General Information

Patients name: BM
Age: 21 y/o (1)
Sex: Female (Miller and Thompson, 4th edition, p. 349)
Address: 146 Brgy. Somewhere in antipolo
Civil status: Single
Handedness: Right
Occupation: Marathon Runner (Fulkerson, 4th edition, p. 154)
Referring unit: Orthopedic Department
Referring MD: Dr. N.P
Date of Consultation: September 21, 2016
Date of Referral: September 24, 2016
Date of IE: September 25, 2016
MDDx: Left and Right Patellofemoral Pain Syndrome
History of Present Illness
Patients condition started 6 weeks prior to Physical Therapy IE (2). BM, a 21 y/o
marathon runner, started preparing last August 11, 2016 for her first local marathon
competition. Being a novice on the training drills, BM does not follow strictly the
plan schedule exercises as part of the training program. On the first two weeks,
patient mentioned of skipping 10 minute warm up brisk walking exercises and
immediately proceeds to moderate intensity running for about 20 miles per week on
a flat surface. On the third week, due to the patients attitude of winning, BM
decided to add one day of running on her 5 day regular routine and save one day
for rest. Concurrent to this, patient also mentioned of increasing her running
intensity and distance from 20 miles to 50 miles weekly and move from flat surface
to hilly areas (3)(4). Initially, BM started having pain graded 5/10 on the anterior
aspect of both knees following these routine changes. BM ignore the discomfort and
just take Panadol whenever pain occurs. On the sixth week, while on her third mile
of running, BM was force to stop because of an intense anterior knee pain she felt
and decided to discontinue the training plan temporarily to seek medical assistance
(5).
Patient described pain as dull, aching type with a grade of 7/10 and reported
an increase in pain on arising after sitting for 4 to 6 hours of having movie marathon
during her rest day. Patient also had difficulty ambulating especially when
descending stairs due to pain. Patient then went to see a doctor and was asked to
undergo radiography (see ancillary procedures). After physician examination,
patient is now referred to physical therapy rehabilitation for management.
*REF HPI
Anterior Knee Pain: Papadakis (CMDT), 55th edition, p. 1693
Bilateral Knees: Colyar, 1st edition, p. 2228
Dull, aching pain: Anderson (Fundamentals of sports injury management), 2 nd edition, p. 208
Radiography: Biedert (Patellofemoral disorders: Dx and Treatment), 1st edition, p. 13
Pain on arising after sitting, descending stairs, ambulation: Magee, 5 th edition, p. 798

Past Medical History

(+) Appendectomy, 1999
(-) HTN
(-) DM

(-) Cancer
(-) Asthma
(-) Arthritis
Family Medical History
Disease
HTN
DM
Asthma
CA

Paternal
+
-

Maternal
+
-

Personal Social History

Patient is a novice marathon runner. Patient is currently on her 16-week
training course, 5 day (Tuesday to Saturday) regular running routine with 2
day (Sunday and Monday) rest.
Patient likes to do movie marathon during rest days from training. Patient
spends 4-6 hours watching movies in sitting.
Patient does not use illegal drugs.
Patient is non-smoker and non-alcoholic.
Patient has a balance and healthy diet.

Environmental Assessment
Home
Patient lives in a 1-story house.
All rooms are well lit with marble floors.
Using door as a reference:
Living area: 4m
Kitchen: 8m
Dining area: 7m
Comfort room: 8m
Bed room: 9m
Theatre area: 6m
Work
Patients training ground has a flat surface and a hilly, uneven terrain
Patient uses low arch shoe support when training
Ref:
Mode of transportation
Patient travels 20 minutes from her house
training ground. Patient's
older brother drives her to the training ground.
Home Situation
Patient lives with her parents and older brother. Patient does minimal household
chores when needed because her family has a house helper. 100% of rehabilitation
expenses will be paid from patients's personal savings.
Ancillary Procedure/Laboratory Procedure

