Outpatient Physical Therapy Management for a 34-year-old Male New Runner with

Anterior Knee Pain

Author: Chase J. Cochran

Advisor: Linda Hall, PT, MS, DPT

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

Date: April 14, 2021

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctorate of Physical Therapy

Accepted by the Faculty Research Advisors(s)

Linda Hall PT, MS, DPT

Linda Hall, PT, MS, DPT

Date of Approval:

April 11, 2021

 ABSTRACT

Background and Purpose

Knee pain or injury to the knees are some of the most common injuries that an athlete and

anyone physical active can obtain. Knee pain is the second most common cause of chronic pain.1

In athletes and in those physically active, around 40% of injuries that occur are knee injuries.2

There are many different knee injuries that can cause knee pain, more commonly they occur in

the anterior aspect of the knee.3 Any acute or chronic knee injury can be very problematic,

especially due to the complex anatomy and arthrokinematics that are involved with the knee.

Conservative intervention via physical therapy has been shown to be an effective intervention in

reduction of anterior knee pain.33, 24 The purpose of this case report is to describe the physical

therapy management and prescription of exercise in an outpatient environment for a 34-year-old-

male who is a new runner experiencing anterior knee pain.

Case Description

The patient is a 34-year-old male with chief complaints of right sided anterior knee pain

when running. The patient was referred by his primary care physician (PCP) to an outpatient

orthopedic Physical Therapy location for examination and treatment.

Upon examination the patient exhibited weakness in his hips and knee bilaterally,

decreased ankle dorsiflexion range of motion, decreased hamstring and hip flexor flexibility, no

tenderness to palpation along the patellar tendon or around the knee, and no pain when

performing a single leg squat. He was able to stand on one leg for 60 seconds with his eyes open

bilaterally, but only able to stand on his right for 10 seconds and his left for 24 seconds when

closing his eyes. He scored a 74/80 on the Lower Extremity Functional Scale (LEFS) and a

21/36 on the University of Wisconsin Running Injury and Recovery Index (UWRI).
Outcomes

After 6 weeks which included 12 total treatment sessions, the patient achieved almost all

functional goals set for him. He improved his hip and knee strength to close to full strength

bilaterally, improve his hamstring flexibility, achieved within functional limits (WFL) for ankle

dorsiflexion ROM, and continued to achieve no pain during a single leg squat. He increased his

single leg balance with his eyes closed to 18 seconds on his right leg and 25 seconds on his left.

His LEFS improve to a 77/80 and his UWRI improved to a 33/36. He was running throughout

the entire 6 weeks with some pain but in the final three weeks he had no pain during or following

running.

Discussion

This case report showed how physical therapy management and progression of a lower

extremity strengthening program individualized to a patient may reduce a runner’s anterior knee

pain. By completing thorough examination and differential diagnosis as well as proper exercise

prescription and patient education, this can help a new runner increase their strength, balance,

ROM, reduce pain, and improve their tolerance and ability to run pain free. Limitations of this

case report were that the patient saw two different physical therapists throughout his plan of care,

he performed only one gait evaluation towards the end of his plan of care rather than earlier and

a re-evaluation towards the end of his plan of care, as well as that his running was not tracked

specifically outside of the clinic. Future research should also look at specific exercise

prescription with a specific return to running program and see how this affects pain and

functional outcomes.
Background and Purpose

Knee pain and injury to the knees are some of the most common injuries that an athlete

and anyone physically active could obtain. Knee pain is the second most common cause of

chronic pain.1 In athletes and in those physically active, around 40% of injuries that occur are

knee injuries.2 Different knee injuries that can cause knee pain are fat pad syndrome, plica

syndrome, pes anserine pathology, hamstring injury, ligamentous injury, meniscal injuries,

iliotibial band syndrome, patellar tendinopathies, or patellofemoral pain syndrome (PFPS).3 Any

acute or chronic knee injury can be very problematic, especially due to the complex anatomy and

arthrokinematics that are involved with the knee.

The tibiofemoral joint, or the knee joint, is the largest joint in the entire body.3 The bone

in the thigh, the femur, and the bone in the lower leg, the tibia, come together to form a complex

hinge joint that allows for the knee to be flexed and extended.4 Deep in the knee there are two

menisci that add to the congruency for the joint for stability and shock absorption, the lateral and

medical menisci.3, 4 Laterally, along the outside, and medially, along the inside, of the knee sit

two ligaments that prevent medial and lateral translation of the knee for stability.3, 4 These are

known as the lateral cruciate and medical cruciate ligaments. The anterior cruciate ligament

(ACL) sits in the center of the knee and controls anterior translation of the tibia on the femur as

well as rotation.3, 4, 5 The posterior cruciate ligament (PCL) sits in the center of the knee and

controls posterior translation of the tibia on the femur.3, 4 There are also numerous bursae, or fluid

filled sacs, that help the knee move smoothly.3 The patella is a bone that sits on the front aspect

of the knee which is connected to the quadriceps muscles in the front of the thigh by the

quadriceps tendon and to the tibia by the patellar tendon.4 The patella helps the knee obtain the

1
last 30 degrees of extension and allows for smooth motion throughout the entire knee bending

phase.3

The knee is a hinge joint, which means it allows for two degrees of freedom being

flexion, where the knee bends, and extension, where the knee straightens.3 The average

individual should obtain around 135-140 degrees of flexion and obtain around 0 degrees of

extension.6 Along with flexion and extension there is also some rotation that occurs at the knee.

As the knee flexes and extends, the tibia and the femur move very particularly on one another.

The gliding that occurs at the knee is dependent on if the foot is planted on the ground or is not

planted in the ground and is described as either an open or closed kinetic chain. In an open

kinetic chain, where the foot is not planted on the ground, the tibia glides anteriorly on the femur

during extension.7 Open kinetic chain flexion and extension occurs during the swing phase of

gait. From 20 degrees to 0 degrees full extension the tibia externally rotates, called the “screw

home mechanism” to achieve maximum stability in the knee.7 The screw home mechanism is

very important during activities like running where a lot of stability is required during certain

movements. During open kinetic chain flexion, the tibia glides back posteriorly on the femur and

from full extension to 20 degrees flexion, the knee unlocks, creating internal rotation of the

tibia.7 When the foot is planted such as during the stance phase of gait and a squat, the femur

glides posteriorly on the tibia during extension and anteriorly during flexion.7 The screw home

mechanism occurs during the last 20 degrees of full extension here as well, where there is tibial

external rotation during the last 20 degrees of full extension and to unlock from 0 degrees to 20

degrees extension there is internal rotation.7

The knee requires complex stability that comes from ligaments, meniscus, and other

anatomy listed above, as well as arthrokinematics processes like the screw home mechanism.

2
Along with this, there are complex musculature that surround the knee above and below to

provide stability as well as motion at the knee. Above the knee, the quadriceps femoris is the

strong extensor of the knee.8 The quadricep femoris include four muscles: the vastus medialis

oblique, the vastus intermedius, the vastus lateralis, and the rectus femoris.8 The hamstrings,

consisting of the semitendinosus and semimembranosus and biceps femoris work to flex the

knee.8 The semitendinosus and semimembranosus also internally rotate the knee and the biceps

femoris externally rotates the knee.8 Along the thigh crossing the knee the gracilis and sartorius

flex and internally rotate the knee.8 On the back side of the knee the popliteus also flexes and

internally rotate the knee.8 And finally, below the knee the calf muscle or the gastrocnemius is a

weak flexor of the knee.8

There are multiple other muscles at the hip and the ankle that work to have function on

the knee as well. The most notable being the hip abductors, the gluteus medius and gluteus

minimus as well as the tensor fasciae latae.8 These muscles primarily work to move the hip out to

the side, but in a closed kinetic chain they work to control knee valgus, described as when the

knee caves inwards.8, 9 Knee valgus is a common position that when not controlled correctly can

cause knee pain and injury.10

Due to this complex anatomy and arthrokinematics that occur at and around the knee,

there are a lot of injuries that can occur. Out of all of the knee injuries that could occur, 40% of

knee pain complaints orient specifically to the anterior portion of the knee making anterior knee

pain one of the most common knee complaints in individuals that are physically active.2, 11

