PT Assessment & Management Notes

Right Knee OA + Left Hip Hike / Lateral Pelvic Drop

SUBJECTIVE

• Chief complaint: Right knee pain (OA) with compensatory left hip hike / lateral pelvic drop during gait
• Record: onset, duration, pain VAS/NRS, aggravating/relieving factors
• Functional complaints: difficulty walking, stair climbing, sit-to-stand, balance issues, falls history (past 12 months)
• Comorbidities: CVD, diabetes, obesity, depression, renal/liver disease (influence treatment selection)
• Patient goals, expectations, and knowledge of their condition

OBJECTIVE ASSESSMENT

Observation (Standing & Gait)

Joint Assessment — Right Knee

• ROM: Flexion/extension (compare bilaterally; OA typically limits full flexion/extension)
• Palpation: Joint line tenderness (medial > lateral in typical OA), effusion, warmth
• Special tests: Varus/valgus stress (laxity), McMurray (meniscal contribution), patellar grind
• Giving way: document for bracing/gait aid decision

Hip Assessment — Left Side

• ROM: Hip flexion, extension, abduction, IR/ER
• Muscle length: TFL/IT band (Ober's), hip flexors (Thomas test), QL
• Strength testing: Left hip abductors (gluteus medius — MMT/dynamometry), QL, TFL
• Trendelenburg test (single-leg stance — left side): positive if pelvis drops opposite side

Muscle Strength

• Bilateral quadriceps strength (key in knee OA — weakness is primary driver of pain and functional loss)
• Right hip abductors, extensors
• Left gluteus medius (likely inhibited/weak)
• Core and lumbar stabilizers

Functional Tests

• Timed Up and Go (TUG) — falls risk
• 30-second chair stand test
• 6-minute walk test (if indicated)
• Single-leg stance time (balance)
• Stair climb test

Outcome Measures

• KOOS (Knee injury and Osteoarthritis Outcome Score) for right knee
• HOOS (Hip disability and Osteoarthritis Outcome Score) if hip OA co-exists
• VAS / NRS pain

PROBLEM LIST

1. Right knee OA — pain, reduced ROM, effusion, quadriceps weakness
2. Antalgic gait right — reduced right stance time
3. Left hip hike during right swing / lateral pelvic drop during left stance → compensatory gluteus medius inhibition bilaterally
4. Varus thrust right knee (if present) — increased medial compartment loading
5. Impaired balance and fall risk
6. Functional limitations: walking, stairs, sit-to-stand
7. Possible psychosocial factors (assess mood, sleep, coping)

PHYSIOTHERAPY MANAGEMENT PLAN

1. Patient Education (First Priority)

• Explain OA as a joint health condition, not "wear and tear" doom
• Clarify that exercise is medicine — strongly evidence-based for pain and function
• Set realistic expectations; involve patient in goal-setting
• Advise on activity pacing and joint protection

2. Therapeutic Exercise (Core Treatment — Strongly Recommended)

• Seated knee extension (low load initially)
• Straight leg raises
• Mini squats / wall squats
• Step-ups (low step, controlled)
• Cycling (stationary) — low impact, effective for aerobic + quad strengthening

• Side-lying hip abduction
• Clamshell exercises (with resistance band progression)
• Single-leg bridges (left stance)
• Lateral band walks
• Single-leg squat progressions (controlled Trendelenburg correction)

• Side-lying QL stretch
• Standing lateral trunk stretch
• Myofascial release / dry needling to left QL and TFL if indicated

• Single-leg stance on firm → foam surface
• Wobble board training
• Tai chi — strongly recommended (reduces falls, improves balance in knee/hip OA)

• Walking, cycling, swimming/hydrotherapy (pool reduces joint load)
• Target: raise heart rate, 150 min/week moderate intensity (build gradually)

• Particularly useful when pain limits land-based activity
• Aqua therapy for right knee OA allows greater ROM and loading tolerance

3. Manual Therapy

• Knee joint mobilization (tibiofemoral, patellofemoral) — adjunct to exercise
• Soft tissue therapy to right knee periarticular structures
• Left QL and hip flexor manual release

4. Gait Retraining

• Cue patient to reduce left hip hike: mirror/video feedback, tactile cueing
• Encourage symmetrical step length and weight acceptance on right
• Gait aid (walking stick in LEFT hand) if varus thrust or giving way is present — reduces right knee loading by ~20%

