Knee Pain: Role of Osteopathic Principles
By J. Robert Mannino, DO, FACOFP dist.
ABSTRACT: Musculoskeletal complaints comprise a large segment of an active family practice. The majority of these are amenable to life style changes and simple analgesics, easily managed by any competent family physician. When the complaint centers on a single joint, the diagnostic challenge becomes a little more demanding and attention to osteopathic principles and practice is an added tool in the armamentarium of the osteopathic family physician, which can be of significant benefit to the patient. This case report illustrates the benefit of a complete osteopathic examination in a patient with a chief complaint of recurrent knee pain.
Monoarticular joint pain, either in a small joint such as finger, or in a large joint such as knee, is a common complaint and usually the result of some degree of inflammation. In most cases it is relieved by simple analgesia in the form of non-steroidal anti-inflammatory drugs (NSAIDs).
Some cases require steroid injection for relief while still others will require surgical intervention. Overall, the well-trained family physician can care for approximately 85 percent of the patients that present with joint pain, with the remaining 15 percent needing referral to specialists for surgical intervention. As with most of medicine, the secret to success is a carefully taken history and physical, which, in turn, leads to an accurate diagnosis. Given an accurate diagnosis, treatment stands a better chance of being effective.
The differential diagnosis of knee pain may be categorized by anatomic site: anterior, medial, lateral or posterior knee pain.1 Complaints of anterior knee pain most commonly are due to patellar subluxation, chondromalacia patellae, patellar tendonitis or Osgood-Schlatters. Medial knee pain is most commonly due to medial collateral ligament sprain, medial meniscal tear, pes anserine bursitis or medial pica syndrome. Lateral knee pain is most commonly due to lateral collateral ligament sprain, lateral meniscal tear or iliotibial band tendonitis while posterior knee pain usually is caused by either posterior cruciate ligament injury or a Baker’s cyst. By performing a thorough history and physical, including a complete Osteopathic examination, it is possible to not only treat the patient more effectively, but also eliminate unnecessary referrals and by extension, prevent needless surgery, and more quickly return the patient to a symptom-free state.
CASE REPORT
A 56-year-old male presented with a chief complaint of left knee pain. The pain had been
present off and on for the past 20 years and there was no related trauma or injury. The pain was confined to the medial aspect of the left knee, encompassing an area of approximately 2 cm at the juncture of the femur with the tibial plateau. The patient related that the pain is always at the same spot and goes away as quickly as it comes. This time the pain had been more persistent and bothersome than previously noted.
From a historical standpoint, the patient has hypertension, well controlled on amlodipine. He is sedentary at his workplace, but engages in vigorous physical activity for 30 minutes three times a week. He does not smoke, and drinks socially.
Approximately one month prior to presenting to the office, the patient had been seen by an orthopod for a similar complaint. Studies and treatment previously completed include left knee x-rays, magnetic resonance imaging (MRI), and an intraarticular steroid injection. The x-rays and the MRI were reported as negative and the patient stated that he received no relief from the injection. The patient also stated that prescription-strength NSAIDs had no effect on the pain.
The recently performed laboratory studies were all normal, including a CBC and differential, complete chemistry profile, sedimentation rate and rheumatoid factor. Subsequently, an arthocentesis was performed with complete analysis of the synovial fluid. In addition, a serum uric acid level and ANA were also performed. The synovial fluid was reported as negative for crystals and infection, while the uric acid was reported as 3.5 mg/dl and the ANA was found to be negative.
Physical examination identified stable ligamentous attachments with a negative Drawer sign, full passive and active range of motion, no edema, no color change, no calor change, intact menisci, and the inability to duplicate the pain in a non-weight bearing stance. With weight bearing, the pain was present on the medial aspect of the left knee, unaffected by motion. The remainder of the physical examination was unremarkable, with height 70 inches, weight 165 lbs., BP 124/78 mmHg, pulse 74, respirations 16, and body temperature 98.40 Fahrenheit.