Anterior knee pain can be caused by two mechanisms: acute traumatic injuries and

overuse injuries.12 Acute traumatic injuries are related to those where there is a traumatic event

that caused injury. These injuries to any muscle that is strained or torn causing anterior knee

3
pain, there is a tear or sprain to a ligament in the knee causing anterior knee pain, or there is a

meniscal injury leading to anterior knee pain.12 Overuse injuries are very common in those

physically active due to the amount that the knee is used in activities that include running and

walking. Common overuse injuries are patellofemoral pain syndrome (PFPS), patellar tendonitis

and any other tendinopathy causing anterior knee pain, iliotibial band syndrome, and more.13

Some of the most common injuries that can lead to anterior knee pain are ligamentous

injuries such as an ACL sprain or tear, patellar tendonitis, and PFPS. Ligamentous tears are very

common, with ACL injuries alone being reported with an injury rate of 2.8 and 3.2 per 10,000

collegiate athletes.14 These often occur during non-contact situations, making them fall into the

acute traumatic injury category. Approximately 75% of ACL tears occur in a non-contact related

incident during sport.15 ACLs occur often during a cut and plant or landing scenario where the

athlete is in a weight bearing position and an increase force is being placed on the ACL that the

ligament cannot accept, so it tears.15

Patellar tendonitis is a very common injury that occurs to the anterior portion of the knee,

especially in runners.16 Increase incidence of patellar tendonitis occur because of the repetitive

loading that occurs to the patellar tendon, during running, which makes it a chronic anterior knee

pain diagnosis. Repetitive loading of the patellar tendon where the quadricep is consistently

working to extend the knee causes stress on the patellar tendon and has been shown to be the

most significant risk factor in those suffering from patellar tendonitis.17

PFPS is an umbrella term used to describe some sort of anterior knee pain that is coming

directly from the patellofemoral joint itself. PFPS is a chronic injury that tends to hurt when an

individual performs activities like squatting, stairs, and running.18 This can be caused from

4
overuse of the patellofemoral joint, abnormalities in anatomical makeup of the knee, abnormal

biomechanics during gait, or muscle weakness, specifically in the quadriceps and hip abductors.18

There are a lot of common impairments and abnormalities that can lead to an increase

risk of obtaining an acute traumatic and chronic overuse anterior knee injury. Anatomical

differences such as decreased concavity of the medial tibial plateau, increased slope of the tibial

plateaus, and increased anterior-posterior knee laxity have been shown to have increased risk for

ACL injury.14 Other anatomical differences such as improper patellar tracking have also been

shown to lead to anterior knee injury. Improper patellar tracking, otherwise known as

patellofemoral maltracking, accounts for up to 8% anterior knee pain and is the second most

common cause for an early revision of a knee arthroplasty.19 Patellofemoral maltracking can lead

to anterior knee pain and is often associated with PFPS.20

Weakness is another very common result of anterior knee pain. Most commonly,

weakness in the quadriceps is often seen in those with anterior knee pain.21 Weakness has been

shown to increase risk of obtaining an ACL injury and general lower extremity strengthening and

neuromuscular training, especially the quadriceps and gluteus medius in particular, have been

shown to decrease risk of obtaining an ACL injury.22, 23 Patellofemoral mal-tracking begins with

muscle imbalances and muscle weakness in the quadriceps and can lead to overuse injuries such

as patellar tendonitis if the patella tracks abnormally for too long.24

Biomechanical changes such as gait abnormalities, running form, and jumping/landing

form during physical activity are a common cause of anterior knee pain. Increased knee valgus,

in a weight bearing position, has been shown to be a common impairment to cause and increase

risk in ACL injuries as well as PFPS.22, 25 Knee valgus relates to both jumping off and landing on

one and two legs as well as pushing off and landing on a single leg during running. During gait,

5
lower extremity injuries have been reported to range from 19-79% in runners.26 Altered running

mechanics has been shown to lead to an increase risk for PFPS.27 Examples of altered running

mechanics are pelvic drop, excessive knee valgus during stance phase, excessive subtalar

pronation during stance, and delayed resupination and during the late phase of stance.

Due to there being so many different conditions associated with anterior knee pain,

differential diagnosis is very important. Diagnostic imaging is a very good indicator to obtain an

in-depth examination of the knee. This includes anterior posterior, lateral and transverse views of

the knee. X-rays are often used to diagnosis arthritic changes in the knee.28 Magnetic resonance

imaging (MRI) is a great diagnostic tool with a very high percentage of accuracy for correct

diagnosis for ligamentous injuries and meniscal injuries.29 MRI will also show any thickening or

tearing to the patellar tendon which can show changes for patellar tendinopathy diagnosis.30 And

finally, diagnostic ultrasounds are often used to diagnosis patellar tendonitis and ligamentous

injuries in the knee.31

Differential diagnosis also occurs during subjective and physical examination of the knee.

Subjective examination can allow for information to be obtained specifically on mechanism of

injury to relate whether the knee pathology is an acute or chronic condition and whether trauma

was involved. Subjective evaluation also can allow for insight on the overall lifestyle and habits

of an individual which can determine a lot on the type of knee diagnosis that is appropriate. This

can help provide a lot of incite on overuse knee injuries. Along with subjective examination,

physical examination looking at range of motion (ROM), strength, balance, and gait can allow

for further incite on the type of knee injury. Some movement patterns such as a single leg squat

can indicate patellar tendonitis, if there is pain in the patellar tendon with the single leg squat.32

6
 Conservative intervention via physical therapy has been shown to be an effective

intervention in reduction of anterior knee pain.24, 33 As described by the American Physical

Therapy Association (APTA), physical therapy can prescribe a progressive exercise program that

is not only limited to improve strength and ROM, but also improve balance, coordination,

endurance, flexibility, and provide biomechanical evaluation and intervention for gait and

running.34 Every program should be individualized based off the presented findings that are seen

following an examination.

Depending on the examination findings and diagnosis given, interventions implemented

by physical therapy will vary. Management and reduction of pain occurrence includes

decreasing activity level and activities that are causing pain to give time to irritated tissues that

need to heal. Modalities can be implemented through physical therapy practice. Cryotherapy, or

the use of cold for reduction of pain are very frequently administered to reduce anterior knee

pain. There is a lack of current clear evidence for the use of cryotherapy in patients with anterior

knee pain, but it has been shown to decrease inflammation, swelling, and pain.35 A very

commonly implemented modality, neuromuscular electrical stimulation (NMES) has insufficient

evidence to be an effective means for pain relief in those experiencing anterior knee pain.

Thermotherapy, the use of heat and hot packs for pain reduction also has insufficient evidence in

terms of pain reduction for anterior knee pain.36

Physical therapy can help in addressing ROM deficits and flexibility which is often seen

in patients with anterior knee pain.37 Increase ROM is done by prescribing a stretching program

and soft tissue mobilization. Static stretching for at least 30 seconds is shown to be effective at

improving acute flexibility in musculature.38 Improvement in flexibility of the quadriceps and

7
hamstrings have been shown to improve patellofemoral joint mechanics.37 Soft tissue

mobilization has been shown to increase range of motion as well as reduce pain.39

Physical therapists can also prescribe an individualized strengthening program.

Strengthening of the hips and knees is widely supported to help reduce anterior knee pain.18, 40, 41

This includes performing different exercises using gravity, elastic bands, weights, and machines

to increase strength in the hips and knees to reduce anterior knee pain. Strengthening of the knee

extensors leads to increase in neuromuscular control with proper recruitment and firing pattern of

the quadricep muscles, to provide proper patellar tracking.41 Strengthening of the hip abductors

leads to increase in neuromuscular control of knee valgus during dynamic activities like

running.9 Different exercises using isometric, eccentric, and isotonic contractions can be used

based off of the patient’s pain and pathology they are dealing with. Isometric exercises where the

muscles length is not changing, tend to provide the least amount of stress on tendons, causing

minimal to no pain in patients with patellar tendonitis during exercise.42 This allows for strength

to be built without causing an increase of pain. This can be progressed to eccentric exercises

where the muscle is lengthening through the contraction, as these too are shown to be less

painful in patients with tendonitis as well as build the most strength as compared to isometric and

concentric exercises.42 Eccentric exercises are also proven to provide the least amount of stress

on the patellofemoral joint, meaning they are less stress and painful on the joint itself.41

Physical therapists can prescribe balance exercises to increase both static and dynamic

balance to reduce risk of falls and increase balance during activities like gait and sport. Dynamic

balance is an important component to have control over to reduce risk of further knee injury as

this is often associated with anterior knee pathologies.22, 25

8
 Finally, physical therapists can perform gait and functional movement evaluations to

address biomechanical changes that occur during different activities like running and squatting.

