Radiological Analysis - Mrs. Aruna Patil, 52F (ID: PAT003208)

DIAGNOSIS

Primary Diagnosis: Medial Compartment Knee Osteoarthritis (Right Knee) - Kellgren-Lawrence Grade 3

Radiological Findings Summary

KL Grading Rationale

PHYSIOTHERAPY PROTOCOL

PHASE 1 - Acute/Inflammatory Phase (Week 1-2)

• TENS (Transcutaneous Electrical Nerve Stimulation): Conventional mode (80-100 Hz, 50-80 µs pulse width) for 20-30 min/session, daily - effective analgesic for OA pain
• Therapeutic ultrasound: 1 MHz, 0.5-1 W/cm², pulsed 1:4 duty cycle - periarticular application 5-7 min, 5 sessions/week
• Cryotherapy: Ice pack 15-20 minutes post-session to reduce inflammation

• Ankle pumps - 20 reps x 3 sets
• Quad sets (isometric quadriceps contraction in extension) - 10-second holds x 15 reps
• Straight leg raises (SLR) in supine - 15 reps x 3 sets
• Inner range quads (0-30° range) - gentle, pain-free

• Activity modification: avoid squatting, kneeling on hard floors, stairs climbing when painful
• Weight management counseling (BMI check - if overweight, AAOS guidelines cite moderate evidence for weight loss)
• Correct footwear advice
• Joint protection techniques

PHASE 2 - Subacute/Strengthening Phase (Week 3-6)

• Closed Kinetic Chain (CKC) preferred - reduces joint compressive forces:
  • Mini squats (0-45°) at wall - 15 reps x 3 sets
  • Step-ups on low step (5-10 cm) - 10 reps x 3 sets
  • Leg press (limited arc) - 3 x 15 reps
• Open Kinetic Chain (OKC) with caution:
  • Terminal knee extension (last 30°) with resistance band
  • Prone hamstring curls
• Hip strengthening (reduces medial compartment load):
  • Side-lying hip abduction - 20 reps x 3 sets
  • Clamshells with resistance band
  • Hip extension in prone

• Hamstring stretches - 3 x 30 sec holds
• Calf/gastrocnemius stretches
• ITB stretching (foam roller)
• Quadriceps stretches

• Single-leg standing on flat surface, progressing to foam pad - 30 sec x 3
• Mini trampoline balance training

• Patellar mobilization (medial, inferior glides)
• Tibiofemoral joint mobilization - Grade I-II Maitland oscillations for pain relief
• Soft tissue massage to quadriceps and hamstrings

• IFT (Interferential Therapy): 4-pole, carrier 4000 Hz, beat frequency 80-120 Hz for analgesia - 20 min/session
• Moist heat (hot pack) before exercises: 15-20 min

PHASE 3 - Functional Rehabilitation (Week 7-12)

• Wall squats (0-60°) with resistance - 3 x 15 reps
• Stationary cycling (low resistance, seat height adjusted) - 20-30 min
• Swimming / hydrotherapy (pool exercise reduces joint load by ~50%)
• Nordic walking with trekking poles (reduces knee load)
• Tai Chi - evidence supports it for OA pain and balance (Cochrane 2024)

• Balance board exercises
• Functional movement patterns: sit-to-stand training, stair negotiation
• Gait re-education with mirror feedback

• Valgus unloader knee brace: Offloads the medial compartment in varus OA - strong recommendation. Can reduce pain by 20-40%
• Lateral wedge insoles (5°): Controversial but may reduce medial compartment load in varus knee - trial for 4-6 weeks

PHASE 4 - Long-Term Maintenance (Month 3+)

• Home exercise program (HEP) - progressive resistance training 3x/week
• Aerobic conditioning: walking, cycling, swimming - 150 min/week moderate intensity
• Hydrotherapy sessions 1-2x/week if accessible
• Periodic physiotherapy review every 6-8 weeks
• Yoga or gentle stretching program
• KOOS (Knee injury and Osteoarthritis Outcome Score) monitoring at 6 and 12 weeks to track progress

ADJUNCT MANAGEMENT (Coordinate with Orthopedician)

• NSAIDs / Analgesics: Oral/topical diclofenac or naproxen (short-term); topical preparations preferred in elderly/women to reduce GI risk
• Intra-articular Corticosteroid Injection: For flare-ups/effusion - provides short-term relief (6-12 weeks)
• Intra-articular Hyaluronic Acid: Viscosupplementation - moderate evidence for Grade 2-3
• BMI management: If overweight, each kg weight loss reduces knee load by ~4 kg
• Surgical Consideration: If Grade 3 OA fails conservative management over 3-6 months, discuss High Tibial Osteotomy (HTO) - good option for a 52-year-old with isolated medial compartment disease and varus deformity, to delay TKR

OUTCOME MEASURES TO TRACK

PRECAUTIONS

• Avoid deep squatting (>90° flexion) and kneeling
• Avoid high-impact activities: running, jumping
• Progress exercises only when pain score remains <4/10 during activity
• Monitor for effusion after exercise - if knee swells, reduce intensity
• Vascular calcification noted on X-ray: coordinate with treating physician regarding cardiovascular risk factors

EVIDENCE BASE

• The 2024 Cochrane Review on Exercise for Knee OA (Lawford et al., 139 RCTs, 12,468 participants) confirms land-based exercise significantly improves pain and physical function with moderate-certainty evidence - PMID: 39625083
• Holden et al. 2023 (Lancet Rheumatology) - exercise benefits for knee OA are consistent regardless of age, BMI, or pain severity - PMID: 38251550
• Gibbs et al. 2023 systematic review of international guidelines universally recommends exercise, weight management, and patient education as first-line management - PMID: 37394226
• Campbell's Operative Orthopaedics 15th Ed, 2026 (AAOS Table 10.4): Strong evidence for physical activity and low-impact aerobic strengthening exercise; moderate evidence for weight loss in BMI >25

Note: This report is based on radiological findings only. Final diagnosis and treatment decisions should be made by the treating orthopaedician in correlation with full clinical examination, history, and relevant investigations (CBC, ESR, CRP, uric acid, DEXA scan for bone density given patient's age/sex).