Editor's note: Click here to read part 1 of this article, which appeared in the Feb. 15, 2014 issue.
The patient presented to the chiropractic clinic with symptoms of genu varum and pain on the medial aspect of the tibiofemoral joint. After a detailed consultation and thorough comprehensive orthopedic examination of the patient's post-surgical knee, the clinician felt informed enough to proceed.
The orthopedic examination consisted of palpation and ranges of motion of the involved knee. The clinician performed an extensive orthopedic examination of the post surgical knee that involved the following: Apley's compression and distraction tests, McMurray test, bounce home test, anterior and posterior drawer sign, and valgus and vagus stress test.
Examination revealed that the medial tibial femoral joint did not open during the valgus stress test. This indicated that the tibia had rotated anteriorally on the medial side. This was also confirmed by the pinpoint tenderness around where the medial menicus would have been prior to total knee replacement.
Genu varum, or bowleg, is the result of a medial angulation of the tibiofemoral joint. This angulation creates pressures on the inside of the knee joint, the medial meniscus. Genu valgum, or knock knee, is a lateral angulation of the tibiofemoral joint. This angulation creates pressure on the outside of the knee joint, the lateral meniscus. Genu varum and valgum create unequal weight distribution, and lead to deformities and degeneration of the tibiofemoral joint.6,9,18
Knee Manipulation / Mobilization
Due to the total knee replacement, some fluid motion had been lost between the tibia and femur. Moss, et al., wrote that joint mobilization may be an effective means of reducing osteoarthritic pain and may potentially improve motor function.13
Treatment of the artificial joint is based on the orthopedic examination of this patient's knee and pain description. As a result of these findings, the chiropractor performed an adjustment that included the following corrective movements. With the patient lying supine, the left knee was flexed to the limits of the artificial joint, ending in a position with the leg itself flexed to the patient's chest. The chiropractor placed his left hand on the distal tibia and fibula, and the right hand on the lateral aspect of the proximal tibia and distal femur. He then pushed the distal femur and proximal tibia into a genu valgus position to relieve pressure from the medial aspect of the tibiofemoral joint.
While the left knee was held in the genu valgus position, the tibia was rotated medially and the leg was pulled to an extended position. The chiropractor performed a Maitland grade IV mobilization technique on the patient's knee. It should be noted that the same technique (with different amplitudes) can be used in a normal knee.
Maitland makes an important distinction between mobilization and manipulation. Maitland states that mobilizations are passive movements under the control of the patient, while manipulations are "sudden movements or thrusts of small amplitude performed at a speed that renders the patient powerless."15 Chiropractors must form a union of science, physical techniques and an understanding of Maitland's levels of amplitude.
The material above describes the physical techniques the chiropractor used; however, the chiropractor also must have awareness of the amount of force to be used during the treatment. This is where the Maitland scale helps to standardize this treatment and allow for more precise amplitudes of force.15 That scale has five grades15 [see table].
|Intensity of Mobilization Techniques According to the Maitland 5-Grade Classification System15|
|Grade I||Small amplitude at the beginning of the range of motion (ROM)|
|Grade 2||Large amplitude not reaching the end of the ROM|
|Grade 3||Large amplitude reaching the limited ROM|
|Grade 4||Small amplitude at the end of the limited ROM|
|Grade 5||Small amplitude and high velocity at the end of limited ROM (manipulation or thrust)|
PNF Stretches of the Surrounding Musculature
After adjustment of the artificial knee, the chiropractor performed proprioceptive neuromuscular facilitation (PNF) stretches of the muscles surrounding the knee. The stretches promote an isometric contraction which lengthens the non-contractile and fibrotic muscle adhesions.
There is evolving interest in PNF as a technique to improve functional ability. After reviewing several published articles, Westwater-Wood, et al., found that PNF stretches were beneficial for flexibility and isometric strengthening of muscles.16 The muscles being stretched were the biceps femoris muscles, tensor fascia lata muscles and the quadriceps muscles: rectus femoris, vatus lateralis, vastus medialis, and vastus intermedius.
To stretch the biceps femoris muscles, the patient is lying supine with the hip flexed and knee extended on the involved leg. The clinician stands on the side of the treating leg with the cephalad hand of the clinician proximal to the patella to maintain the knee in extension. The patient's leg is supported on the doctor's shoulder with the clinician's caudal hand and forearm supporting the distal leg.