Providing augmented feedback via visual feedback by recording someone walk has been proven

to be a very effective intervention to decrease biomechanical abnormalities during gait.43 This

allows for in-depth assessment of abnormalities such as dynamic knee valgus and pelvic drop

associated with gluteus medius weakness so that physical therapy can prescribe functional

exercises to improve strength in these muscles and help reduce anterior knee pain.8, 9

The purpose of this case report is to describe the physical therapy management and

prescription of exercise in an outpatient environment for a 34-year-old-male who is a new runner

experiencing anterior knee pain. Prior to preparing this report consent was obtained from the

patient to proceed. All information contained in this case report meets the Health Insurance

Portability Accountability ACT (HIPPA) requirements of the clinical agency for disclosure of

protected health information. This case report was completed under the direction of the

Department of Physical Therapy and with the oversight of the College of Graduate Studies at

Central Michigan University.

Case Description

The patient is a 34-year-old male with chief complaints of right sided anterior knee pain

when running. The patient was referred by his primary care physician (PCP) to an outpatient

orthopedic Physical Therapy location for examination and treatment.

Patient History and Systems Review

9
 Per a review of the patient’s information prior to the initial evaluation (IE), the

information that was available was that his chief complain was right sided anterior knee pain

while running and he had been initially screened by his PCP 7 days prior. The patient had started

running in the past year and had been running around 12-15 miles a week. He also had pain

rolling in bed as well as going downstairs. At its worst, the patient rated his pain a 5/10, but at

rest he would be pain free. The patient was independent for all community and activities of daily

living (ADLs) for his prior and current level of function. The patient was currently on no

medications. There were no listed comorbidities that would affect physical therapy outcomes. Of

note, the patient was allergic to coconut. This was marked as a warning in the patient’s chart

because Biotone Dual Purpose Massage Cream (Biotone Massage Products, 4757 Old Cliffs Rd.

San Diego, California 92120) has coconut as a listed ingredient and was often used as a lubricant

for soft tissue mobilization (STM) in the clinic. The patient reported that he would break out in a

rash if he were to consume, or come in contact, with coconut. It was also noted that the patient

worked in the educational system of a local church, where he performed a lot of standing and

sitting for long periods of time.

Clinical Impression #1

Following the review of the patient’s history, with the patient being a newer runner and

having anterior knee pain, the initial impression is of an overuse injury within the realms of

patellofemoral pain syndrome. Patellar tendonitis is the most common knee injury experienced in

runners.44 Newer runners also may increase their mileage too quickly.44 Both of these factors will

have to be taken into consideration during the examination process. The patient seems to be at a

very high level of function given that he is running 12-15 miles a week and is performing ADLs

10
and community activities independently. He is on no medications and has no comorbidities that

will affect physical therapy treatment.

Physical Therapy seems appropriate for the patient due to his given complaint of anterior

knee pain. Physical Therapy has been shown to be an effective intervention in reduction of

anterior knee pain.33 Given his present history and complaints the following will be tested. ROM,

muscle length testing (MLT), and manual muscle testing (MMT) of the core and lower

extremities (LE) will be assessed and compared bilaterally. Strength deficits, especially in the

hip abductors and knee extensors are important to measure as these are often associated in those

with anterior knee pain.21 ROM deficits can lead to changes in biomechanics during activities

such as running, which can lead to anterior knee pain, so measurement of lower extremity range

of motion is also important.45 Palpation of different anatomical landmarks and soft tissue are also

indicators for certain anterior knee pathologies. Tenderness along the patellar tendon is an

indicator for patellar tendonitis.46

Special testing of muscle length and fascial tension may also be included. Functional

mobility will be assessed by performance of functional squat and single leg squat. Pain with a

single leg squat is likely to be correlated with patellar tendonitis.32 Given the similar

biomechanics a functional squat also may be painful. Balance will be assessed with use of a

timed Single-Leg stance test with and without the eyes open. Balance should be address due to

the fact that neuromuscular deficits have been shown to be common in those with anterior knee

pathologies.23 The patient will be graded on LE function by taking a Lower Extremity Functional

Scale (LEFS) as well as the University of Wisconsin Running Injury and Recovery Index

(UWRI). Both of these outcome measures have been shown to be reliable and valid in previous

research.47, 48, 49 If approved by the patient’s insurance, a gait evaluation with use of recording the

11
patient on a treadmill and computer software to analyze gait during walking and running will

also be performed.

Examination

Range of Motion. The patient’s lower extremity (LE) active range of motion (AROM) was

grossly assessed.6 ROM measurements have been shown to have good interrater reliability

(r=0.98, ICC: 0.99) and have a good content validity (r=0.97, ICC: 0.99). 50, 51 The patient’s

AROM was grossly screened without utilization of a goniometer. A goniometer was not used

because it was deemed that the patient was within functional limits (WFL) for the AROM screen.

WFL is defined as the patient being able to achieve AROM that would allow them to complete

their activities of daily living (ADLs) independently.6 The patient was WFL for hip flexion, hip

extension, hip abduction, hip adduction, knee extension, knee flexion, and ankle plantarflexion.

His only noted deficit was in ankle dorsiflexion where he had 9 degrees on his right and 4

degrees on his left when measured in non-weight bearing. The normal AROM when measured in

non-weight bearing is 16 degrees of dorsiflexion.52 This could affect running because a runner

should have at least 15 degrees of AROM for efficient running.45

Manual Muscle Testing. MMT has been shown to be both valid and reliable in previous research

to assess strength of individual muscles or groups, with good interrater reliability (k=0.62-0.67

for different muscle groups).53 MMT has been shown to have strong content validity in previous

research as well.54 MMT was screened in a non-standardized position and utilized the widely

known MMT scale ranging from 0-5.6 The relevant grades for the patient are as listed: 3+/5: Full

AROM against gravity; minimum resistance. 4/5: Full AROM against gravity, moderate

resistance. 5/5: Full AROM against gravity; maximum resistance.6 Addition of 4-/5, 4+/5, and

12
5-/5 were also utilizes to allow for documentable changes in strength as the patient may not be at

a 5/5 strength but has gotten stronger due to treatment. The patient scored a 5/5 for knee

extension on the left and 4-/5 on the right, with no pain. He scored a 4-/5 for knee flexion on the

left and 4-/5 on the right. He scored a 4+/5 bilaterally for internal rotation, external rotation, and

flexion of the hips. He scored a 4/5 for hip abduction on the left and a 3+/5 on the right. He also

scored a 4/5 for hip extension on the left and 3+/5 on the right. This indicated that the patient

exhibited weakness bilaterally in his hips with his right hip being weaker than his left.

Muscle Length Testing. MLT has been shown to have good intra-tester reliability (ICC: 0.97-

0.98) and good content validity (r=0.97, ICC: 0.99).51, 55 The patient’s hamstrings were assessed

using a passive knee extension test at 90 degrees hip flexion and beginning at 90 degrees knee

flexion. The patient received scores of 60 degrees on his left and 65 degrees on his right,

indicating tightness bilaterally. Muscle length testing of the hip flexors was also assessed with

utilization of the Thomas Test. The patient is supine and passively holds his opposing hip into

maximum flexion and lays back on a table with the opposite thigh and leg hanging off to

maximally stretch the hip flexor musculature. The patient received positive scores bilaterally as

his extended thigh did not touch the table when holding the opposing thigh at his chest at

maximal hip flexion. This indicated tightness in the hip flexors bilaterally.