5. Orthotic / Bracing

• Right knee brace: If varus thrust present → valgus unloader brace (offloads medial compartment)
• Foot orthotics: If pes planus/abnormal foot posture → refer to podiatrist; lateral wedge insoles may reduce medial knee load in varus OA
• Assess footwear — cushioned, supportive shoes

6. Weight Management

• If BMI > 25 kg/m²: counsel on weight loss (target 5–10% body weight)
• Refer to dietitian; combined diet + exercise more effective than either alone
• Even 5 kg loss has measurable benefit on knee joint load

7. Pain Management (Adjuncts to Exercise)

8. Psychosocial Screening

• Screen for depression/anxiety (PHQ-9, GAD-7)
• Poor sleep, catastrophizing, fear-avoidance → refer to psychologist
• Consider pain neuroscience education if central sensitization features present

9. Referral Pathways

SHORT-TERM GOALS (4–6 weeks)

• Reduce right knee pain by ≥ 2 NRS points
• Improve TUG by ≥ 2 seconds
• Correct left hip hike pattern during gait (visual/video feedback)
• Independent home exercise program (HEP) compliance ≥ 3×/week

LONG-TERM GOALS (3–6 months)

• Normalize gait symmetry — eliminate compensatory hip hike
• Achieve 5–10% weight loss (if overweight)
• Return to desired activities (walking, ADLs without limitation)
• Prevent/delay surgical intervention

ADDENDUM: FFD Correction + ACL Tear

FIXED FLEXION DEFORMITY (FFD) — Right Knee

What It Is

• Posterior capsule contracture
• Hamstring tightness/spasm
• Chronic effusion (joint held in ~30° — position of maximum intra-articular volume)
• Quadriceps inhibition with compensatory flexion posture
• Pain-avoidance holding pattern

Assessment of FFD

PT Management — FFD Correction

• RICE (Rest, Ice, Compression, Elevation) for acute flare
• Electrotherapy: TENS for pain, interferential therapy to reduce effusion
• Manual lymphatic drainage / effleurage
• Compression bandaging
• Reduce provocative activities temporarily

• Prone lying extension: Patient lies prone with knee hanging off bed edge — gravity provides gentle sustained stretch; progress with small ankle weight (0.5–1 kg)
• Heel prop in supine: Place bolster/roll under heel (not under knee) → gravity allows passive knee extension; hold 10–20 min, 2–3×/day
• Low-load prolonged stretch (LLPS): Most effective for capsular contracture — sustained low load over 20–30 minutes preferred over high-load brief stretches
• Dynamic splinting / serial casting: For FFD > 15–20° not responding to exercise — static progressive or dynamic extension splint worn for periods through day; serial casting in more severe/chronic cases

• Supine hamstring stretch (towel/strap assisted)
• Standing hamstring stretch (knee straight, hip flexed)
• Gastrocnemius stretch (contributes to knee flexion posture)
• Posterior capsule mobilization: Posterior glide of tibia on femur (accessory joint mobilization)

• Posterior tibial glide in near-extension range to improve terminal extension
• Patellofemoral superior glide (restricted superior glide limits full knee extension)
• Sustained end-range mobilization into extension

• Terminal knee extension (TKE): Using resistance band fixed behind knee, patient actively extends from 20° to 0° → targets VMO in terminal range
• Prone knee extension with quad contraction: Contract quads at end of prone hang
• Vastus Medialis Oblique (VMO) activation: Essential for active extension recovery

• Applied to quadriceps to augment voluntary activation
• Reduces quadriceps inhibition from effusion/pain
• Use in conjunction with active exercise

• Walking re-education — ensure heel strike and terminal knee extension in stance
• Stair training — emphasize full extension at top of step
• Avoid prolonged sitting in flexion (>90°) — advise frequent position changes

• < 5° FFD: conservative PT (4–8 weeks intensive)
• 5–15° FFD: aggressive PT + splinting (8–12 weeks)

• 20° FFD or bony block: orthopaedic referral (posterior capsular release, osteotomy considerations)

ACL TEAR — Assessment & Management

Background (in context of this patient)

• Acute ACL tear (recent injury — haemarthrosis, significant instability)
• Chronic ACL deficiency (longstanding, with adaptive strategies)
• Post-ACL reconstruction (rehab protocol)