The patient actively pushes the leg down toward the table as the clinician resists; this keeps the biceps femoris muscles in isometric contraction. This is repeated three or four times with an increased upper angle of the patient's leg; i.e., the leg is angled up toward the head in small increments.17
To stretch the tensor fascia lata muscle, the patient is side-lying with involved side up. The non-treated leg is bent at the knee and hip at 45 degrees. The thigh is adducted behind the patient until muscular resistance is felt. The clinician stands behind the patient and adducts the patient's thigh with the caudal hand above the knee. The cephalad hand stabilizes the patient's pelvis as the patient attempts to push the thigh into abduction toward the ceiling. The clinician resists with the caudal hand to keep the tensor fascia lata in isometric contraction.17
The quadriceps muscles are stretched with the patient lying supine. The involved leg is flexed at the knee until muscle resistance is felt. The clinician's hands are placed at the distal tibia. The patient presses the involved leg to the table while the clinician resists, keeping the quadriceps muscles in isometric contraction.17
Stretching the muscles surrounding the left knee joint, the fibrotic lesions associated with the surgery, allowed for proper re-education of the muscular fibers. The muscular fibers containing the fibrotic lesions from the surgery were properly re-educated for quasi-normal physiological function.
This procedure resulted in a clicking / popping sound in the medial aspect of the artificial joint and instant relief of the patient's knee pain. The clicking currently indicates only when the patient is exercising in the gym on the gluteal machine, which has the patient standing and extending his leg in a posterior and inferior direction. The clicking in the patient's knee during this exercise may be related to chronically overactive quadriceps muscles. Recent gluteal exercises indicate no clicking when done slowly.
The patient consistently reported that these procedures were the single most effective treatments during this protocol. After 12 treatments (one month of care) at the chiropractic clinic in 2010, the patient reported less tenderness, pain and clicking in his left knee. The pain relief continued through 2010, 2011, 2012 and 2013. Two- or three-week maintenance visits keep the patient mobile, normally gaited and pain free most of the time. Increased awareness of tenderness in the left knee generally signals that it is time for a visit to the chiropractor.
During follow-up visits to the orthopedic specialists, two theories have been offered to partially explain pain and resulting pain relief in the 10-year-old mechanical implant area. The first theory is that fibrotic tissue had formed around the medial aspect of the mechanical joint. Upon weight-bearing activities, the tissue was being pinched, causing inflammation and irritation of those tissues. The patient felt relief in the medial aspect of the knee when a form of traction was applied, relieving pressure off the tissues.
A second theory is that the PNF stretches decreased the fibrotic adhesions in the muscles surrounding the knee implant. This allowed for the muscles to lengthen, creating more elasticity, which decreased constrictions around the mechanical joint.
The first theory emphasizes possible ridges of fibrotic scar tissue that has formed near the medial aspect of the femur, tibia and patella. The second theory emphasizes the persistently tender area where the two medial edges of the implant interface. Neither theory is definitive or suggests a method of pain relief beyond analgesics and exercise. The patient's orthopedic surgeon has offered no definitive explanation for the left knee pain. His recommendation to see a chiropractor was the single best pain-relief advice offered!
This case study demonstrates that chiropractic manipulation and therapy effectively decreased the pain on a patient's total knee replacement arthroplasty. According to Maitland, mobilization and manipulation show the best effect when directed at mechanical problems for which they perform three main roles:
- Restoring structures within a joint to their normal position or pain-free positions so as to allow a full-range painless movement.
- Stretching a stiff, painless joint to restore range of motion.
- Relieving pain by using special techniques.
Maitland suggests that most musculoskeletal problems have two components: a pain component and a stiffness component. He states that a joint should be tested for range of motion and pain, and the muscles surrounding the joint should be tested for strength and pain.
If a patient has damage to a joint – or in this case study, a total knee replacement – there will be pain and restricted ranges of motion during certain movements. According to Maitland, restoring the normal positional relation of the tibia to the femur of this patient allowed for a painless, free-moving joint.
The chiropractic treatment, as described in this case study, rotated the tibia to a quasi-normal function in relation to the femur. According to the patient, this instantly decreased his pain and allowed for a more normal range of motion. After a pain-free movement in the patient's knee was accomplished the chiropractor stretched the stiff joint to create elasticity in the muscles. Proprioceptive neuromuscular facilitative stretches were performed to muscles surrounding the knee to encourage contraction and stabilization of those muscles.