Palpation. There was no tenderness to palpation along the right-side patellar tendon when

palpated by the therapist. Patellar tracking was assessed in the supine position with the patient

actively performing knee extension to assess superior glide of the patella. Left and right sides

were compared with the right side demonstrating a slight lateral superior tracking pattern rather

13
than direct superior as compared to the left. Tenderness to palpation is a clinical indicator for

patellar tendinopathy, therefore, this may not be the appropriate diagnosis for this patient.46

Balance. The Single-Leg Stance Test was utilized to assess balance. The Single-Leg Stance Test

has good intra-rater reliability (ICC: 0.91) and has been shown to be an effective and valid tool

to measure static balance.57, 58 The patient was able to perform SLS for 60 seconds (s) on the left

side with his eyes open and 24s with his eyes closed. He scored 60s on his right with his eyes

open and 10s with his eyes closed. Males aged 18-39 normative values are 44.4s with eyes open

and 16.9s with eyes closed indicating that he has balance deficits bilaterally with more deficits

present when balancing on his right leg.59

Pain. The patient was then grossly screened for pain with functional squatting movement

patterns as pain with a single leg squat can be indicative of patellar tendonitis.32 There was no

pain during both a standard shoulder width squat and a single leg squat when assessed.

Outcome Measures. The Lower Extremity Functional Scale (LEFS) was utilized to assess LE

function during specific ADLs. This functional scale is scored 0-4 with 0 being extremely

difficult or unable to perform, 1 being equivalent to quite a bit of difficulty, 2 being equivalent to

moderate difficulty, 3 being a little bit of difficulty and 4 being no difficulty at all for a multitude

of different ADLs. The LEFS has excellent internal validity (α=0.96) and is also a valid tool to

assess individual change in LE function, as compared to the 36-Item Short Form Survey. 47, 48

The patient scored a 74/80, indicating that he has 7% limitation during ADLs. This indicates

that the patient is not very limited in his general ADLs by his knee pain. Additional

14
information regarding AROM, MMT, and outcome measurements can also be viewed in Tables

1, 2 and 3.

Clinical Impression #2

Tenderness along the patellar tendon during palpation as well as pain along the patellar

tendon during a single leg squat are both indicators for patellar tendonitis.32, 46 Due to the lack of

pain with functional squats as well as there being no pain upon palpation of the patellar tendon, it

is unlikely that the hypothesized diagnosis of patellar tendonitis is correct. Based off of the

examination findings, patellar tendonitis is not the true diagnosis. In saying that though, it is not

ruled out based on the fact that the patient is a new runner, has been logging over 12 miles a

week and still has anterior knee pain. This means that overuse of the patellar tendon is still

possible.

The patient exhibited weaknesses in his right hip as compared to his left, especially

present in hip abduction, and hip extension. These weaknesses could lead to some biomechanical

changes at the knee, as strong hip abductors lead to reduction in dynamic knee valgus during

activities such as running.9 Reduced hip abduction strength and increased knee valgus in runners

can lead to an increase in patellofemoral pain during running.10 The patient could be having an

increase in knee valgus during running which could be leading to knee pain. The patients

dynamic knee valgus will be looked into further during a running specific gait assessment.

The patient also demonstrated reduction in flexibility with a positive Thomas test, and

reduced hamstring flexibility during the passive knee extension test at 90 degrees hip flexion and

90 degrees knee extension. The patient's lack of flexibility in these areas could also lead to

15
biomechanical changes during gait causing pain. The patient’s lack of flexibility will be further

assessed during a running specific gait assessment.

Improper patellar tracking can also lead to an increase in patellofemoral pain56 When

assessed with using active knee extension it was found that the patient’s right patella was

tracking slightly laterally, potentially indicating muscle imbalances throughout the vastus

lateralis and vastus medialis oblique.56

The patient’s goals were determined after the examination. The patient will be

independent with his home exercise program (HEP) to allow for safe completion of exercises

outside of the clinic. The patient will return to performance of ascending and descending stairs

without reports of pain to allow for pain free community activities. The patient will deny pain

with rolling over in bed in both directions to allow for pain free sleeping. The patient will

increase balance Single Leg Stance Test to greater than 15s with eyes closed bilaterally to allow

for increase balance and reduce risk of falls or injury. The patient will improve hamstring

flexibility to 90 degrees and a negative Thomas Test bilaterally to allow for improved running

mechanics. The patient will improve MMT grades to 5/5 to allow for increase LE strength to

improve running mechanics at the hips and knees.

All of the goals were to be completed by discharge. Due to the proposed plan of care

(POC) and prognosis of the patient it was expected he would participate in physical therapy for 2

visits a week for 4 weeks and evaluate at that time if more intervention is needed. Running

outside of the clinic will also be monitored and if pain surfaces, the patient will be advised to

stop running. In the clinic and for his HEP the focus would be on hip and knee strength, as well

as dynamic and static balance, with primary focus on the hip abductors to control knee

16
mechanics. Pending insurance approval, a running specific gait evaluation will be performed to

gain more insight on the patient’s specific mechanics during running and walking.

Interventions

Interventions will be described on a per week timeline and organized into therapeutic

exercise, therapeutic activity, neuromuscular re-education, and gait. Not all interventions will be

utilized weekly as interventions may differ from week to week. See Table 5 for full interventions

log.

Week 1. The patient was instructed in therapeutic exercise during the initial evaluation at the end

of the session. Due to the patient's flexibility deficits, he was instructed in a 3-way belt assisted

straight leg raise (SLR) hamstring stretch as well as a half kneeling couch hip flexor stretch.

Each of these were done for 3 sets of 30 seconds as static stretching for at least 30 seconds is

shown to be effective at improving acute flexibility in musculature.38 The patient was instructed

to perform these exercises 2-3 times a day, every day. The patient was also educated on the

difference between static and dynamic stretching prior to running. Static stretching has shown to

lead to an increase in LE injury rate and a reduction in force and jumping performance prior to

physical activity.60 whereas dynamic stretching does not and allows for a sufficient warmup prior

to physical activity.61

The patient progressed by tolerating an increase in therapeutic activity the following visit.

The patient was seen by another therapist the second visit due to scheduling change but

completed the exercise log written by the therapist that performed the evaluation. This included

the Total Gym (Total Gym Fitness, LLC) squatting for 6 minutes at level 7 as a warmup as well

as to build endurance in the hip extensors and knee extensors. Squats improve strength in the hip

17
extensors and knee extensors and performing in a gravity minimized position where an

individual can perform the movement for a period of 6 minutes allows for muscular endurance to

be improved.62, 63 He progressed to performing supine bridges for 2 sets of 10 repetitions, to build

strength in his hip extensors.64 Performing exercises in 2-3 sets of 10 repetitions promotes

muscular strength rather than power or endurance to be built in the muscle.63 He also performed

side lying banded clamshells and side lying hip abduction to increase strength in his hip

abductors and hip external rotators for 2 sets of 10 repetitions.65

Following these exercises, therapeutic activity progressed to performing forward and

lateral step ups onto a 6-inch box to improve hip extension, knee extension, and gluteus medius

strength as well as improve single leg balance.66, 67 This exercise was performed for 1 set of 10

repetitions leading with each foot for each direction leading, totaling 40 steps by the end.

Additionally, the patient was instructed in the steamboat exercise. The patient placed a band

around the back of one heel which was then lifted into the air during active hip extension,

abduction, adduction, and flexion. The opposite leg remained planted on the ground. The

exercise was performed while facing four different directions on both legs for 1 set of 10

repetitions in each direction. This exercise works on improving the stance leg ability to control

the oscillatory motions being created at the hip by the opposing leg building stability and

strength bilaterally in the hips and knees as well as in the core.68

Therapeutic activity continued with TRX band (TRX Training, 1990 N California Blvd

Suite 20 PMB 1058, Walnut Creek, California 94596) squats for 2 sets of 10. TRX squats were

done to challenge the hip and knee extensors.62 Seated hamstring curls were also performed with

a green band around the posterior aspect of the heel for knee flexion resistance. Seated hamstring

curls were done for 2 sets of 10 to build strength in the knee flexors.69

18
 Following therapeutic activity, neuro-reeducation was completed. The patient completed

prone gluteus maximus isometrics with a terminal knee extension hold to promote corticomotor

excitability in the gluteal complex. The exercise may also retrain the gluteus maximus to

contract in the correct neuromuscular pattern for exercises where the gluteus maximus have to

contract, such as a squat or running.70 Prone gluteus maximus isometrics with a terminal knee

extension hold was done for 2 sets of 10 for 3 second holds to increase neuromuscular control of

the gluteus maximus. The patient completed static balance on a rocker board in four directions to

improve dynamic balance by challenging oscillatory motions during the functional stance

pattern.71 Static balance on a rocker board has been shown to increase ankle, hip, and trunk

strategies throughout to maintain upright. Static balance was done with the rocker board facing

anterior-posterior, medial-lateral, and two oblique planes for 60s each. The patient also

performed alternating single leg stance of 10 seconds on one leg, and 10 seconds on the other leg

for a total of 3 minutes. By reducing the patient’s base of support, alternating leg stance

improves static balance.58, 71 Following the session, the patient reported feeling fatigued but

reported no pain during or after exercise.