Assessment

• Mechanism: Non-contact pivot/twist, valgus collapse, hyperextension, or contact
• Acute: "Pop," immediate haemarthrosis (within 2 hours), inability to continue activity
• Chronic: Giving way with pivoting, cutting, deceleration
• Previous surgery or prior ACL injury

• MRI: Investigation of choice — confirms ACL tear, assesses meniscal/chondral/collateral damage (associated injuries very common — "terrible triad": ACL + MCL + medial meniscus)
• X-ray: Exclude fracture; Segond fracture (lateral tibial plateau avulsion) = pathognomonic of ACL injury
• Joint line tenderness + Lachman positive + MRI = standard diagnostic pathway

• Single-leg squat quality (dynamic valgus — indicates poor neuromuscular control)
• Single-leg hop tests: Single hop, triple hop, crossover hop (for chronic/post-surgical)
• Y-Balance test / Star Excursion Balance Test
• Quadriceps and hamstring strength (dynamometry) — H:Q ratio target > 0.6

PT Management — ACL Tear

Phase 1: Acute / Pre-operative (0–2 weeks)

• RICE — ice 15–20 min every 2 hours, compression, elevation
• Crutches — partial weight bearing as tolerated
• Effusion management (as per FFD section above)
• Quadriceps activation: Quad sets, SLR in brace — critical to prevent inhibition
• ROM: Heel slides for knee flexion; terminal knee extension (TKE) for extension
• Gait re-education with crutches
• Educate on surgical vs. conservative management options

Conservative Management (Non-surgical — selected patients)

• Structured neuromuscular training program (e.g., MOON, KANON protocols)
• Emphasis on: Quadriceps strengthening, hamstring strengthening, neuromuscular control, proprioception
• Functional bracing for sports/instability episodes
• Activity modification — avoid pivoting/cutting sports without reconstruction
• Note: In this patient's context (right knee OA + ACL), conservative management with structured PT is a reasonable first approach especially if activity demands are low

Surgical Management — ACL Reconstruction (ACLR)

• Most common graft: Bone-patellar tendon-bone (BPTB) or hamstring autograft
• Surgery timing: Wait until full ROM restored and swelling resolved (reduces risk of arthrofibrosis)
• Prehabilitation ("prehab") before surgery strongly improves post-op outcomes

Post-ACLR Rehabilitation Phases

Phase 1 — Protection (0–2 weeks)

• Crutches, brace locked in extension for ambulation
• Goals: Control swelling, achieve 0–90° ROM, quad activation
• Exercises: Quad sets, SLR (all planes), heel props, ankle pumps, NMES to quads
• Avoid: Hamstring loading (graft protection — hamstring graft)
• Cryotherapy after exercise

Phase 2 — Early Strengthening (2–6 weeks)

• Wean crutches as quad control adequate
• ROM target: 0–120°+ by week 6
• Closed Kinetic Chain (CKC) exercises — safer for graft:
  • Mini squats, leg press (0–60°), step-ups/downs, stationary cycling
  • Terminal knee extension with band
• Open Kinetic Chain (OKC): Quad extension 90–40° range (avoids anterior shear at 0–40°); initiate week 4–6 depending on protocol
• Hamstring curls: Start week 4+ (graft-dependent)
• Proprioception: Single-leg balance, wobble board (eyes open → closed)
• Pool walking / hydrotherapy

Phase 3 — Advanced Strengthening (6–12 weeks)

• Full ROM expected
• Progressive loading: Leg press full range, squats, lunges, step machine
• Neuromuscular training: Single-leg squat, lateral band walks, perturbation training
• Low-impact cardio: Cycling, swimming, elliptical
• Gait normalization — eliminate antalgic pattern

Phase 4 — Return to Running (3–4 months)

• Criteria-based (not time-based):

  • 80% limb symmetry index (LSI) on quad/hamstring strength

  • Good single-leg squat quality (no dynamic valgus)
  • Normal gait
• Jogging program (walk-jog intervals), progress to running
• Agility ladder, straight-line cutting

Phase 5 — Return to Sport (6–9+ months)

• Criteria (all must be met):
  • LSI ≥ 90% on hop tests (single, triple, crossover hop)
  • LSI ≥ 90% on isokinetic quad/hamstring strength
  • Psychological readiness (ACL-RSI questionnaire)
  • No pain/swelling with loading
• Sport-specific drills: Pivoting, cutting, change of direction
• ACL injury prevention program (FIFA 11+, PEP) before return

Integration with Right Knee OA + Hip Hike

Red Flags / Referral