The authors wrote this article to share a pain-mitigation strategy that evolved during the course of what started as a standard chiropractic approach. The lead author's experience with implanted clients led him to devise an anatomically sound sequence of manipulations and therapies that provided pain relief for a noticeable, albeit impermanent, time period.
Our search of the print and electronic literature motivated us to try to add a case report that chiropractors could apply to their own patients. With the large and increasing numbers of Americans who receive hip and knee implants, we see a real need for continued research and writing about the use of chiropractic techniques to lessen post-operative pain. Further publications will help determine if this type of treatment on a knee arthroplasty produces the same results.
Limitations / Final Thoughts
This case study has reduced pain in one patient's arthroplastic knee. A study of how this chiropractic technique reduces pain in a larger subject set will determine more accurate results. Further research and publications will help determine if this type of treatment on a knee arthroplasty produces the same results. There seems to be a limitation on how to accurately collect anecdotal results from other practicing chiropractors who use this technique to reduce pain on arthroplastic knee pain.
No external funding source was obtained. Written permission from the patient was obtained for the use of the case history and X-rays.
References (Parts 1-2)
- Rubenstein RA Jr. The incidence and results of manipulation after primary total knee arthroplasty. Knee, 2010 Jan;17(1):29-32.
- National Center for Health Statistics, Data Warehouse on Trends in Health and Aging, National Hospital Discharge Survey, 2002.
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Information Clearinghouse, National Institutes of Health.
- Centers for Disease Control and Prevention, National Hospital Discharge Survey: 2007 Summary, table 8.
- Jordon KM, Arden NK, Doherty M, et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis, 2003;62(12):1145-1155.
- Moore K, Dalley A. Clinically Oriented Anatomy, Fourth Edition. Lippincott Williams & Wilkins, Philadelphia, 1999:536.
- Pollard H, Ward G, Hoskins W, Hardy K. The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial. J Can Chiropr Assoc, 2008;52:229-42.
- Sponseller PD (editor). The 5-Minute Orthopedic Consult. Lippincott Williams & Wilkins, Philadelphia, 2001:178-179.
- Levangie P, Norkin C. Joint Structure and Function; A Comprehensive Analysis, Third Edition. F.A. Davis Company, Philadelphia, 2001:341-346, 331-332.
- Netter F. Atlas of Human Anatomy, Third Edition. ICON Learning Systems, Teterboro, NJ, 2003:492-493.
- Interview with the patient, Aug. 26, 2010.
- Fulkerson J. Disorders of the Patellofemoral Joint. Lippincott, Williams and Wilkins, Philadelphia, 2004.
- Moss P, Sluka K, Wright A. The initial effects of knee joint mobilization on osteoarthritic hyperalgesia. Man Ther, 2007;12:109-118.
- Rollins CA, Robinson JL. Evaluation of undergraduate physical therapy students' comprehension of Maitland's grades (I-IV) for posterior mobilization of the glenohumeral joint. J Ortho Sports Phys Ther, 1980:215.
- Maitland GD. Peripheral Manipulation. Second Edition. Butterworths, London, 1977:3-4, 29-30.
- Westwater-Wood S, et al. The use of proprioceptive neuromuscular facilitation in physiotherapy practice. Phys Ther Rev, 2010;15(1):23-27.
- Liebenson C. Rehabilitation of the Spine: A Practitioner's Manual. Lippincott Williams & Wilkins, Baltimore, 1996:33-34.
- Hoppenfeld S. Physical Examination of the Spine and Extremities. Prentice Hall, Upper Saddle River, NJ, 1976:172.
Dr. Jeffrey Bentz, the treating chiropractor in this case study, is a 2007 graduate of Palmer Chiropractic Florida and practices in Pittsburgh, Pa. His practice is integrated into a multi-doctor corporation, in which he works directly with family physicians, orthopedists and neurosurgeons. He has successfully treated thousands of patients with complex musculoskeletal conditions where multi-doctoral co-management is the standard of patient care.
Dr. V. Robert Agostino owns the knee in this case study and assisted as co-author. Recently retired from the Duquesne University School of Education, he broadened his interests from social science education to chiropractic education.