Week 2. The patient filled out the University of Wisconsin Running Injury and Recovery Index

(UWRI) prior to the first session for week 2. The UWRI is a valid tool to assess running ability

after an injury and has been shown to have acceptable internal consistency (α = .82) and good

test-retest reliability (ICC = 0.93).49 He received a score of a 21 out of 36. The categories that

significantly stood out are that the patient reports moderate frustration with his pain when

running as well as with his injury, and that his injury has moderately reduced the amount he can

run. The patient self-reported that this only limited his mileage by a mile or two a week, but that

19
he was not on any particular program for running that exactly tracked his mileage. If the pain

does not decrease as he continues to run while also attending physical therapy then mileage may

need to be something that is tracked and reduced specifically. More information can be found in

Table 4 for the UWRI.

The patient reported that he ran four miles total in two different sessions over the

weekend with no knee pain. Week two was very similar to the previous session ending the first

week. The patient self-reported an increase in soreness the day after the second session on week

one in the glutes, as well as decreased but still present soreness following the first session during

week two. Therefore, very minimal changes were made to the POC for therapeutic activity and

neuro-reeducation for week two. For therapeutic activity, the patient completed the Total Gym at

level 7 for 6 minutes for hip and knee extension endurance and to warm up. The patient

progressed to 1 set of 10 each direction during the banded steamboat exercise on each leg to

improve hip strength and stability as well as knee and ankle stability. 1x10 of forward and lateral

step ups on the 6-inch box was the only exercise progressed based off of clinical reasoning by

the therapists that the exercise was too easy for the patient. The patient was agreeable that the

exercise was not challenging enough on his hips to build strength. This was progressed the 2nd

session of week 2 from a 6-inch box to 1 10-inch box for the same frequency of 1 set of 10. In

addition to the increase in box height progression to challenge more hip extension progression

strength, a march was added at the top of the step up.

The goal of this progression was to increase neuromuscular control of the hip abductors by the

patient having to maintain a stable pelvis as he held a march.8, 33 He then progressed to 2 sets of

10 repetitions of supine bridges, side lying banded clamshells and side-lying banded hip

abduction to improve hip extension, hip abduction, and external rotation strength. To continue to

20
build hamstring strength, seated hamstring curls were completed for 2 sets of 10 with a green

band. TRX squats were performed to build hip and knee extension strength in the functional

squat position for 2 sets of 10.

Neuro re-education continued with prone glute isometric with terminal knee extension for

2 sets of 10 bilaterally for 3 second holds to improve neuromuscular firing of the gluteal

complex. 3 minutes of alternating 10 second single leg stance with no upper extremity support

for improved single leg balance. He also performed the 4-way rocker board exercise for static

balance control during in a functional stance pattern for 60s each direction. The patient exhibited

increased sway with trunk, hip, knee, and ankle strategies as similar to the last week, so balance

exercises were not progressed at this time.

Week 3. The patient reported a continued but decreased muscle soreness following exercise on

the first session of the third week and he had run twice over the weekend with both runs being

about 2 miles long. He felt pain following the second run of 3/10 in the anterior portion of his

right knee. Although the patient reported soreness and some increase in pain following running

this weekend, a clinical reasoning decision was made to progress therapeutic activity during both

sessions to continue to challenge strength. Progression of therapeutic activity was done because

this would likely not increase his pain and the patient has been reporting decrease muscle

soreness.

Therapeutic activity continued with Total Gym squatting at level 7 for 6 minutes for hip

and knee extension endurance and to warm up for both sessions. Steamboats continued with the

green band around the ankles for 10 repetitions all four directions as this was still challenging for

the patient. Step ups remained the same frequency and difficulty for x10 with a march forward

21
and laterally, as the patient was just recently progressed in this exercise and this was deemed an

adequate challenge for hip and knee extension strength.

Side lying clamshells, and side lying hip abductions were some of the movements

progressed to 2 sets of 15 rather than 2 sets of 10 to continue to challenge hip abduction and

external rotation strength. Supine bridges were progressed with an addition of a red band just

above the patient’s knees to force a hip abductor isometric during the hip extension pattern.

Supine bridges were done for 2 sets of 10 and was progressed because this exercise was reported

becoming less difficult by the patient. TRX squats were progressed this first session this week to

performing goblet squats with a 4kg kettlebell held at the patient’s chest for 2 sets of 10. An

informal squat assessment was done prior to addition of the weight and it was determined that

addition of the kettlebell would be done to continue to challenge the knee extensors and hip

extensors in a squat position, but that that patient could handle an increase load without a loss in

form. The goblet squat has been shown to be an effective means of improving gluteal complex

and quadricep strength.63 The patient tolerated the 4kg well and reported that it felt easy after the

first visit on the third week, so he was progressed to 6kg the second visit on the third week.

Seated hamstring curls remained with 2 sets of 10 the first session of week three but then

were progressed the second sessions this week to supine hamstring curls with an exercise ball for

2 sets of 8. Seated hamstring curls were progressed to supine to challenge the hamstrings even

more than just through hip flexion but also being in supine allowed for hip extension to be

performed as the patient has to completed the exercise with a hip extension isometric while he

repetitively flexes the ball in with his knees.8 Addition of lateral stepping and monster walks with

a red band around the patient’s forefoot was done to build strength in the hip abductors during a

single leg stance pattern. These exercises have been shown to be very effective at increasing

22
gluteus medius strength.68 The band was placed around the forefoot rather than around the knees

or ankles to increase gluteus medius activation rather than tensor fascia latae activation.72 Lateral

stepping and monster walks were done for 45 feet for two times for the first session during the

third week and progressed to 45 feet for four times during the second session on the third week

due to the fact that the patient stated he believed he could complete two bouts of the exercises

rather than one.

Neuro-reeducation remained consistent with the prone gluteus maximus isometric with

terminal knee extension exercise as this was still challenging for the patient. Terminal knee

extension was done for 2 sets of 10 bilaterally for 3 second holds. The rocker board balance

exercise also was not progressed due to consistent sway present in the trunk and ankles during

the exercise. Rocker board balance was performed for 60s in each four directions to continue to

challenge balance in a functional stance pattern. Single leg balance was progressed to be

performed on a foam pad. Addition of the foam pad has been shown to still improve balance

ability and was deemed as an appropriate progression to simulate an unstable surface such as

grass.73 Single leg balance was performed for 3 minutes total, alternating 10 seconds on one leg,

and 10 seconds on the other leg.

Following the second session in the third week it was deemed that the prone gluteus

maximus isometrics with terminal knee extensions, the banded side lying hip abduction and

clamshells would be performed at home to continue to progress strength outside of the clinic.

The patient was educated on this and it was deemed by the therapist he was able to do so safely

with correct form.

23
Week 4. Week four began during the first sessions with an updated progress note where strength,

ROM, and outcome assessments were reevaluated to deem if Physical Therapy was still

appropriate for the patient. The patient scored a 75/80 on the LEFS indicating a 6% limitation

during his ADLs indicating that the patient is not very limited in his general ADLs by his

knee pain. The patient increased his URWI score from a 21 to a 24/36 indicating improvement

with frustration on pain when running. His AROM in his ankle dorsiflexion increased to 6

degrees on his left and 10 degrees on his right, however there are continued limitations in this

motion. And finally, strength improved in his bilateral LE. He scored a 5/5 on bilateral hip

flexion, bilateral hip internal rotation and right knee extension. Left knee extension was not

tested because this was a 5/5 during initial testing. He scored a 4+/5 on bilateral hip external

rotation, bilateral knee flexion, and left hip abduction. He scored a 4/5 on right hip abduction and

left hip extension, and he scored a 4-/5 on right hip extension.

Therapeutic activity and neuro-reeducation was progressed this week due to therapist

clinical reasoning that it was time to progress exercises and patient perceived challenge during

the exercise. The patient reported running 2 miles one day and 4 miles the second day over the

weekend and reported zero knee pain during and following running.

