Case Record 01

Knee Osteoarthritis

A.M.I.C ATHAPATHTHU
AHS/PHY/09/003
 ASSESSMENT

Demographic data

Name of the patient: Mrs. Lalani de silva

 Age : 48 Years
 Sex : Female
 Address : Ampitiya, ragama
 Occupation : House wife

Chief complaint – Severe left knee joint pain,stiffness, having slight sound inside the joint
when knee was moving, cannot walk long distance and difficult to
climbing stairs and cannot bend the knee joint.

History

Present history- She is complaining severe pain in left side of knee joint, stiffness,
crepitus,limitation of knee joint movement and cannot walk properly
and climbing stairs since 1 years.

Past history-

 Hypertension
 Diabetes mellitus

Medical history-

 Drugs for hypertension and diabetes

Personal and social history-

 House wife
 No regular exercise pattern
 Non alcoholic
 Non smoking

Family history-

 History about osteoarthritis in her family

Pain assessment
 Side - Left
 Site - Posterior medial
 Type - Stabbing
 Onset - Gradual
 24 hours pattern - More in night
 Aggravating factor - Walking
 Reliving factor - Rest, sleeping

Visual analogue scale

0 – No pain
5 – Moderate pain
10 – Severe pain 2015.07.29

X
0 1 2 3 4 5 6 7 8 9 10

On observation

 The patient was obeys

 Limping gait
 Swelling over left knee joint
 No muscle wasting
 No genu varus or valgus deformity
 No changes in colour of the skin
 Normal patella positioning

On palpation

 Slightly Temperature had increased over left knee joint

 Crepitus present
 Pain over left side medial knee joint margin
 Tenderness over left hamstring and quadriceps muscles tendons
On examination
Motor assessment

 Active range of motion

Left side Right side

Hip

0 - 115 Flexion 0 - 120

0-30 Extension 0 - 30

0 - 40 Abduction 0 - 40

0 - 25 Adduction 0 - 25

Knee

0 - 115 Flexion 0 - 130

Ankle

0 - 40 Plantar flexion 0 - 40

0 - 15 Dorsi flexion 0 - 15

Manual muscle testing

Left side Muscle group Right side

Hip

5 Flexors 5

5 Extensors 5

5 Abductors 5

5 Adductors 5

Knee

4 Flexors 5
 4 Extensors 5

Ankle

5 Dorsi flexors 5

5 Plantar flexors 5

Limb girth measurement

Left level Right

43.5 4” above the base of the patella 44
35 4” below the tip of the patella 35

Limb length measurement

 ASIS to medial malleolus

Left – 81 cm
Right – 81 cm

Special tests
 Valgus stress test - positive

 Varus stress test- positive

 Lachman test -Negative

 Anterior drawer/ posterior darwer test - Negative

Activities of daily living

 Walking, stair climbing, toileting affected

Investigations

 X ray

Diagnosis

 Left side knee osteoarthritis(chronic)

Problem list

 Joint pain
 Tenderness
 Swelling of joint
 Reduce range of motion
 Reduce the muscle strength
 Morning stiffness
 Loss of function
Gait, stair climbing

Discussion

Definition
Is a non inflammatory degenerative disorder of joints characterized by progressive
deterioration of the articular cartilage and formation of new bones(osteophytes)

Generally osteoarthritis classified in to types as primary and secondary. In primary OA

there is no obvious course. Secondary OA arises as a consequence of other conditions.

Pathology

Articular cartilage - Erosion occurs often central and frequently in the weight-bearing
areas. Cartilage is usually the first structure to be affected. Fibrillation which causes
softening, splitting and fragmentation of the cartilage occur in both weight-bearing and
non-weight-bearing areas. Collagen fibres split and there is disorganization of the
proteoglycan- collagen relationship such that water is attracted into the cartilage which
causes future softening and flaking. Flakes of cartilage break off and may be impacted
between the joint surface causing locking and inflammation.

Proliferation occurs at the periphery of the cartilage.

Bone - Eburnation- The bone surfaces become hard and polished as there is loss of
protection from the cartilage. Cystic cavities from in the subchondral bone because
eburnated bone is brittle and microfractures occur allowing the passage of synovial fluid
into the bone tissue. There can also be venous congestion in the subchondral bone.
Osteophytes from at the margin of the articular surface where they may project into the
capsule and ligaments. Bone of the weight-bearing joints alters in shape – the femoral head
becomes flat and mushroom shaped. The tibial condyles become flattened.

Synovial membrane - This undergoes hypertrophy and becomes oedematous. Later there is
fibrous degeneration. Reduction of synovial fluid secretion results in loss of nutrition and
lubrication of the articular cartilage.

Capsule - This undergoes fibrous degeneration and there are low- grade chronic
inflammatory changes.
Ligaments - These undergoes the same changes as the capsule and according to the aspect
of the joint become contracted or elongated.

