This topic contains 5 replies, has 2 voices, and was last updated by Carl Nottoli, DC February 19, 2018 at 9:21 am.
February 15, 2018 at 11:41 am #5291
I’ve got an interesting patient and this is the best thing I could come up with, so please pick apart my reasoning–I’m here to learn!
VERY active 35 year old female patient who donated a kidney to her dad 2.5 months ago. She has been on a 30# weight restriction for weights and so in her infinite wisdom does a TON of reps. She complains of an intense (6-7/10) ache on the posterior medial side of her proximal left leg the morning after intense workouts. It gets better throughout the day as she does her ADLs.
AD: L 3″, adhesion at FHL, some adhesion on her achilles as well. Her achilles was surgically reattached in 2015.
SLR: B 90/0
QLF: 22222 no adhesion, valsalva negative
Lunge test: FAIL
On paper it seems like a huge DUH for the FHL, but the point she is complaining about is superior to its proximal attachment on the tibia. My reason for asking about the popliteus is because she is training for a triathlon and her training is running, cycling, swimming and lifting. Considering her lunge test, I believe that since her hamstrings aren’t doing their job flexing the knee, the popliteus is putting in extra work to help flex the knee and its overused from doing so. Palpating from the edge of the tibia going posterior medially behind the gastroc is very tender (no throbbing) and I got some good tension taking a superior lateral tension when going from knee flexion to extension. I told her to not lift quads on her gym days and to perform the hip lift. Any thoughts are greatly appreciated.February 15, 2018 at 12:07 pm #5292
Seth Schultz, DCParticipant
Great start, I think there needs to be more data extracted before pointing towards popliteus. Did you do the knee exam or the other 2 tests of the ankle exam? If so, what did those tests look like?February 15, 2018 at 2:57 pm #5293
Brandon Cohen DC, CSCSParticipant
It could be……but, what Seth said. We need knee information, also how was the lunge a fail? Bilaterally?February 15, 2018 at 5:08 pm #5294
Keith Puri, DCParticipant
I agree with Seth and Brandon. Getting the specific results/scores from the other tests will allow for a more accurate interpretation of the relevance of the popliteus and the rest of the of the MSK system.
That said, I would be more concerned she is pushing the recovery of her kidney donation surgery. I know you said she has been put on a 30 Ib weight restriction but would question what other restrictions she might have. I am not sure the surgeon would agree with her interpretation as she trains for a triathlon. This definitely sounds like a load vs capacity MSK issue but if she is not respecting the surgeon’s restrictions she will more than likely not follow yours. This is a sure-fire recipe for non-compliance and a poor outcome.February 16, 2018 at 12:23 pm #5295
Seth- Her PKF was 0″ but her RFLT is 2″/6–I should probably work on cleaning that up. Her PK test is full/0 bilaterally but fails the lockout test bilaterally. Stick to the tests and trust the process. Lesson learned…again.
Brandon- Her lunge was a fail bilaterally because she basically could not load either heel at any point of the lunge, even with coaching. Her body doesn’t remotely trust her quads.
Keith- This patient has been explained time and time again that the load on her body far exceeds what she can do with health. She acknowledges this, but states that she will go crazy if she doesn’t compete. It is a constant fight, but she also is well aware of why she needs to keep coming back: the unrelenting load on her body. I’m basically keeping the wheels from totally falling off the wagon with her and she knows it.February 19, 2018 at 9:21 am #5296
Carl Nottoli, DCParticipant
As we say in ID, good tests with a high level of pain are highly suggestive of pathology. So while the popliteus could in fact be complaining, it’s not reverse compatible based on the other negative tests and the high level of pain. Start to think in terms of, “What else lives in or around the knee and could be responsible for these symptoms?”
In this case, articular cartilage and/or meniscus is high on my list of suspects. Perform some simple orthopedic tests like Thessaly’s and McMurray’s to see if anything pops up. Either way getting an MRI would be a good step for further diagnosis and management of these patient.
Her lunge is also positive for posterior chain weakness, which will shear the knees more and create more degeneration. Since her SLR is clean, implement hip lifts once the importance of imaging is discussed and the MRI is ordered.
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