Therapeutic activity continued with Total Gym squatting at level 7 for 6 minutes for hip

and knee extension endurance and to warm up for both sessions. Steamboats continued with the

green band around the ankles for 10 repetitions all four directions for the first session of week

four and was progressed to a blue band, or increased resistance for the second session during

week four. Step ups were progressed during the first session of week four to increase the

patient’s perceived challenge to a 12-inch box for the same frequency of 10 each leg forward and

laterally. Goblet squats were progressed during the first session of week four to 3 sets of 10 with

24
the 6kg kettlebell to continue to challenge quadricep and gluteus maximus strength. Lateral

stepping and monster walking were progressed in band resistance to a green band to improve

gluteus medius strength for the same distance and frequency of 45 feet for four times.

Three new exercises were added the first session during the fourth week as time allotted

for this due to multiple exercises being added to the patient’s HEP during week three. Standing

banded clamshells with the green band were performed for 2 sets of 5. One leg was in single leg

stance and the opposing was planted into the wall and performed hip abduction. The goal of this

exercise was to challenge bilateral gluteus medius strength in a single leg’s stance pattern. The

patient reported moderate fatigue during this, therefore only 5 repetitions were performed.

Hip thrusts with a green band above the knee for gluteus medius isometric were also

added. Hip thrusts were performed off of the lowest exercise table at 18 inches above the ground,

for 2 sets of 10 to improve gluteus maximus, as this has been shown as one of the most effective

exercises to do.74, 75The patient was thoroughly educated on proper hip thrusting form and was

able to perform the exercise correctly.

Finally, resisted corded walking for 10 feet in all four directions was performed for 5 reps

during the second session of week four. This being anterior, lateral both directions, and posterior.

Resisted cord walking was completed to apply an external resistance during walking to improve

general lower extremity strength during walking. The patient tolerated this increase in

therapeutic activity well with no pain and minimal to moderate reported fatigue following.

Neuro-reeducation balance exercise remained consistent this week as the patient still

exhibited increase sway in his trunk and ankles to counteract his loss of balance. These exercises

consisted 3 minutes total, alternating 10 seconds on one leg, and 10 seconds on the other leg on

the foam pad, and the 4-way rocker board balance for 60s each direction.

25
Week 5. At this date the patient reported that he ran 3 miles both days over the weekend and had

no pain during or following running. When in Physical Therapy, a formal gait evaluation

utilizing an iPad (Apple Inc, One Apple Park Way Cupertino, California 95014)and the Coach’s

Eye – Video Analysis (TechSmith Corporation, 2405 Woodlake Drive Okemos, Michigan

48864-5910) application was used for recording and analysis of the patient’s gait on a treadmill.

The patient was instructed to walk at a comfortable pace for 10 minutes and then ran for around

5 minutes at 7.5 miles per hour as a posterior and lateral view were recorded for 10 seconds each

in the middle of the 5-minute interval. Following the recording, the patient was instructed to

walk for 5 minutes before getting off of the treadmill. Following the 5 minutes of walking the

patient performed resisted corded walking in an anterior, lateral in both directions, and a

posterior direction were completed for 10 feet.

During the time the patient was finishing up on the treadmill and performing the resisted

walking, gait analysis was completed. Markers were placed on the patient’s posterior superior

iliac spines, greater trochanters, midline of the posterior aspect of the knee, midline of the

posterior aspect of the calves, and midline of the calcaneus to allow for specific angles to be

obtained for pelvic drop, and supination/pronation. The testing assessments that stood out

following the patients gait analysis were that he had pelvic drop bilaterally with his left being 16

degrees and his right being 9 degrees. During running, pelvic drop should stay within 5-7

degrees.76 Increased pelvic drop indicated gluteus medius weakness.76 The patient also exhibited

delayed resupination bilaterally from midstance to toe off, as the foot should supinate with no

delay during this time.43 And finally, he also had increased heel strike during stance phase at

initial contact. The patient was educated on these abnormalities and was shown these specifically

26
as providing visual feedback by recording someone run can help reduce biomechanical

abnormalities during gait.43 There were no adjustments made to his plan of care as increasing

gluteus medius strength has been a goal. The only exception for changes that were made was that

a posting was created to fit on the underside of his show lining across the 1st and 2nd metatarsal

heads to help with the delayed resupination. This has been shown to be an effective way to help

improve supination during running.77

The following Physical Therapy appointment for week five, the patient was able to get

back on his similar exercise regimen as the gait evaluation took up a lot of time for the previous

visit. Therapeutic activity continued as he performed 10 repetitions of the steamboat exercise in

all four directions as instructed during previous visits to help increase strength in the hip flexors,

abductors, extensors, and adductors bilaterally. Steamboats were completed using the blue band

wrapped around his ankle to provide external resistance. He progressed to performing step ups to

a 12-inch box for 10 repetitions forward and laterally on both sides to build hip extensor and

knee extension strength. Following, he performed 3 sets of 10 of goblet squats with a 8kg

kettlebell to increase quadricep and gluteus maximus strength as well as endurance. Single leg

clamshells were performed on the wall with a green circle band above the patients knees to

increase gluteus medius strength in bilateral hips for 2 sets of 8.

Therapeutic activity then progressed to the patient performing supine hamstring curls

with an exercise ball for 2 sets of 10 to increase hamstring strength and gluteus maximus

endurance as the patient was instructed to hold his hips up in a hip extension isometric. Hip

thrusts were performed for 2 sets of 10 with a 10-pound dumbbell on the patient’s pelvis for

glute maximus strength and a band above the patient’s knees for gluteus medius endurance.

Resisted walking for all four directions anteriorly, laterally, and posteriorly were also completed

27
for 5 times each direction. Finally, lateral stepping and monster walks were performed for 45 feet

four times. This was added to the patient’s HEP t continue to progress strength in the gluteus

medius outside of the clinic.

Week 6. The patient reported that he ran 3 miles one day and 2 miles the other day over the

weekend once again with no pain in his knees. Due to there being no pain over the past three

weeks, it was deemed clinically appropriate by the Student Physical Therapist to progress some

exercises to more explosive plyometric movements and monitor how the knee responds.

Plyometrics have been shown to increase muscular power as well as increase neuromuscular

control for explosive movement patterns.63 During the second session of week six final objective

outcomes were obtained. These can be viewed in the outcomes section below.

Plyometrics were introduced early on in the session following a couple exercises to

warmup the body as explosive movements should be done following a light warmup but prior to

fatiguing the bod to reduce risk of injury.63 On both days for week six the patient performed

depth drops off of a 12-inch box for 2 sets of 5 to increase neuromuscular control by controlling

knee valgus during the deceleration period of a landing.78 These were progressed to performing 2

sets of 5 each of a depth drop into a vertical jump and a depth drop into a lateral jump. These

were done to increased knee and hip extension power but also to increase high velocity forceful

loading of the knee to increase strength in this movement pattern.63, 79 Speed skaters where the

patient was instructed to jump laterally back and forth and land on the outside single leg was

done for 2 sets of 5 each leg. Speed skaters were done to increase gluteal complex power and

also increase high velocity forceful loading of the knee both during the acceleration and

deceleration phase of this movement.80

28
 Therapeutic activity continued this week with progressing steamboats to increase global

hip strength for 12 repetitions with a blue band around the patient’s ankles. Step ups were

progress in repetitions as well to performing 12 repetitions forward and laterally on both sides.

Goblet squats were progressed to 3 sets of 15 with the 8kg kettlebell to increase gluteus maximus

and quadriceps endurance. Due to their continued difficulty as reported by the patient, clamshells

were performed for 2 sets of 8 against the wall with a looped green band above the knees to

increase gluteus medius strength. Hamstring curls with a hip extension isometric continued for 2

sets of 10 to increase hamstring strength as well as gluteus maximus endurance. Hip thrusts were

performed for 2 sets of 10 with the 10-pound dumbbell along the patient’s pelvis and a green

band looped above his knees to increase gluteus maximus strength and gluteus medius

endurance. Finally, the patient performed resisted corded walking in all four directions for 5 reps

forward, laterally, and backwards to increase global lower extremity strength.

