John is a 58-year-old, 5-foot-11, 220-pound retired correctional officer. He experiences left knee pain and range-of-motion (ROM) restrictions from past knee surgeries that have been unresolved by previous therapies. His medical history includes a left total-knee replacement (TKR) in November 2012, followed by another surgery in December 2012 due to a staph infection. Although he underwent physical therapy, it was limited due to pain and soft tissue restrictions around the scar matrix and into his left hip and lumbar spine (L/S).
In February 2014, the patient had surgery to add a spacer in his left knee, only to undergo a second TKR on that knee in May 2014. John began physical therapy treatment shortly after this surgical intervention but it proved ineffective, again limited by pain and soft tissue restrictions. His left knee was also manipulated in October 2014, followed by physical therapy that produced little positive impact.
Since the last surgery, John remains active but has multiple compensatory patterns throughout his left knee and hip region, affecting his gait mechanics and L/S mobility. He has spent the past three years doing whatever he can to minimize his knee pain while refusing further surgical intervention. John is also skeptical about any physical therapy treatment, having tried three prior regimens without much success.
Presentation and Examination
He reports left knee pain anteriorly in the peripatellar region and along his 12-inch scar. His pain ranges from 0-7 out of 10 on the Visual Analogue Scale (VAS), and he describes it as achy, stabbing, sharp, and shooting. John states the pain is worse with stair negotiation, as well as with trying to stand and move after sitting for a prolonged period of time, only to be resolved by weight-bearing/walking for a longer period of time. He is right-side dominant and hasn’t had any recent diagnostic testing.
His physical examination demonstrates: mild temperature in the left knee region, minimal to moderate swelling, and varicose veins with bruising to the mid-left quadriceps musculature. No lateral lumbar shift, and no significant muscle-guarding during ambulation or transfers. The patient appears alert and oriented and is cooperative with exam and history-taking.
No significant tenderness to palpation of lower quadrant and sacroiliac joints. He presents with an increased L/S lordosis and thoracic spine (T/S) kyphosis with moderately poor posture. L/S AROM (active range of motion) is within normal limits, 2/6 hypomobility with posterior-anterior intervertebral mobilization (PAIVM) testing, and no crepitus or discomfort at end-range.
Hip AROM is within functional limits for his age-specific range, and strength rates 5/5 in manual muscle testing (MMT). Left is limited 0-65 degrees with moderate hamstring tightness and 15 degrees of knee flexion to complete the task. The patient demonstrates 3+/5 MMT abduction on the right, 0-30 degrees, 4/5 MMT on the left, 0-20 degrees, and gluteus medius deficiency 4-/5 MMT. Internal/external rotation is limited on the left due to poor knee mobility, extension 0-10 degrees with multiple compensatory patterns, and altered firing pattern between the hamstrings and gluteus maximus (3/5 MMT).
Knee AROM on the right is 0-125 degrees, 5/5 MMT, left AROM -10 to 81 degrees, and PROM (passive range of motion) -8 to 87 degrees with swelling. Abnormality is present in the scar region, with moderate to severe adhesion formation approximately 1/2-1 inch around his scar. Patellar mobility is limited L>R in all directions, lateral lying to the left. Gait mechanics are altered with knee valgus, hip varus, and bilateral ankle pronation with proximal instability on the left. Trunk rotation is altered bilaterally, with decreased weight-bearing on the left and a positive Trendelenburg sign. Negative neurological exam, normal pulses, with both dorsal pedal and posterior tibial pulses strong and regular.
The treatment plan for John is to improve mobility throughout his L/S, hip, and knee; as well as improve gait mechanics, balance and kinesthetic sense; utilizing modalities, manual therapy, gait training, therapeutic exercise, and a comprehensive home exercise program. He is being treated two to three times a week for 8-12 weeks or until his goals are met. John has currently been seen for 12 visits, demonstrating the following treatment outcomes:
During this time period, treatment included modalities to the left knee to improve blood flow and initiate soft tissue mobility. Specifically, we utilized the HawkGrips HG8 (“Scanner”) and HG9 (“Tongue Depressor”) around the scar, working proximal to distal initially away from it, using a sweeping and then strumming stroke. The Scanner was applied around the quadriceps with the left knee supported at 30 degrees (resting position), progressing to end-range for the patient (87 degrees of knee flexion). We integrated manual therapy to improve L/S and hip mobility with joint mobilizations, and closed-kinetic-chain exercises for proximal stability (gluteus medius/maximus). Gait training was started to promote bilateral heel strike and stance time.
Results: Knee AROM improved -3 to 94 degrees, with decreased adhesion formation around the scar. Regarding gait mechanics, John demonstrated improved stance time bilaterally, 50-percent improvement in trunk rotation with reciprocal arm swing, straight leg raise on the left 0-70 degrees, and 9 degrees of knee flexion.
This part of the treatment regimen included warm-up on the elliptical machine for 5 minutes followed by IASTM utilizing HawkGrips (HG8 and HG9) to the scar region in both a static and dynamic position. Statically in supine, full-knee flexion, per patient to 94 degrees of flexion using IASTM around the scar and surrounding tissues (quadriceps/medial collateral ligament/lateral collateral ligament region), including the Tongue Depressor over the patellar tendon. Began working into AROM, asking the patient at end-range knee flexion where he felt the limitation, and using HawkGrips instruments to work out the tissue in the area.
John progressed to riding the bike for 10 minutes, followed by the leg press/shuttle machine with HG8 treatment along the scar and to surrounding tissues throughout the movement. Clinical observations included negative skin check prior to treatment, petechiae forming throughout treatment, minimal swelling and no ecchymosis, with full patient education before and after all IASTM treatment. This was followed by the application of RockTape to sustain proper blood flow and mobility in the left knee.
Results: Currently the patient can actively flex his knee to 98 degrees and extend to -2 degrees, with improvements in gait mechanics and overall balance and transfer transitions. The scar matrix is decreasing, with minimal to no swelling in the area, as well as minimal adhesions (< 1/4 inch) around the scar (more proximally than distally). Gait mechanics include symmetrical trunk rotation, minimal left Trendelenburg, and improved bilateral heel strike.
Conclusion: Since his last surgery in 2014, John has progressed from 81 degrees to 98 degrees (a difference of 17 degrees over 12 visits), and can now ambulate with improved mechanics, better balance, and enhanced soft tissue mobility around his left scar. His physician is very happy with the results and has increasingly referred patients to us while specifically requesting that HawkGrips be utilized in treatment. For John to achieve such a high degree of AROM progression after three years, as well as make such significant gains in functional ability through soft tissue mobilization, is a testament to the importance of integrating HawkGrips into any plan of care.
Dr. Chris Capilli received his undergraduate degree in sports medicine from Canisius College, Buffalo, NY, followed by his master’s and doctoral degrees in physical therapy from D’Youville College, also in Buffalo. He completed his Fellowship in Manual Therapy at Daemen College, Buffalo. Dr. Capilli works for Arnot Health in Elmira, NY, and has been a practicing clinician for more than 10 years, working in a number of different settings but primarily outpatient orthopedic.
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