made orthotics resulted in an excellent response. In fact, he is now embarking on a wellness plan that includes addressing his lifestyle choices to improve his health potential. He has made a commitment and a plan to quit his smoking. He has already improved his diet, and is exercising regularly now for fitness.
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 and 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 can be reached by e-mail at [email protected].