Muscles- These undergo atrophy which may be related to disuse because pain limits
movement and function. Without adequate exercises the muscle may undergo fibrous
atrophy.

Clinical features

Pain, joint instability and buckling, loss of movement, morning stiffness, crepitus , joint
enlargement, deformity, loss of function

The patient’s age, gender, physiological deterioration (menopause), body weight,job and
hereditary factors also contributes greatly for the degenerative changes. Osteoarthritis is
often associated with decreased bone density, osteoporosis, especially women after
menopause. This patient also had some of these risk factors that are age, obesity, genetic
factors. So it would also influence the occurrence of degenerative changes of the knee
joint. Some changes in X ray, crepitus with motion and morning stiffness lasting less than
30 minutes. So it helps to diagnosed as osteoarthritis. This pain since 1 year so this is
chronic phase of disease. She was limping due to pain and joint instability of the left knee
joint. Range of motion and muscle power reduced due to pain. So pain of the joint is the
major cause for above clinical features.
Physiotherapy goals

Short term goals

 Patient education
 Relive pain
 Reduce the swelling
 Increase the range of motion
 Strengthen the muscles around knee joint
 Prevent further damage to joint structures
Long term goals

 Restore the normal functionality of the left lower limb to allow patient engage in
her activities of daily living.

Physiotherapy interventions selected

Objective Intervention / Frequency/ Duration

Educate & advice the patient
Reduce the pain
 Regarding condition, risk factors, prevention,
weight control and importance of continuing the
exercise programme correctly at home
 Short wave diathermy
(Continuous mode/ 15 minutes/ 2 times per week)

 IFT
( 15 minutes/2 times per week)

 Hot fermentation at home

(before every exercise session)

Muscle strengthening  Isometric exercises for quadriceps/ hamstrings

(10 repetitions/3 rounds/ 2 times per day)

 SLR, hip extension, with adding a small weight

(10 repetitions per one muscle group/2 times per day)
Improve range of motion  Suspension therapy
and maintain mobility of the (side lying/20 minutes/2 times per week)
knee joint  Sitting on a high surface, free knee swing
(20 repetitions /2 times per day)

Wear a knee brace  During the working and walking.

 Use cane in walking

Home advice.  Reduce climbing stair
 Use commode

Rationale for selecting specific therapy

01 Reduce the pain

 Short wave diathermy
Principle effect of SWD to the body is heating of tissues. Which provide deepest
heating of the tissues. The main physiological effects due to heating are increase
the metabolism of the body and increase the blood supply.

 IFT
Pain relief occurs through several mechanisms. Mainly by pain gait theory.short
duration impulse stimulate large diameter fibers and it inhibit transmission of
small diameter impulses. Others are descending pain suppression, increased
circulation and placebo.

02 Muscle strengthening
 Isometric exercises for quadriceps/ hamstrings
 SLR, hip extension, with adding a small weight
Both helps to strengthen the muscles around the affected joints to keep fit and
maintain a good range joint movement.
03 Improve range of motion and maintain mobility of the knee joint
 Suspension therapy
Reduce friction and gravity eliminates position help to eliminate weight of leg that
principle use to maintain and improve the range of motion in knee joint.
 Sitting on a high surface, free knee swing
Gravity helps to pull the leg down wards that help to distract the joint and easy to
move this helps to maintain the mobility of knee joint.

04 Wear a knee brace

 This helps to support the knee joint, reduce the pain and reduce swelling.

05 Walking aids
 Cane – hold it in the opposite side of the body to the affected join that help to ease
symptoms by takes some pressure off the affected joint.

Outcomes of the treatment program

2015.08.12

 Pain reduce up to 5 of VAS scale

X
0 1 2 3 4 5 6 7 8 9 10

 Joint range of motion increased

Left side Right side

Hip

0 - 115 Flexion 0 – 120

0-30 Extension 0 – 30

0 - 40 Abduction 0 – 40
 0 - 25 Adduction 0 – 25

Knee

0 - 118 Flexion 0 – 130

Ankle

0 - 40 Plantar flexion 0 – 40

0 - 15 Dorsi flexion 0 – 15

 Muscle power not increased

 Same treatments continued and add vastus medialis oblique muscle strengthening
exercise.

2015.08.19

 Pain reduce up to 4 of VAS scale

X
0 1 2 3 4 5 6 7 8 9 10

 Range of motion same as 2015.08.12

 Muscle power increased up to 4+ of knee flexors and extensors
 Same treatments continued

Reference

 Downie P.A, (1993), Cash’s Textbook of Orthopedics and Rheumatology for

Physiotherapists. Jaypee Brothers, New Delhi, India.
 Porter, S. (2008). Tidy’s Physiotherapy. Butterworth- Heinemann, London.
 Brotzman B S, Wilk E K; clinical orthopedic rehabilitation.edition 2, Texas; Mosby
publishing Company, 652, 2003
 McRae, R. (1999). Clinical Orthopedic Examination. Churchill Livingstone,
Edinburgh.