Hip and Knee Pain treated with Integrative Manual Therapy
Author: Martha Moran
Abstract: This is a case study of a 46 year old woman which complaints of left hip and knee pain. At evaluation, patient presented with postural deviations and limitations in range of motion of her bilateral lower extremities and spine. Patient was treated with Integrative Manual Therapy focusing on multiple systems of the body specific to the left leg, including musculoskeletal, vascular, and neural systems. After therapy was completed, patient showed evidence of significant increases in range of motion of her left leg including reports of elimination of pain in her left hip and knee.
Key Words: Hip, Knee, Chondromalacia, Arthritis
History
Client: 46 year-old female, Height: 5’4", Weight: 140 lbs.
Chief Complaint: Chronic left hip and left knee pain
Over the past two years, client has noticed pain and a significant reduction in range of motion of left hip joint and left knee joint. No specific injury was noted during this time. Ice makes the pain better. Exercise and sitting for long periods of time makes the pain worse, as well as, any movement with external rotation or abduction.
A chiropractor was consulted. Lumbar spine x-rays were obtained, and a leg length discrepancy observed. The chiropractor adjusted the patient’s spine and knee using thrust manipulation and prescribed a heel lift for the left shoe. An increase in left knee pain was noted for the several months the client used the heel lift. Monitored Pilate’s exercises were attempted causing a significant increase in left hip and left knee symptoms. A physical therapist confirmed the leg length discrepancy and advised against use of the heel lift. The left knee and left hip symptoms increased after abandoning use of heel lift. An MRI was taken through the suggestion of an osteopathic physician.
Medications: none
Childhood Illnesses:
Possibly suffered from rickets at an early age.
Chicken pox
Pneumonia, 4 years old
Adult Illnesses:
Sporadically fainted through pregnancy up to 6th month, 1981.
Difficulty in walking, standing and sitting throughout entire pregnancy. Client feels she never recovered fully from pregnancy.
Surgeries:
Wisdom teeth, 1985
Appendectomy, 1977
2 abortions: 1983, 1986
Accidents or Injuries:
Briefly lost consciousness after falling out of a tree on her back as a child.
Lost hearing in left ear during a thunderstorm as a teenager
Fell down several stairs and sprained her right ankle, 1993
Current Health Status: No tobacco products, drinks alcohol occasionally and eats a diet consisting mainly of grains, vegetables, chicken and fish. Client previously engaged in an exercise program of Pilate’s 3-4 times/week and jogging/swimming 2-3 times/week. She is now unable to run as before, but continues Pilate’s exercises with discomfort. Emotionally she feels unsupported and stressed at home and work.
Vaccinations: Unknown childhood vaccines
Screening Tests:
MRI showed bone chips in hip socket, arthritis in left hip and chondromalacia of the left knee.
Low back and left hip x-ray showed no significant abnormalities with hip joint itself (per D.O.).
Family History:
Mother had epilepsy and mental illness.
Father died of a stroke at 69.
Doesn’t know much about family history.
Personal and Social History: Client is a married woman with one child. She grew up in the rural Ural Mountains of Russia where she was malnourished. At the age of five she moved to a city where her nutrition improved. She is self-employed in the family business working 4 hrs/day in a stressful, busy environment.
Examination
Observation/Palpation: Rigid stature, forward head, shoulders elevated, rigid mid thoracic spine – no thoracic respiratory expansion, left leg very guarded/stiff/little range of motion (ROM), right leg also restricted with some flexibility.
Mapping: Full body still
5 Point Longitudinal Pressure Scan (LPS): Several – full body. Most predominant left leg/hip/knee, heart and head.
Local and Global Listening: Several – full body. Most predominant left leg/hip/knee, heart and head.
Range of Motion:
Cervical: Limited.
Thoracic: Limited – especially on extension.
Lumbar: Braced – no flexion, extension, side-bending or rotation
Upper Extremities: Restricted greater than 90° flexion and extension.
Lower Extremities: Flexion at 45° reproduced pain in the medial knee.
Treatment
Full body treatment was given using Integrative Manual Therapy Systems Approach including techniques learned in:
Discussion
Mapping, local and global listening, and LPS’s were a key in determining the course of treatment. Scan tests helped to discover the cause of dysfunction and treatments using the Integrated Systems Approach facilitated a decrease in pain and an increase in ROM with each session.
Advanced Strain and Counterstrain techniques (Giammatteo, T., Weiselfish-Giammatteo, S., Autonomic Nervous Systems and Related Disorders, 1997.) were used to reduce the protective muscle spasms present in the vascular and lymphatic systems throughout the cranial, cervical, thoracic, lumbar, lower extremities, pelvic floor and visceral areas. Client had considerable reduction in pain of left knee and hip, although no change in ROM was noted.
Cranial Therapy and Bone Bruise techniques (Weiselfish-Giammatteo, S., DCR Cranial Series, DCR Diagnostic Series) were used to release the right temporal and sphenoid. Techniques from the Biologic Analog series (Weiselfish-Giammatteo, S., Lowen, F., Biologic Analogs for Neural Mobilization) allowed for a release of many restricted structures within the right hemisphere, most importantly, cranial nerve VIII, lateral and medial lemniscus, internal capsule, cerebral peduncles and corticospinal tracts. The use of this combined approach allowed the client to experience the greatest relief in pain symptoms of left hip and knee even though slight ROM restriction was still observed. Stature was no longer rigid and full thoracic/respiratory expansion was attained post treatments.
Visceral Mobilization techniques, Muscle Energy and ‘Beyond’ Technique, and Neural Tissue Tension Techniques were also applied with little or no affect on pain and ROM symptoms in this case.