Procedure

Date

Result

Radiography on
the
L Knee

September 22,
2016

(+) 5mm Lateral

Patellar
Displacement
(-) joint
demineralization
(-) joint space
narrowing

Radiography on
the R Knee

September 22,
2016

(+) Patellar
maltracking
(-) joint
demineralization
(-) joint space
narrowing

Ref: Manske (Postsurgical Orthopedic Sports Rehabilitation: Knee & Shoulder), 1st edition, p.
424

Medications taken
Meds
Panadol
Multivitamins

Route
Orally taken
Orally taken

Dosage
500mg, prn
500mg, 1x/day

Indications
Pain reliever
Supplements

Reference
S:
Chief complaint:
Pt. c/o localized dull, aching pain on the anterior aspect of both knees graded 7/10
making it difficult to ambulate and perform her running training routine.
Pt.s goal
I need to return to my training as soon as possible.
O:
VS:
BP: 110/70 mmHg Goodman, 5th edition, p. 164
HR: 68 bpm (Goodman, 5th edition, p. 161)
RR:15 cpm (Goodman, 5th edition, p. 163)
Temp: 36.7C (Goodman, 5th edition, p. 170)

Findings: All VS are normal

Significance: For baseline purposes
OI:
Patient arrived at the rehab center without any AD and independently walking.
Patient is alert, coherent and cooperative.
Mesomorph
Skin conditions:
(+) Trendelenburg
(+) Hyperpronation of foot (?)
(-) swelling
(-) wound
(-) scar

Ref:
Trendelenburg (West and Colvin, 1st edition, p. 38)
Swelling: France (Introduction to Sports Medicine and Athletic Training), 2nd edition, p. 375

Palpation:
Normothermic on exposed areas of the body
(+) Grade 1 Tenderness
(-) Edema
Ref:
Tenderness: Frontera, Silver, Rizzo, 3rd edition, p. 385
ROM
All major joints of the UE/LE and spine assessed using goniometer are within normal
limits actively and passively done except:
Motion
L Knee Flexion
L Knee
Extension
L Hip ER
L Hip
abduction
R Knee Flexion
R Knee
Extension
R Hip
Abduction
R Hip ER
Ref:

AROM
0-100
0-5

PROM
0-105
0-6

Normal
0-135
0-10

Dif
0-35/0-30
0-5/0-4

Endfeel
Empty
Empty

0-38
0-35

0-42
0-40

0-45
0-45

7/3
0-10/0-5

Firm
Firm

0-100
0-5

0-105
0-7

0-135
0-10

0-35/0-30
0-5/0-3

Empty
Empty

0-40

0-42

0-45

0-5/0-3

Firm

0-41

0-43

0-45

0-4/0-2

Firm

Norkin,
Norkin,
Norkin,
Norkin,

4th
4th
4th
4th

edition,
edition,
edition,
edition,

p.
p.
p.
p.

205
211
244
249

(Hip Abd)
(Hip ER)
(Knee Flexion)
(Knee Ext)

Findings: Pt. has decreased range of motion on bilat hip and knee
Significance: Pt. has difficulty ambulating d/t limitation of motions on the knee and
hip 2 to pain
MMT
All muscles of UE/LE and spine are graded 5/5 except:
Muscle (L)

Grad
e
2/5
3/5
2/5
3/5

Muscle (L)

Grad
e
2/5
3/5
4/5
4/5

Daniels and Worthingthams, 9th edition, p. 249

(Quads)
L Quadriceps
Daniels and Worthingthams, 9th edition, p. 243
L Hamstring
(Hams)
L Gluteus medius (6)
Daniels and Worthingthams, 9th edition, p. 223
L Hip ER (6)
(G. Med)
Daniels and Worthingthams, 9th edition, p. 235 (ExtRot)

L
L
L
L

Quadriceps
Hamstring
Gluteus medius (6)
Hip ER (6)

