Combination therapy greatly helped a woman who presented with a right-knee sprain and subluxation of the right tibia, with lateral rotation of the proximal tibia

Presentation
A 56-year-old female presented to my office complaining of right-knee pain. She said that the problem began 2 days earlier, as she was picking up her 2-year-old grandson off the floor. Her grandson was situated to the left, and was next to a chair that didn’t allow her to go right up to him and lift him. As a result, she had to twist her body to the left and bend over to pick him up off the floor. In doing so, she felt a “snap” in the right knee, with immediate sharp pain and subsequent swelling. She was unable to put pressure on the knee due to the pain, and as a result she was basically unable to stand or walk.

The patient attempted to care for it herself with the use of ice, rest, and over-the-counter pain medications, including ibuprofen, aspirin, and acetaminophen. Nothing was effective in relieving the pain or swelling, and she was still unable to stand or walk. As she had previously been a patient in my office, she presented again for evaluation and possible treatment of her knee problem.

The patient stated that she had pain throughout the right knee, but especially intense pain at the inner portion. The intense pain actually was very localized and was at a small area toward the front inner part of the knee. Although she related that the swelling had gone down slightly, it was present throughout the knee but more so at the front inner portion.

Any attempt to put pressure on the knee caused an increase in the intensity of pain. Therefore, she was very apprehensive about standing, let alone walking.

Additional questioning by me revealed the absence of the knee “giving out” or “locking up” at this point in time. She had no prior history relative to her right knee.

Examination
The patient is five feet two inches tall and weighs 115 pounds.

Visible, moderate edema was present from the suprapatellar through the infrapatellar areas, with noticeably more edema at the medial portion of the right knee. No discoloration, laceration, mass, muscle atrophy, or deformity such as genu valgus or genu varus was noted.

Palpation of the right knee revealed an elicited moderate pain throughout the anterior knee, and a severe pain in an area below the medial femoral condyle. The area is approximately 1 inch in diameter.

Range-of-motion tests were attempted, but due the extent of the edema and the severity of the pain, the tests were done cautiously. Most significantly was the fact that attempted passive motion of the joint caused pain, in particular in the inferior medial area. This implies possible ligamentous involvement, that is to say, a sprain. It was also apparent that lateral rotation of the tibia was quite possible to perform but medial rotation was not.

Orthopedic testing of the right knee was attempted and actually performed. The A-P Drawer, McMurray’s Sign, compression, and depression tests were all negative. This implied the probability that there was no menisceal, cruciate ligament, medial, or lateral collateral ligament involvement.

Radiographic examination of the right knee was then performed, consisting of a PA view and a lateral view with the medial knee against the film.

Grossly, the edema was evident via the disturbances in the myofascial planes. There was no evidence of any osteoarthritis or joint mice. Additionally, there was no evidence of tumor, in particular osteoma or osteochondroma, which are very common in this area.

Working Diagnosis
Based on the patient’s history of injury, and findings upon physical examination, including review of x-rays, the following diagnostic impression was reached: She had a right-knee sprain and subluxation of the right tibia, with lateral rotation of the proximal tibia.

Treatment
I decided to use manipulative and supportive procedures to treat the right knee.

The first rationale was to use appropriate physiotherapy modalities to reduce the edema, relax the supporting musculature, and possibly alleviate some pain in the area. To that end, I used a combination therapy of sinusoidal current and ultrasound with the patient in the supine position. This was performed by linking the modalities together through the ultrasound machine, thus allowing the ultrasound head to emit sound waves and act as an electrode for the muscle stimulation of the sinusoidal current. In addition, the ultrasound was administered in the intermittent mode so as not to allow the buildup of heat in the knee. The muscle stimulator was performed at the patient’s tolerance level, while the ultrasound was raised to 1.2 watts per square centimeter. The therapy was performed for 12 minutes.

Subsequent evaluation revealed a decrease in edema and muscle splinting around the right knee. It was now time to adjust the laterally rotated tibia.

The patient remained in the supine position, and I was on the right side of the table. The move of preference is a traction/thrust on the tibia. My specific contact is with my left thenar area on the lateral head of the tibia. Tissue slack must be taken out first. To accomplish this I first contacted the fibular head and took out the slack by pushing up to the tibial head. Simultaneously, with the right arm, I wrapped my arm around the middle of the tibia and brought my right hand up to the level that I was able to grab the dorsum of my left wrist. This actually enables both of my arms to act as one during the adjustment.

To effect the adjustment, there must be a simultaneous tractioning of the joint and lateral to medial thrusting of the tibial head. I start the move by leaning my body toward the caudal end of the table, thus initiating traction. When the slack has been taken out of the joint, I then torque my body and left arm lateral to medial. The adjustment generally elicits quite a loud audible release, and the doctor and patient feel a distinct movement of the tibia. Such was the case regarding this adjustment.

A full-body adjustment was subsequently performed to address the areas of the spine that compensated for the right-knee subluxation. The patient’s knee was then surrounded by an ice pack for 10 minutes. The patient reported instantaneous relief after the adjustment, and a sense of pressure release within the knee. A light elastic wrap was placed on the knee, and crutches were provided with instructions for their use. The patient was advised to use ice and rest at home, and to return to the office in 2 days for follow-up.

Follow-up Treatment
Two days later, the patient returned for follow-up. Upon brief evaluation, the knee was greatly improved. Mild edema was present in the antero-medial area, as well as palpable elicited slight tenderness. The same treatment was administered. The main adjustment of the tibia had held very nicely, so after a very light force adjustment of the tibial head, some capsular stretches were performed. These are simply flexion maneuvers to the knee. However, I put my forearm in the popliteal fossa during a light forced flexion of the knee. I then, progressively, use different parts of my arm in the same manner to achieve varying degrees of capsular stretching around the knee. A full-spine adjustment was performed as well. The patient was advised to return in 1 week.

Upon the patient’s return in a week, she related that the knee felt fine and functioned perfectly. Brief examination corroborated this. The knee was administered combination therapy to get rid of residual edema and to soften any adhesions, as well as to tone the supporting musculature. Light capsular stretches were performed, as was a full-spine adjustment. The patient was then released to a per required need basis for any exacerbations.

This case was successfully resolved in a very short period of time with a minimal treatment program. Although the presenting complaints were moderate to severe in nature, the laterally rotated proximal tibia subluxation was the offender. This actually is an extremely common subluxation with varying degrees of severity in presentation. The most significant finding of this specific subluxation, both subjectively and objectively, is a “dime-sized” area of pain in the antero-medial area of the medial tibial tuberosity. This particular case was the extreme range of a classic clinical presentation.

The laterally rotated proximal tibia should be a main line of thought when examining any knee complaints. This is truly a condition that the DC can handle better than any other practitioner. CP

Alan Forrest, DC, graduated magna cum laude from Los Angeles College of Chiropractic in 1980. He has been in private practice in Tarzana, Calif, since that time. He has also been an associate professor at Los Angeles College of Chiropractic and Cleveland College of Chiropractic, lecturing in orthopedics, manipulative technique, and clinical diagnosis. He has lectured extensively at seminars on various chiropractic topics. He can be reached at (818) 996-4994 or forrestdc@yahoo.com.