Addition of gluteus medius isometrics were performed for 5 second holds and 5 second

rests for 2 minutes bilaterally. This exercise was prescribed to progress gluteus medius

endurance and is performed by flexing up the inside hip when facing parallel to a wall, and

isometrically abducting the hip, pushing into a towel against the wall. The goal was to increase

endurance both in gluteus medius that was providing the isometric hip abduction contraction as

well as on the opposing hip as this hip has to remain level in a weight bearing position, firing the

gluteus medius on this side as well.

Outcomes

Outcomes were obtained on the second session of the sixth week. These can also be

viewed in Tables 1, 2, 3, and 4.

29
Range of Motion. The patient’s ankle dorsiflexion AROM increased from 4 degrees on his L

ankle and 9 degrees on his right ankle to 10 degrees bilaterally. He was WFL for all other lower

extremity ROM measurements during the initial evaluation. This can be viewed in Table 1.

Manual Muscle Tests. The patient’s strength increased in both his hips and knees bilaterally. His

right hip flexion increased from 4+/5 to 5/5 bilaterally. His hip extension increased from 3+/5 on

the right to 4+/5 and 4/5 on the left to 4+/5. Hip abduction increased from 3+/5 on the right to

5-/5 and 4/5 to 4+/5 on the left hip. Hip internal rotation and external rotation improved from

4+/5 to 5/5 bilaterally. Knee extension was 5/5 on the left side during the initial evaluation but

improved on the right from 4-/5 to 5/5. Finally, knee flexion improved from 4-/5 to 5/5

bilaterally. This can be viewed in Table 2.

Muscle Length Tests. The patients MLT for the 90/90-degree supine hamstring test improved

from 60 degrees on his left and 65 degrees on his right to 75 degrees bilaterally. Although

improvements in hamstring flexibility, the patient still received a positive Thomas Test where his

posterior thigh did not achieve below or at parallel when flexing one knee to the chest and

assessing the opposing. This indicated remained tightness in the hip flexors bilaterally.

Palpation. The patient had no tenderness to palpation during the initial evaluation along the

patellar tendon and had no tenderness to palpation to the patellar tendon or anywhere around the

knee during the final date as well.

30
Balance. During the initial evaluation the patient was able to balance on both legs with his eyes

open for up to 60 seconds bilaterally. He was able to stand on his right leg for 10 seconds with

his eyes closed and on his left for 24 seconds with his eyes closed. This progressed to 16 seconds

on his right leg and 25 seconds with his eyes closed.

Pain. During the initial evaluation the patient performed a single leg squat to assess if there was

any knee pain on the right side during this movement pattern. There was no pain during that date

as well as during the final date during a single leg squat on the right leg. The patient has been

pain free running outside of the clinic for the past 3 weeks.

Outcome Measures. The LEFS was used to assess LE function during specific ADLs. On initial

evaluation the patient scored a 74/80 reporting a little bit of difficulty with his usual hobbies or

recreational sporting activities, going up and down a flight of stairs, running on both even and

uneven ground, making sharp turns when running, and rolling over in bed. The patients score

correlates to a 7% limitation in ADLs. In the final date, the patient scored a 77/80 reporting only

a little bit of difficulty in running on even ground, making sharp turns when running, and rolling

over in bed. 77/80 correlates to a 4% limitation in ADLs. The minimal detectable change

(MDC) for the LEFS is 9 points.47 The patient improved his score 3 points total, indicating that

this change could have occurred from a variation in measurement. Although this was not looked

into further due to the fact that he scored so high on his initial evaluation.

The patient also completed the UWRI to measure running ability after an injury. He

initially scored a 21 out of 36. The categories that stood out were that the patient reports

moderate frustration with his pain when running as well as with his injury, and that his injury has

31
moderately reduced the amount he can run, and that the patient reported that this only limited his

mileage by a mile or two a week. On the final date his score increased to a 33/36. The only

categories that were not a maximum score were that he reported feeling that he has made

significant recovery from his running injury, minimal pain following a run for the next 24 hours,

and that his confidence might be fine if he increased his running. The MDC for the UWRI is 5

points and the patient improved a total of 12 points indicating that there was an actual noticeable

true change in the patients running ability after an injury. More information on these outcome

measures can be found in Tables 3 and 4.

Discussion

Knee pain is the second most common cause of chronic pain.1 In athletes and in those that

are physically active, around 40% of injuries that occur are knee injuries.2 The purpose of this

case report was to describe the physical therapy management and prescription of exercise in an

outpatient environment for a 34-year-old new runner experiencing anterior knee pain. This case

report did achieve its intended purpose by showing how proper management and progression of a

lower extremity strengthening program can reduce a runner’s anterior knee pain.

In this case report, the patient demonstrated clinical findings that were consistent with

anterior knee pain. Physical therapy has been shown to be effective in treatment for anterior knee

pain.24, 33 All of the interventions provided were evidence based and proven to be very beneficial

at increasing overall outcomes in those with anterior knee pain by increasing ROM in the knees

and hips for flexibility, increasing quadriceps, gluteus maximus, and gluteus medius strength,

increasing balance, and adjusting running mechanics.18, 22, 25, 37, 40, 41, 43 Through proper evaluation

32
and assessment for anterior knee pain, prescription of the correct interventions allowed the

patient to achieve their goals and see positive outcomes with gains in strength, balance, ROM,

reduction in pain, all leading to improved tolerance for running.

Altered running mechanics has been shown to lead to an increase risk for PFPS.27

Therefore, a gait evaluation was performed during the case report which provided incite on

specific biomechanical abnormalities that could have been attributing to the patient’s knee pain.

These allowed for adjustment of the plan of care along the lines of exercise prescription for the

patient and also provided confirmation that the current treatment was aiding in fixing the

abnormalities found. Showing the patient the abnormalities specifically provided visual feedback

which has been proven to be a very effective intervention to decrease biomechanical

abnormalities during gait.43

Potential limitations during this case report were that he saw more than one physical

therapist. Although the clinic is quite small and collaboration on the entire plan of care was done

for the patient between the two therapists, this still allows for variability in terms of exercise

prescription, instructions, and cueing that could influence functional outcomes. Having the

patient see only one therapist may have been more appropriate to ensure that these variables did

not occur. Another limitation could possibly be not performing two gait evaluations, more

specifically one during the initial evaluation date and another one towards the final date. This

would allow for proper tracking of these biomechanical abnormalities to be able to link if the

interventions being provided were having an influence on the patient’s main goal which was pain

free running. Finally, another possibly limitation was that the patient’s mileage running outside

of the clinic was not controlled for. Had the patient been in increased pain with running towards

33
the end of his POC this would have been something to control for, but the fact that he was pain

free for the final 3 weeks, this was not an issue.

Future research should also look at specific exercise prescription with a specific return to

running program and see how this affects pain and functional outcomes. Providing a specific

exercise regime with proper progressions and regressions along with a proper return to run

program individualized for a patient would allow for more knowledge to be gained for their

given diagnosis.

Overall, proper management and progression of a lower extremity strengthening program

can reduce a runner’s anterior knee pain. Completing thorough examination and differential

diagnosis as well as proper exercise prescription and patient education can help a new runner

increase their strength, balance, ROM, reduce pain, and improve their tolerance and ability to run

pain free.