Ref: Casey, Rho, Press, 1st edition, p. 122

Findings: There is a significant weakness on the L and R quads muscle as

compared to hamstring and hip muscles.
Significance: Pt. cannot tolerate applied resistance thus limiting her ambulation
Sensory testing:
All sensations of the UE, LE and Spine are intact
Findings: No sensory deficit
Significance: There is no nerve afectation and sensation is intact. Modalities can
be safely use.
Ref:
Special Tests
Patellar grind test Magee, 5th edition, p. 798
(+) Patellofemoral dysfunction
Findings: Pt. reports retropatellar pain and cannot hold contraction of the quadriceps
muscle

Significance: Pt.'s condition and cause of pain is due to patellofemoral joint

dysfunction
Mital Hayden Test Magee, 5th edition, p. 795
(-) Mediopatellar Plica Syndrome
Findings: No clicking or pain elicited upon pinching the edge of the plica
Significance: To rule out plica syndrome
Gait Assessment****
Reference leg: (Trendelenburg)
Phase

Hip

Knee

Ankle

ADL Assessment
Findings: Pt. has moderate difficulty in ambulation and in tolerating prolonged
sitting due to pain upon standing. Pt. ocasionally requires minimal assistance in
ascending and descending stairs.
Significance: Pt.s condition afects her ADLs mostly during ambulation due to pain

A:
Physical Therapy Diagnosis:
Patient's MDDx of Patellofemoral Pain Syndrome on bilat knees further
defined by difficulty running, ascending and descending stairs and tolerance to
prolonged sitting 2 to pain, weakness of knee ext, tightness of knee flexor muscles
and LOM of the joint present on bilateral knees.
Physical therapy Impression
Prognosis
Pt. has a good prognosis in terms of returning to normal function, pt. presents
with no red flags, able to do tasks not involving the knees by herself and shows
muscle weakness mostly in knee extensors only. Pt is consistent on going to her
therapy sessions and is cooperative in all treatment sessions emotionally, physically
and financially stable with no other co-morbidities present.
Rehabilitation Potential
Pt. has good rehab potential because she is very willing to undergo PT rehab
and her family is supporting her with ADLs that she couldnt do by herself. Also half
of the expenses of PT management will be handled by the company she is working
with.

Pt. has good rehab potential in terms of her willingness attitude and
compliance to undergo PT rehab and has a strong family support physically with
stable financial assistance.
Long Term Goal
Pt. will be able to perform ADLs, return to training course and decrease pain from
grade 7/10 to 1/10 from after ~ 2 months of PT session
Problem list
1.
2.
3.
4.
5.

Pain of the anterior aspect of bilat knees

Weakness of hips and knees during ambulation
LOM of the joints of bilat knees 2 to pain
Tightness of the vastus medialis obliquus muscle
Decreased ADL performance due to pain

Short Term Goal

1. Pt.

P:
Patient will be seen and treated 4x a week for 6 weeks.
1.
2. ;
3.
Sources:
Patient Education:
Proper joint positioning
Energy conservation techniques
Wear of brace support prn such as when walking for long distances
Avoid strenous LE activities continuously without adequate rest ~2days
Wearing of proper fitting shoes for running such as putting of orthotics
Home Exercise Program:

**https://books.google.com.ph/books?
id=ZSkODAAAQBAJ&pg=PA122&dq=q+angle+in+pfps&hl=en&sa=X&ved=0ahUKE
wiu-Yu-roTPAhVKFZQKHfIeD08Q6AEIJzAC#v=onepage&q=q%20angle%20in
%20pfps&f=false
**http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3625796/
REFERENCES:
1.https://www.researchgate.net/publication/264434530_Efectiveness_of_Exercise_T
herapy_in_Treatment_of_Patients_With_Patellofemoral_Pain_Syndrome_A_Systematic
_Review_and_Meta-Analysis
2. http://www.ncbi.nlm.nih.gov/pubmed/3578639
3. http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=f6dfe5972f7d-4f1e-9af-67694dca085f
4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3497945/
5. http://www.ncbi.nlm.nih.gov/pubmed/?
term=Taunton+JE+a+retrospective+case+control
6. http://www.ncbi.nlm.nih.gov/pubmed/17549951