Knee pain secondary to gluteal weakness
A 26-year-old groundkeeper and local footballer attended the clinic in early 2006. He reported a history of posterior left knee pain and generalised aching in the anterior aspect of the knee. He had resumed preseason football training two months earlier and was struggling to keep up with the expected training levels due to ongoing discomfort in the knee. He rested over the Christmas period and the knee pain returned once he resumed training. He generally trained without discomfort, but the next day he had a sense of weakness in the knee in getting out of bed and found it difficult to weightbear immediately. Within five minutes he was able to move freely, but noticed the increased discomfort in the knee lasting for up to 48 hours. There were no reports of acute injury in the knee and no significant past history of knee pain. He was coping with his work duties as a groundsman even though there was up to 48 hours of discomfort following a training session. There were no reports of instability, swelling or knee locking.
On objective examination, no biomechanical asymmetry was evident and he had a full painfree range of knee flexion and extension. The patellofemoral joint compression caused discomfort at the inferior patella pole. He was clear on ligamentous testing for cruciate and collateral ligaments. The posterior capsule was relatively lax bilaterally and not painful with overpressure to extension. Muscle length testing was unremarkable for iliotibial band, quads and hamstrings. The most obvious problem was decreased stability when hopping on the leg left allowing the right pelvis to dip on landing. This suggested poor holding capacity in the hip abductors in the stance phase of weightbearing or running, which correlated with the gentleman's history.
Specific muscle testing was done to evaluate the gluteus medius in right side lying position and asking him to abduct the hip with the hip and knee flexed 45 degress and keeping the feet together. He was unable to isolate glutmedius contraction, but rather overused his TFL. He also showed fatigue in active hip abduction holding in side lying when compared to the unaffected side. Treatment was directed toward initially gaining an isolated contraction of gluteus medius in side lying and later progressing to a second level of exercises strengthening hip abduction in side lying. The patient was asked to hold the leg in abduction for between 20 to 30 seconds and build up to 3 sets of 10. He later progressed to a functional weightbearing exercise involving pelvic control in left leg standing allowing the right pelvis to dip down and correct to level using gluteus medius.
He reduced his weightbearing work and increased swimming and cycling and played a weekly basketball game. Treatment was continued on a weekly basis for 4 weeks. He reached the stage of managing a basketball game painfree and had resumed training with minimal ill effects for the next 48 hours post training. At his last training session he managed 90 minutes with no increased pain the next day and ran the Tan, which is 3.8km in 20 minutes with no post exercise pain. Hopping also became much more symmetrical and he had increased holding capacity in his hip adductors in side lying.
This example demonstrates the importance of finding the cause of an athletes pain rather than treating the symptoms. The client was motivated and worked at their progressive strengthening regime for 4 weeks. I instructed them to continue with the program for a further 4 weeks once he had become asymptomatic.
|
