Four female amateur triathletes, ages 27–43, developed pain around the right lateral femoral condyle ( ) as a result of a change in their training routine. All four athletes consulted with an orthopedic surgeon, were immobilized or restricted from activity for at least two weeks, had normal MRI results, completed at least six weeks of physical therapy that consisted of therapeutic modalities and strengthening exercises, and were unable train for more than seven months.
Each patient filled out a Lower Extremity Functional Scale (LEFS)(27), Global Rating of Change Scale (GRCS)(28) ( ), and underwent a standardized physical exam. Consent was obtained from each patient to use their information in a case report. The LEFS is a questionnaire containing 20 questions about a person’s ability to perform everyday tasks. The tasks are ranked on a scale from zero (extremely difficult or unable to perform) to four (no difficulty performing the activity). The maximum score is 80; the lower the score, the greater the disability. The minimal clinically important difference is 9 scale points(27). The reliability of the LEFS was found to be excellent .94 and the validity supported by comparison with the SF-36 physical function subscale (r = .80) and the SF-36 physical component score (r = .64)(27). The GRCS provides a means of measuring self-perceived change in health status(28). The main purpose of the GRCS is to quantify the degree to which the patient has improved or deteriorated over time. GRCS involves a single question that asks the patient to rate their change with respect to their condition. The question used in this case series was: “With respect to your knee pain, how would you compare yourself now compared to when you first came in for treatment?” In this study, a 15-point scale, ranging from −7 (a very great deal worse), through 0 (unchanged) to +7 (a very great deal better) was utilized. The minimal clinically important difference is 5 scale points(28). The reliability of the GRCS was found to be .90 in a cohort of subjects with low back pain(28). The GRCS has shown good validity when compared to the Roland Morris disability questionnaire (r = 50), Oswestry low back pain disability questionnaire (r = .78), and the numeric pain rating scale (r = .49)(28). The physical exam consisted of bilateral active and passive knee ROM, Valgus and Varus Stress Tests, Lachman’s Test, Posterior Drawer Test, Apley’s Compression Test, Patellar Grind Test, Knee Extension Angle (KEA) (29,30) to measure hamstring flexibility, and the Ober’s test(31) to measure iliotibial band flexibility. Patients were also observed while squatting and jumping to identify the presence of dynamic valgus.
Case 1Case 2Case 3Case 4
Baseline4wksBaseline4wksBaseline4wksBaseline4wksLower Extremity Functional Scale5877597465744952Global Rating of Change16362700Knee Ext Angle Right30°10°24°7°22°0°16°15° Left8°5°16°15°0°0°5°7°Ober’s Test Right10°−10°12°−18°5°−22°−14°−20° Left−13°−15°−20°−17°−19°−20°−20°−22°Running Distance/Miles.323.5531.23324.3Numeric Pain Scale91907099Open in a separate window
The KEA and the Ober’s tests were measured with a bubble inclinometer ( ). The KEA was performed as described by Gajdosik(30,32) ( ). The patient was positioned supine on the exam table with one mobilization belt placed across the anterior superior iliac spines and another across the mid-thigh of the left lower extremity. The patient was asked to bring her right thigh toward her chest and support it with both hands clasped behind the knee. The examiner placed a level along the patient’s anterior thigh to ensure that the leg was perpendicular to the table. (In the study performed by Gajdosik, a wooden dowel was used to block the subject’s thigh to keep the leg perpendicular to the table). A bubble inclinometer was placed on the patient’s shin and she was asked to actively straighten her lower leg. The measurement was taken at the end of the range of active knee extension, which is the degree of knee flexion from terminal knee extension. The intratester reliability of the KEA test has been reported to be .99(30,32,33). A KEA angle of 20° has been defined as a cutoff score indicating hamstring muscle tightness(34). Therefore, a KEA angle of greater than 20° indicates hamstring tightness; three of the four athletes exceeded the threshold for hamstring tightness.
The Ober’s test was performed ( ), as described by Reese and Bandy(31). The patient was positioned on the examination table on her left side with the hip and knee of the left lower extremity flexed to 45° and 90°, respectively, in order to stabilize the pelvis. The examiner stood behind the patient and with his left hand stabilized the patient’s pelvis. With his right hand the examiner reached under the patient’s lower leg and grasped the thigh just above the knee, supporting the lower leg with his forearm. The examiner then passively abducted and extended the hip in line with the trunk. The examiner asked the patient to relax all muscles of the lower extremity, while allowing the uppermost limb to drop toward the table through the available hip adduction range of motion. The end position of hip adduction was defined as the point at which lateral tilting of the pelvis was palpated or when the hip adduction movement stopped, or both. In this position, the examiner maintained the alignment and ensured that no tilting of the pelvis nor internal rotation and flexion of the hip occurred, while a second examiner placed the bubble inclinometer over the lateral epicondyle. If the leg was below horizontal it was recorded as a negative number and if it was above horizontal it was recorded as a positive number. Reese and Bandy(31) found the Ober’s test to have excellent reliability with an ICC value of .90.
After the physical exam was completed, each athlete ran on a treadmill, 0% grade, at her normal running speed until she experienced knee pain sufficient to make her stop running. She was then asked to rate her pain on a numeric scale (NPS) of zero to ten (zero representing no pain and ten representing unbearable pain) just before she stopped running ( ). The athletes each filled out a pain diagram illustrating exactly where they were experiencing the pain.