Wow! What would you do?
This is part 1 of a 2 part post. Look for the other one a few minutes after this one with a video up top for the conclusion
PRESENTING PROBLEM: This 54 YO female patient presents with with left sided knee pain. She had a total knee replacement (TKR) done in 2011. She’s had a significant amount of discomfort on the medial aspect of the knee since then. She had an MRI of the hip done thinking the problem was there, and found nothing. She is walking with a bad limp, left leg is half inch shorter than the right. Pain is worse at night, changes with weather.
She has knee pain on the lateral aspect (points to tibial plateau and joint line) with swelling that goes down to the ankle left side. She has been wearing a “Good Feet” OTC orthotic on the left side which she states helps quite a bit.
Generally speaking, stretching and analgesics make the discomfort better. Ibuprofen 400 mg. b.i.d. can take the edge off Soft sided brace (neoprene sleeve) makes a difference as well. The hard sided brace gives her difficulty.
WORK HISTORY: She works for a preschool. Her job involves standing and getting up and down a lot.
FAMILY HISTORY: She has left sided lid ptosis, this evidently is familial.
PHYSICAL EXAM: She stood 5’ 1” and weighed approx. 150 pounds.
Viewing the knees bi-lat., the left knee is markedly externally rotated.
She does have a left short leg; tibial and femoral. She has bilateral tibial torsion (look at the tibial tuberosities and drop a line straight down; it should pass through the 2nd metatarsal head) and marked internal tibial torsion on the left side (>60 degrees) with femoral retrotorsion (less than 8 degree angle of femoral head with the shaft) on this side. There is no rotation of the thigh or leg past zero degrees midline. . She had 10 degrees of tibial varum on the left hand side. Her Q-angle is 10 degrees on that side. There is plantar flexion inversion of the foot. Left lower extremity has less sensation secondary to the her TKR surgery.
Gait evaluation reveals a fair amount of midfoot pronation noted on the left hand side in addition to an intoed gait. She has to lean her body over to the left to get the right leg to clear.
Some mild weakness noted of hip abduction musculature left hand side gluteus medius, middle and anterior fibers. Knee stability tests were negative.
Neurologically, otherwise, she had full integrity with respect to sensation, motor strength and deep tendon reflexes in the upper and lower extremities.
Please see part 2 of this post for additional info including our assessment and what WE did.
special thanks to SZ for allowing us to publish her case, so others can learn
