Rob is an active businessman in his late 50s who travels by car and plane a great deal of the time. When he is home, in Syracuse, he works out regularly at one of the local gyms with a personal trainer. Unfortunately, Rob is twice as old as his trainer, so there is not much empathy between them regarding what it’s like to work out at 60 years of age. I can tell you one thing for sure (because I’m 62, and still work out regularly), it’s not the same as when you are in your 30s.
Rob came to see me complaining of L lateral knee pain. He reported the onset of the pain occurring during, and/or as the result of his training. He had informed his trainer of his condition, but it was not getting any better, in fact it was becoming more of a problem as time went on.
The first thing I did was perform a standing postural assessment with Rob. Rob is a pretty tall guy, about 6’2”, and lean. Right off, I could notice some ankle pronation that was a bit more prominent on the left side, and valgus knees again more prominent on the left side. Neither the ankle pronation nor the valgus knees were extreme, just there, and slightly more noticeable on the left side. (Tight ITB, short/tight TFL, dominant adductor complex)
Next, I had Rob move into a single-leg stance with his right leg as the stance leg and his left leg flexed to 90˚ at both the hip and knee. I observed the L femur pull across the midline and the left foot abduct to about 20˚. (dominant adductors, short/tight biceps femoris, short/tight TFL)
Following the standing postural assessment, I had Rob move to the table where I could test for hypermobility situations. I began by testing single-plane anterior, posterior, and lateral instability. The anterior drawer, Lachman’s and posterior drawer tests were all negative, as were the valgus and varus stress tests. Apley’s Compression and Distraction were also negative. This pretty much ruled out ligament and meniscus injury, so I continued by testing for Patellar Tendinosis and Chondromalacia. The Patellar Tendinosis test was definitely negative, but the Test for Chondromalacia was minimally positive. There may have been some minor lateral patellar tracking, but I didn’t think it was the major cause of Rob’s discomfort.
Finally, I used a resisted test for a possible Plantaris/Popliteus strain. It was a long shot, but since the Plantaris and Popliteus both originate at the lateral epicondyle of the femur, I wanted to be sure. Both tests were negative, so my last option was to check for Iliotibial Band Friction Syndrome.
I placed Rob in a sitting position, with his legs hanging off the side of the table. I then C-clamped the distal end of the L ITB with my right hand and had Rob slowly extend his knee. This reproduced his pain exactly, and was most painful at about 30˚ of extension.
ITB Friction Syndrome would probably be anyone’s first guess, but you have to rule out the other possibilities, to be sure.
I moved Rob into the prone position to test PROM and RROM and began treatment by performing the anterior quadriceps release (from the pelvic stabilization protocol). ROM was a bit restricted at about 120˚ with a tissue-on-tissue (leathery) end-feel.
Next, I checked for a possible anterior rotation of the L ilium (sagittal plane) by assessing the relative positions of Rob’s ASISs. His L ASIS was slightly inferior. I utilized a muscle energy technique to correct this rotation (resisting anterior rotation). I followed this with myofascial release up the quadriceps and rectus femoris. These techniques returned Rob’s ROM to about 135˚, which was appropriate.
Since RROM of Rob’s L Quad revealed no trigger/tender points, I moved on to releasing the Gmax/med and TFL utilizing myofascial release and compression broadening techniques, respectively. I followed with a Gmax Lateral Fibers Stretch and a TFL Stretch.
To finish the session, I performed an ITB Mobilization Technique, working from the hip to the knee. To follow up on the possibility of some minor patellar tracking, I also performed a compression broadening technique working proximal to distal through the Vastus Lateralis.
I then had Rob actively perform knee flexion and extension, testing for pain-free movement. Rob was able to perform this test pain-free.
I completed the work by instructing Rob in an at home program for stretching the Gmax and TFL, and strengthening the VMO.