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