Case study – Pelvic driven knee pain in a netballer

by David Pope

I thought you might enjoy reading a few case studies on how I have incorporated various treatment approaches. Let me know below if you want to read any more and I will write up a few. In my first case study, Ms B is an 18-year-old female that plays netball and swims at a high level.

Ms B presented with pain in both Achilles after playing netball and right knee pain along the superior aspect of her patella. The knee pain was her main complaint, this had stopped her playing netball last season as it got progressively worse throughout the season, and after starting up netball again this season she was getting pain after netball training, after a 3 km run, which she performed weekly, and after playing netball. Because of the start of the netball season, she had ramped up her training and playing significantly.

When I examined her, she had tenderness along the superior aspect of her patella, and pain with one leg squat, and going upstairs. Her one leg squat was very ordinary, and she could hardly stand on one leg because of poor balance. All other knee tests and ligament tests were clear. On weight shift to her right she unlocked immediately in her right SIJ, then her right femoral head moved anteriorly and internally rotated. Her right knee went medially with her one leg squat and her navicular and cuboid internally rotated. She also had failed load transfer (FLT) of her fourth and fifth thoracic rings, but fairly late in the timing of FLT, relative to her SIJ.

Timing suggested her SIJ could be the primary driver, but I needed a few more tests to confirm this. Correcting and supporting her foot made her balance worse, plus the late timing of failed load transfer helped me to rule out the foot. Correcting her fourth and fifth thoracic rings made no change to her one leg stance or squat. Gliding her right femoral head posteriorly helped somewhat with one leg squat, and her knee alignment was improved. Supporting her pelvis and unwinding her pelvic torsion, helped the most, made her knee alignment perfect, took away her knee pain, and got a “Wow” from Miss B.

With all this evidence, I was happy to go ahead and treat her pelvis. On testing her passive glides of her SI J, she was compressed across the right superior and inferior poles, and left inferior pole of her SI J.

I started with some Release with Awareness techniques for her right superficial multifidus and Erector Spinae muscles, and her right and left Ischio-Coccygeus.  Her SI joint glides were improved, but she still had some remaining compression of her right superior pole and left inferior pole. I performed some dry needling to her right superficial Multifidus and left Ischio-Coccygeus. We retested her one leg squat, which was much improved, her knee alignment was much improved, and she now had no pain with one leg squat. Adding compression to her pelvis did not help her one leg squat any further, so we didn’t need to do any deep muscle retraining. I taught Miss B how to perform self releases of her right superficial multifidus and left Ischio-Coccygeus with a rubber ball, and cued her to release these muscles in her one leg squat.

I then booked her in for the following week, and she re-presented with some slight right hip pain which we treated in the following session, and she did not have any further knee pain, even after playing 6 games of netball the following weekend. In the next blog post I will take you through some running retraining and other cues and treatment that I used with her.

In case you are wondering what on earth I am talking about, and to give you some background on this style of assessment and treatment, I use the Integrated Systems Model created by Diane Lee and Linda-Joy (LJ) Lee of Discover Physio, as taught on the Discover the Sports Pelvis course and Discover Physio Series, which considers that movements like a one leg squat are a whole body task and assesses the whole body for the cause. From there you create a hypothesis of what is causing the musculoskeletal problem, and gather evidence with other tests to support or refute your hypothesis. When performing dry needling, I use the Dry Needling Plus style taught by Andrew Hutton rather than trigger point based needling. I also use McKenzie MDT, running and gait retraining, neural mobility assessment and a bunch of other techniques, which I will expand upon in other posts.

How do you approach PFJ pain? Let me know in the comments below

  • That impressive Dave, I would do exactly what you did! One treatment & no gluts, VMO strengthening or orthotics. Sounds like you really nailed the driver.

    I laughed after listening to 3 consecutive presentations given at the 2010 APA conference on patello-femoral knee pain. The first presenter showed us how the VMO timing was most important. The second talked about his MRI studies confirming that hip internal rotation caused lateral patella tracking & the third told us that it was impossible to get good knee alignment when the foot pronated too quickly. So who was right?

