Client Question

[Isaac Wilkins]

Ok, so I have a client that I'm not sure on her injury/condition. This isn't my strongest area, and I'm trying to work on it, hence my questioning.

Background:
-68 year-old female
-240 lbs, started at 280+ about six months ago
-Is remarkably mobile for her age. One would think she was in her 40's.
-Is very flexible from a long history of ballet, but was inactive for about 5 years before she started working with me.
-Is a hairdresser, so she spends 9-14 hours a day standing.

The pain is in her right leg. It seems more nagging than acute. Primarily her pain is in her lower hamstring and seems to wrap down and around the inside of her knee into the anterior fib. She doesn't experience any instability. There's no real discomfort standing, squatting, or doing most movements. She feels slight sensation lunging (we don't do it now, I was just testing her) and has good lateral mobility.

She says it's VERY painful on her lower hamstring (the pain doesn't radiate up into her buttock) when she drives and presses the gas pedal or when she sits in a chair, compressing the hamstring. Finger manipulation of the hamstring while standing isn't particularly painful. Dorsiflexion/extension of the foot held in space is not at all painful.

There is some slight swelling around the inside area of the knee. There is no indication of popping or cracking.

At one point this was much more painful, to the point where she couldn't squat comfortably, but it healed within a day or two. She also is a firm believer in chiropractic care. The chiro says that her hip "rotates out of alignment" and so she's had several adjustments. After one adjustment the hamstring area throbbed for the rest of the day, but has seemed better since.

When the injury was at its worst I had her doing some TKE's (more for blood flow than anything else), elevation, and self-massage of the area. All of these seemed to help.

Thoughts?

[UConnJulie]

Given her weight, age, and occupation, I would be inclined to look to her back as the possible cause with the distal hamstring pain being referred pain.

[Isaac Wilkins]

Originally Posted by UConnJulie

Given her weight, age, and occupation, I would be inclined to look to her back as the possible cause with the distal hamstring pain being referred pain.

I would normally agree, but would that cause the swelling on the interior below the knee?

[UConnJulie]

No offense to her, but was it truly swelling (ie a circumferential difference from left versus right) or just a fatty deposit? I have treated many women of that size who just have odd lumps of fat around the knees ...

She could also have a pes anserinus bursitus ... it's sort of where the hamstring and adductors meet on the medial tibial plateau ...


In that case, she will benefit from some treatment by a PT ... here's an article on pes bursitis that is good ...

[Maki Riddington]

You may want to look at potential trigger point sites and the referring pain pattern that is associated with them.

[Isaac Wilkins]

Maki: I'll do that. Thanks.

Julie: The pain indicated is in the right place. I'm reasonably sure it is swelling, I checked it out today. I confess that I don't remember her knees looking asymetrical before, but I don't stare at them regularly, either.

My only reservations are that it doesn't seem tender to palpation. Of course, she is very well padded.

[bryanc]

I would personally be very hesitant to make any solid recommendations on your client based on this description. Depending on the expertise of her chiropractor, she should really consider having a full assessment of her problem including a detailed physical exam of her knees and hips by a trained health care professional (I'm biased towards MSK physicians, but that's just me). You've already stated that you're not comfortable hanging your hat on your own assessment of the condition, and hence, any description you've given us is going to be limited by your (no offense) "lack of experience".

It would be irresponsible of us (or rather, me, since I can't speak for the rest of this forum) to make recommendations on treatment of a condition that has no diagnosis. And the differential diagnosis (i.e. all the possible things that _could_ be wrong) is still REALLY wide, and not likely to be narrowed by this forum. I strongly believe the biggest service you can do for this client is to help her get assessed personally, as opposed to "virtually". Could she have pes anserine bursitis? Yes. She would be a rare patient indeed, but yes, she could. Could she have osteoarthritis? Absolutely. She could also have about 10 other conditions that I can think of off the top of my head given your description of her pain.

[Isaac Wilkins]

Bryanc: Sure. I actually have already recommended her to a health care professional. I was more interested in learning for my sake.

[bryanc]

Ah, cool then.

Well, once you have a diagnosis, let us know!