Case #2 – Musculoskeletal – Knee Pain

Case #2 – Geoff

Objective

On manual testing, Geoff’s ligaments are intact however there is considerable pain with McMurray’s testing (test whereby the knee is placed in rotation to determine whether there is a tear of the meniscus, cartilage of the knee). Geoff reports their right knee pain is 4/10 at rest or while trying to sleep and 8/10 when climbing stairs on the Visual Analogue Scale (VAS). Geoff denies any locking, snapping or "catching" in their knee. They are very frustrated by the deep ache that it causes. An x-ray and subsequent MRI of their right knee are ordered. An area of concern is identified.

Guiding Questions

1. Describe additional components you might include in your assessment with Geoff.

Notes: Describe components of your subjective interview and objective assessment.

Subjective Interview: What is Geoff’s home environment like (does it have stairs)? What does their exercise regime entail – number of times per week, what exercises do they perform, does it include lower extremity work that will be impacted by their injury? What other self–management strategies are they using? Overall, how helpful are these techniques? What sleep hygiene and stress management strategies are they using with the onset of pain?  Do they have any other concurrent health conditions that they might be living with? What social supports are available to Geoff to assist with instrumental activities of daily living (IADLs) if needed? What support do they receive from their partner?

Objective Assessment: strength assessment, cognitive assessment (in relation to decreased concentration; despite fact that seems to be attributed to pain and frustration).

2. Given Geoff’s physical examination and MRI findings, what might you think is their diagnosis?

Notes: Differential diagnosis may include Avascular Necrosis, a bone disorder in which the bone deteriorates due to interruption in the blood supply.

3. What are some of the (a) impairments (b) activity limitations and (c) participation restrictions that Geoff is experiencing?

Notes: Consider the physical, cognitive, social, emotional and psychological challenges faced and classify using the ICF framework.

Some examples include:

• Impairments: pain in right knee, night pain, swelling of the ankle, ankle pain, decreased range of motion (ROM) of right knee, decreased concentration.
• Activity limitations: decreased ability to negotiate stairs, decreased ability to sleep due to pain, decreased standing tolerance, and decreased mobility.
• Participation restrictions: impact of personal relationships at work, potential impact on their exercise routine and risk for decline in health, potential impact on their personal relationship with their partner.

There is also the potential for a further decrease in Geoff’s health status if the knee pain is impacting their sleep and exercise routine. This may ultimately affect aspects of their life that they do to maintain their health.

4. What personal and environmental factors might influence Geoff’s recovery?

Notes: Personal factors include Geoff’s young age, active lifestyle, self-management strategies, and overall, their positive attitude towards their illness.  Due to Geoff’s gender fluidity, they have had some negative experiences in the health care system.

Environmental factors include the fact that they like to use the stairs at work and that they have good support from their partner and friends. Determine whether their home environment has stairs as well. Geoff would like to return to wearing heels and working out again.

5. What are some of the short-term and long-term rehabilitation goals for Geoff?

Notes: Consider patient values and preferences, and principles of shared decision-making, when discussing and developing goals. Use the SMART principle.

Short-term goals:

• To decrease pain in right knee as measured by decrease in VAS scale at rest and during stairs to 1/10 by 2 weeks.
• To be able to negotiate stairs pain-free in 2 weeks.
• To increase ROM of right knee to full range in 2 weeks.

Long-term rehabilitation goals might revolve around getting back to their exercise and workplace routine:

• To return to a full exercise routine in 6 weeks.
• To return to stair negotiation at their workplace in 6 weeks.

6. What rehabilitation treatment strategies might be used to address Geoff’s impairments, activity limitations and participation restrictions?

Notes: Consider patient values and preferences as well as key medical issues when discussing treatment strategies. Consider using the process of shared decision-making to prioritize treatment choices/strategies, and provide rationale.
It is important that the strategies used to address their challenges take into account the ICF. By setting goals that address their impairments, this can lead to improvements in their activity limitations and participation restrictions. Some treatment interventions might include active and passive ROM exercises, gentle stretching and strengthening, adaptive equipment if needed to facilitate pain-free ambulation. Strategize ways Geoff can modify their exercise regime so that they are still able to maintain their exercise routine while reducing the weight bearing and pain in their right knee (e.g., upper extremity work, perhaps stationary bike, walking poles, swimming, or water running).

Geoff already practices regular record keeping (e.g., tracking of exercise, medications, and other self-management techniques) which helps many clients to maintain their goals. If Geoff seems overwhelmed, suggest that they set one goal for the day. Additional strategies may include keeping a daily reflection record, especially to identify items for discussion at the next healthcare appointment. All clients should also be encouraged to engage in some type of cognitive activity (e.g., reading, word games, or games on their cell phone).

7. What types of educational health promotion, prevention, care, treatment and support materials or information might the team provide for Geoff?

Notes: After some of the immediate symptoms associated with Geoff’s knee have resolved, they will require education regarding potential prevention of future exacerbation, and how they might modify their exercise regime to prevent exacerbation. Geoff may also benefit from mindfulness techniques to help control their pain.

8. What other health or social services might Geoff also benefit from having access to? Why?

Notes: Identify other services and providers that might help to address Geoff’s impairments, activity limitations and participation restrictions surrounding their avascular necrosis of the right knee. Consider how you would go about referring to the other service providers and services. Consider the potential barriers that Geoff might encounter in attempting to access these services.

9. What issues might Geoff need you to help them advocate for?

Notes: Geoff may need help to access rehabilitation at an outpatient facility (healthcare centre or outpatient hospital clinic). Depending on the types of benefits that Geoff has from their workplace – either private insurance or benefits through work – they may or may not have access to PT services, and the access that they have might be limited to a certain number of visits. You may want to help them arrange the PT sessions so that they align well with their current work hours.  You may be able to find local physiotherapy treatment and care organizations that provide stigma free and inclusive services.