    The integrated systems model assesses the whole body & directs you to the the segment of the initial problem. Otherwise it's just a guess really.

  • Andy G

    Hi Dave,

    Maybe it’s a British thing but I’m not overly familiar with your assessment of the thoracic ring-is this a stability assessment or movement analysis? Or is this mainly covered in the Diana Lee lectures?

    • David Pope

      Hi Andy

      Thoracic ring assessment is taught by LJ Lee and Diane Lee, and assesses the stability and mobility of the entire thoracic ring – the thoracic vertebrae, the ribs, and attachments of the ribs onto the vertebrae and sternum/cartilage. Palpation is often along the sides of the ribcage, feeling for non-optimal patterns like one or two rings (or more) "doing it's own thing" – rotating and laterally shifting excessively or in the wrong direction. For instance, you may feel a prominent 6th rib on the R, and corresponding divot on the L at that level, which is a left rotation and right lateral shift of that ring. As the person weight bears on their R leg, this ring may become more prominent on the R, instead of becoming more level with the ribs above and below (which is more optimal). You can then correct this ring position by gently right rotating and laterally translating it to the left. This approach allows assessment of the segmental control of the thorax during functional tasks, and allows you to decide if the thorax is a cause of the problem or not. This is a really short summary of the ring approach, which doesn't really do it justice, but will give you a bit of an idea. We have a number of videos with LJ on it on <a href="http://www.clinicaledge.com.au” target=”_blank”>www.clinicaledge.com.au for members. I hope that helps.

      David

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  • Pingback: Knee pain in a netballer – assessment and treatment « Tallulah Blue()

  • EC23

    Thank you for sharing this David – I thoroughly enjoyed your clinical reasoning in this case. I would love to hear some more case studies like this!

    • David Pope

      Thanks, glad you like it, I will post a followup and a few more case studies.

      David

  • Rick B

    Hi David,
    This information sounds like exactly what we need. It was very informative. Thank you so much for posting. I have been searching the internet for the past 2 years trying to find some kind of solution for my 14 year old daughter. She plays basketball and loves to run but about 2 years ago (about the time she started going through puberty) she started complaining of knee pain behind the knee cap and to the inside portion of the knee. We went to an orthopedic Dr. multiple times who said it was a hip and possible also ankle issue (she has weak ankles). He put her in orthotics for her sports (and all) shoes and then we did 6 months of therapy and stopped all sports (basketball, soccer, volleyball). The pain was reduced but now it's back strong again. My daughter just tries to play through the pain. If she rests for a few minutes she can then go play again but it still hurts. We have tried all kinds of exercises. The therapy focused on hip exercises. I'm wondering if her situation is similar to the case you described above. It sure sounds like it. We keep trying to find some kind of solution. Are there specific videos or someone you can recommend in the Los Angeles (South Bay) area that might understand what you are talking about so they can perform the proper tests to diagnose her problem and a solution. The physical therapists we have seen so far just don't seem to have found the solution. My daughter will work hard but hard work is meaningless if we aren't doing the right things. It's very frustrating watching her in pain and not being able to play the way she likes to play just because of this nagging knee pain. She also has VERY tight hamstrings and reasonably strong quads and hamstrings although I'm sure they could use some more strengthening. (Everything I have been reading keeps focusing on strengthening quads, gluts, hamstrings along with hip and calve work. Any suggestions or instruction you may have would be most appreciated. We are beginning to wonder if my daughter will ever become pain free again and if the pain persists she may have to stop sports which will absolutely kill her. Thanks again for your wonderful article. Maybe there is hope if we can just find the right person to show us what to do.

    • David Pope

      I don't know of anyone personally, however you can search for a Physio that uses this sort of approach on http://www.discoverphysio.ca in the Find a Physio section. I hope that she finds someone that can help her, so she can get back to sport!

  • Joanna Clouden

    Thanks David, this is a really useful discussion post. I have completed some of the discover physio courses, but years ago and before a long maternity leave break in practice. It gets me excited again about what we can achieve with this system of assessment and treatment. Thanks.

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