34
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2 Majewski M, Susanne H, Klaus S. Epidemiology of athletic knee injuries: A 10-year

study. Knee. 2006;13(3):184-188. Hensley CP. Management of patients with patellofemoral pain
syndrome using a multimodal approach: a case series. J Orthop Sports Phys Ther.
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 Table 1.
Active Range of Motion (AROM) at Initial, Week 4 Session 1, and Final

L LE R LE L LE R LE L LE L LE

Initial Initial Week 4 Week 4 Final Final

AROM AROM Session 1 Session 1 AROM AROM

AROM AROM
Hip flexion WFL WFL Not tested Not tested Not tested Not tested

Hip extension WFL WFL Not tested Not tested Not tested Not tested

Hip adduction WFL WFL Not tested Not tested Not tested Not tested

Hip abduction WFL WFL Not tested Not tested Not tested Not tested

Knee extension WFL WFL Not tested Not tested Not tested Not tested

Knee flexion WFL WFL Not tested Not tested Not tested Not tested

Ankle plantarflexion WFL WFL Not tested Not tested Not tested Not tested

Ankle dorsiflexion 4 deg 9 deg 6 deg 10 deg 10 deg 10 deg

left (L); right (R); lower extremity (LE); Within functional limits (WFL): patient able to achieve
AROM/MMT that would allow them to complete their activities of daily living (ADLs)
independently.6

Table 2.
Manual Muscle Test (MMT at Initial, Progress Note, and Final)
 L LE R LE L LE R LE L LE R LE

Initial Initial Week 4 Week 4 Final Final

MMT MMT Session 1 Session MMT MMT

MMT 1 MMT
Hip flexion 4+/5 4+/5 5/5 5/5 Not tested Not tested

Hip extension 4/5 3+/5 4/5 4-/5 4+/5 4+/5

Hip abduction 4/5 3+/5 4+/5 4/5 4+/5 5-/5

Hip external rotation 4+/5 4+/5 4+/5 4+/5 5/5 5/5

Hip internal rotation 4+/5 4+/5 5/5 5/5 5/5 5/5

Knee extension 5/5 4-/5 Not tested 5/5 Not tested 5/5

Knee flexion 4-/5 4-/5 4+/5 4+/5 5/5 5/5

left (L); right (R); lower extremity (LE); MMT Scoring: 3+/5: Full AROM against gravity;
minimum resistance. 4/5: Full Active Range of Motion (AROM) against gravity, moderate
resistance. 5/5: Full AROM against gravity; maximum resistance.6 4-/5, 4+/5, 5-/5 were to allow
for documentable changes in strength as the patient may not be at a 5/5 strength but has gotten
stronger.6

Table 3.
Lower Extremity Functional Scale (LEFS) Outcome Measure

Activities Initial Score Week 4 Session 1 Final Score

 Score
Any of your usual 4 4 4
work, housework or
school activities.
Your usual Hobbies, 3 3 4
recreational or
sporting activities.
Getting into or out 4 4 4
of the bath.
Walking between 4 4 4
rooms.
Putting on your 4 4 4
shoes or socks.
Squatting. 4 4 4
Lifting an object 4 4 4
like a bag of
groceries from the
floor.
Performing light 4 4 4
activities around
your home.
Performing heavy 4 4 4
activities around
your home.
Getting into or out 4 4 4
of the car.
Walking 2 blocks. 4 4 4
Going up or down 3 4 4
10 stairs.
Standing for 1 hour. 4 4 4
Sitting for 1 hour. 4 4 4
Running on even 3 3 3
ground.
Running on uneven 3 3 4
ground.
Making sharp turns 3 3 3
while running fast.
Hopping. 4 4 4
Rolling over in bed. 3 3 3
Column Totals: 74 75 77
Scoring: 4: No difficulty; 3: A little bit of difficulty; 2: Moderate difficulty; 1: Quite a bit of
difficulty; 0: Extremely difficulty or unable to perform.4
Table 4.
University of Wisconsin Running Injury and Recovery Index (UWRI) Outcome Measure

Question Week 2 Session 1 Week 4 Session 1 Final Response

 Response Response
How does your running Slightly Impact No impact No impact
impact your ability to
perform daily activities
How frustrated are you by Moderately Mildly frustrated Not frustrated
your running injury? frustrated
How much recovery have you Moderate recovery Significant Significant
made from your running recovery recovery
injury?
How much pain do you Moderate pain Minimal pain No pain
experience while running?
How much pain do you Minimal pain Minimal pain Minimal pain
experience during the 24
hours following a run?
How has your weekly mileage Moderately Same or greater Same or greater
or weekly running changed as reduced than before my than before my
a result of your injury? injury injury
How has the distance of your Moderately Same or greater Same or greater
longest weekly run changed as reduced than before my than before my
a result of your injury? injury injury
How has your running pace of Minimally reduced Same or greater Same or greater
speed changed as a result of than before my than before my
your injury? injury injury
How does your injury affect Neutral If I increase, I If I increase, I
your confidence to increase might be fine might be fine
the duration of your running?
Score total: 21/36 27/36 33/36
Scoring: No impact/no pain/complete recovery/same or greater than before: 4;
Slightly/minimally/significant recovery: 3; Moderate/neutral: 2; Significant/minimal recovery: 1;
Unable/no recovery: 0 49

Table 5.
Interventions By Session

Exercise Initia Week 1 Week 2 Week 2 Week 3 Week 3 Week 4 Week 4

 l Session Session Session Session 1 Session 2 Session 1 Session 2
2 1 2
Hip flexor 3x30s
couch bil
stretch
3-way 3x30s
hamstring bil
stretch
Total Gym Level 7 Level 7 Level 7 Level 7 6 Level 7 6 Level 7 6 Level 7 6
Squatting 6 min 6 min 6 min min min min min
Steamboat Bil x10 Bil x10 Bil x10 Bil x10 Bil x10 Bil x10 Bil x10
s green green green green green green green
band band band band band band band
Step Ups 6-inch 6-inch 10-inch 10-inch 10-inch 12-inch 12-inch
x10 x10 x10 x10 x10 x10 x10
forward forward forward forward forward forward forward
& & & & lateral & lateral & lateral & lateral
lateral lateral lateral bil with bil with bil with bil with
bil bil bil with march march march march
march
Single leg Floor Floor Floor Foam Foam Foam Foam
stance 3min 3min 3min pad 3min pad 3min pad 3min pad 3min
10s alt 10s alt 10s alt 10s alt 10s alt 10s alt 10s alt
Rocker 1 min 1 min 1 min 1 min 1 min 1 min 1 min
board 4 each each each each each each each
way
Prone glute 3s holds 3s holds 3s holds 3s holds
isometric x10 bil x10 bil x10 bil x10 bil
with
terminal
knee
extension
Supine 2x10 2x10 2x10 2x10 red 2x10 red
bridge band band
Side lying 2x10 bil 2x10 bil 2x10 bil 2x15 bil
hip red band red band red band red band
abduction
Clamshells 2x10 bil 2x10 bil 2x10 bil 2x15bil
red band red band red band red band
TRX 2x10 2x10 2x10
Squats
Seated Red bil Red bil Green Green bil
hamstring 2x10 2x10 bil 2x10 2x10
curls
Goblet 4kg 6kg 6kg 6kg
Squats kettlebell kettlebell kettlebell kettlebell
 2x10 2x10 2x10 3x10
Lateral Red band Red band Red band Green
stepping & 45ft x2 45 ft x4 45ft x4 band 45ft
monster x4
walks
Supine 2x8 2x8 2x8
hamstring
curls with
exercise
ball
Hip thrusts 2x10 2x10
green green
band band
Resisted Blue cord
walking x5 each
direction
Seconds (s); minutes (min); bil (bilateral); alt(alternating); ft (feet)

Table 5. Continued.
Interventions by Session
Exercise Week 5 Week 5 Session Week 6 Session Week 6 Session
Session 1 2 1 2
Hip flexor couch
 stretch
3-way hamstring
stretch
Total Gym Squatting
Steamboats Bil x10 blue Bil x10 blue Bil x10 blue
band band band
Step Ups 12-inch step x10 12-inch step x10 12-inch step x10
fwd and lateral fwd and lateral fwd and lateral
bil with march bil with march bil with march
Single leg stance
Rocker board 4 way
Prone glute isometric
with terminal knee
extension
Supine bridge
Side lying hip
abduction
Clamshells On wall 2x8 On wall 2x8 On wall 2x8
green band green band green band
TRX Squats
Seated hamstring
curls
Goblet Squats 8kg kettlebell 8kg kettlebell 8kg kettlebell
3x10 3x10 3x15
Lateral stepping & Green band 45ft
monster walks x4
Supine hamstring 2x10 2x10 2x10
curls with exercise
ball
Hip thrusts 2x10 green band 2x10 green band 2x10 green band
10-pound 10-pound 10-pound
dumbbell dumbbell dumbbell
Resisted walking Blue cord x5 Blue cord x5 Blue cord x5 Blue cord x5
each direction each direction each direction each direction
Treadmill Walking 10 minutes +
gait evaluation
+ 5 min
Depth drops 2x5 2x5
Depth drops into 2x5 2x5
vertical jump
Depth drop into 2x5 ea 2x5 ea
lateral jump
Speed Skaters 2x5 ea 2x5 ea
Seconds (s); minutes (min); bil (bilateral); alt(alternating); ft (feet)