Osteopathic examination of the lower extremity identified no restrictions of motion in the knee joint per se or in the proximal fibular head. The pelvis was likewise without any restrictions of motion in either the sacrum or the innominates. There was an increased lordotic curve in the lumbar spine with a slight scoliotic pattern with a concavity to the left with its apex at L2. At L2 on the left was noted a fixed postural tension with the spinous process being ‘locked’ to the left. The thoracic spine maintained a full range of motion without any evidence of a postural tension. There was a fixed postural tension in the right cervical area at C5-6. This was manifested in a restricted C5-6 rotation to the right.
During the discussion with the patient, a course of treatment was described based on the only positive findings identified during the osteopathic structure examination. Having spent many years and thousands of dollars without attaining improvement in his discomfort, the patient agreed to follow the recommendations provided.
The lumbar paravertebral musculature was treated with myofascial release and specific high velocity low amplitude (HVLA) correction directed toward the second lumbar segment on the left. The patient was instructed on exercises to decrease the lordotic curvature. He was then instructed to call with an update in 24 hours.
The following day the patient reported that within approximately eight hours of the treatment the area of pain began to tingle, then the discomfort diminished and was completely resolved by morning. At a follow-up visit in two weeks, the lordosis, while still present, was found to be improved by approximately 50 percent, and the lumbar spine was noted to be without any fixed postural tension. The cervical spine was also palpated without any fixed postural tension.
The patient was instructed to continue the prescribed exercises on a daily basis, and to return for reevaluation if the knee pain recurred.
Knee discomfort resulting from somatic dysfunction in the spine has been well established2, and in fact, a knee-spine syndrome has been described. The finding of a fixed postural tension at L2 on the left, with an increased lordotic curve in this patient causing episodic medial knee pain is consistent with this syndrome. This patient’s complaint of knee pain is an extra articular problem, that is pain not directly the result of derangement in the articular surface. This is supported by several key pieces of information identified during the patient evaluation:
The conclusion of an extra articular cause of the knee pain is also supported by the patient’s dramatic response to the specific lumbar manipulation. Moreover, the cervical fixed postural tension noted at C5-6 on the right was apparently compensatory in nature and spontaneously resolved following the lumbar correction.
After more than 20 years of episodic knee pain, this patient was relieved of his discomfort by the judicious application of osteopathic principles and treatment. Approximately once per year, in spite of continual exercises, the pain returns and a specific high velocity low amplitude correction directed to the second lumbar on the left corrects the patient’s discomfort. “Find it. Fix it. Forget it,” in the words of A. T. Still, appears to be the best way of maintaining a high level of wellness in this patient. It is pertinent to add that although this patient initially sought a DO for the episodic knee pain, he was so pleased with the outcome that he now sees a DO for all his medical care.
Practicing medicine in the 21st century, doctors have become enamored of needles, flashing lights and every type of testing modality commercially available. This has occurred to the point that we have eliminated, or at least severely curtailed the incorporation of basic physical examination techniques into the evaluation of a patient. More to the point, for the practicing DO, osteopathic principles and practice has all too often gone to the wayside.
Over the last 50 years the primary care physician has slowly but inexorably drifted away from the art of practicing physical diagnosis, now spending approximately 90 seconds of the 7 minute routine office encounter3 identifying the problem area, performing a cursory examination and then ordering the appropriate tests. In the majority of cases this approach still works to the benefit of the patient. However, there are situations in which this method of examining and treating a patient is woefully inadequate. This case illustrates the value of listening to what the patient has to say, looking at the whole person, not just an organ system, and actually performing a complete osteopathic structural examination. It is in the best interest of the patient for the osteopathic family physician to maintain a high index of regard for osteopathic principles, prior to referral to a specialist.
Dr. Mannino is a 1971 graduate of the Kansas City College of Osteopathic Medicine in Kansas city, Missouri. He first received his certification in family medicine in 1976, fellow designation in 1978, and a CAQ in geriatrics in 1992. He is currently retired.
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