What do you do with the patient who has seen five other providers, experienced 10-plus years of knee pain, and desperately wants to avoid getting a total-knee replacement (TKR) before turning 60 years old? Plus you only have two visits before they go back to their surgeon to decide on surgery. This was a real patient who I treated, but not that uncommon a situation. No two knee patients are the same, but I can share something that worked with this patient and has been a common finding if you know where to look.
The patient’s chief complaint was anterior knee pain that limited walking, stairs, and prolonged sitting. When I first looked at the patient’s knee, there was a low-grade effusion typical of a knee osteoarthritis patient, but I also noticed a good bit of swelling distal to the patella.
Infrapatellar Fat Pad vs. Patellar Tendon
When I started doing palpation (see Figure), the patient reported a return of her pain. What I palpated was actually the infrapatellar fat pad (IFP). An easy way to differentiate this fat pad from the patellar tendon is simply to have the patient contract the quads to see if the patellar tendon pops into your fingers.
I needed to show meaningful improvement quickly with this patient, so I thought it was worth a shot to explore the IFP more since it replicated her pain. The IFP is a highly vascularized structure that is hypothesized to become fibrotic and a source of pain.1
Before I conducted any intervention, I had her go up and down steps to determine her pain level (6/10). Next, I used the HawkGrips HG9 “Tongue Depressor” instrument (which I love for all types of injuries, especially tendon issues!) and was able to get her pain down to 1/10 within 5 minutes of treatment.
The patient was thrilled! She said that she had “not felt that great in months.” I was able to get immediate buy-in from the patient because I listened to her symptoms, conducted a patient-specific evaluation, and applied effective treatment. The HawkGrips instrument was a huge part in getting this result, but obviously only one (vital) piece of the puzzle. I saw her for 11 more visits and we worked on motor control, stability, mobility, flexibility, and more. The patient was discharged without needing a TKR, and was even able to get back to doing a recreational walking program with her friends.
My takeaways from this case were:
- Listen to the patient; they will tell you what is wrong.
- Know your anatomy, and don’t forget about the fat pads in the knee.
- Learn how to use the instruments (HawkGrips) that get you excellent results, fast!
1. Scapinelli R. Vascular anatomy of the human cruciate ligaments and surrounding structures. Clin Anat. 1997; 10(3): 151-62.
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