616 | october 2008 | volume 38 | number 10 | journal of orthopaedic & sports physical therapy

[ CASE REPORT ]

tant when the patient is unable to iden-tify a specific inciting incident. Recently,a model for patient examination, knownas the regional-interdependence model,has received attention in the literature.In this examination framework, regionsremote to a patient’s primary site of painare considered for their potential contri-bution to that pain.45,46

The patient in this case report was acompetitive runner who presented withright knee pain that had prevented herfrom training for several weeks. In thiscase, limited findings at the knee led thetherapist to a broader examination ofthe lower quarter, including the lumbarspine, pelvis, hip, and ankle/foot. Thecombination of the patient’s symptoms,clinical findings, and response to inter-vention seem to be unique in a review ofthe literature.

The purpose of this case report is todescribe the clinical findings, interven-tion and outcomes in a patient with me-dial knee pain and to highlight the valueof a regional interdependence model ofpatient examination.

CASE DESCRIPTION

History

A25-year-old, Caucasian female

and third-year physical therapystudent self-referred for consulta-

tion regarding medial, right knee pain.She was a cross-country and track athletethroughout high school and her under-

There are an estimated 30 million runners in North America.32

Knee pain is a common complaint in this population. Overuseinjuries, such as chondromalacia patellae, plica syndrome,pes anserine bursitis, iliotibial band syndrome, and popliteus

tendonitis account for many of these painful disorders.4,11,38,47,49 Insome cases, knee pain may be the sole presenting symptom when amore proximal or distal structure is actually at fault, such as the hip,4,24

STUDY DESIGN: Case report.

BACKGROUND: A number of pain referral pat-terns for sacroiliac dysfunction have been reportedin the literature. However, very little has been writ-ten about pain localized to the knee joint for casesinvolving sacroiliac dysfunction.

CASE DESCRIPTION: A 25-year-old femalerunner was self-referred to physical therapy formedial knee pain of 4½ weeks’ duration withouta significant onset event. The pain completelycurtailed her training for the Boston Marathon.Examination of the patient’s knee and hip did notreveal any abnormal findings and there was noreproduction of pain with any test procedures ex-cept for medial knee joint tenderness to palpation.Additional, more proximal examination suggestedsignificant asymmetry of sacral bony landmarks ofthe pelvic girdle without significant findings on theprovocation tests of the sacroiliac joint. A single

session of manual therapy procedures directed tothe pubic symphysis and sacroiliac joint ipsilateralto the side of knee pain was provided.

OUTCOMES: The patient was able to return torunning without further incident of knee pain aftera single therapy session.

DISCUSSION: This case suggests theimportance of regional interdependence in theexamination of patients with an apparentlycommon clinical problem. Furthermore, the casedescribes a previously unreported presentation oflocal knee pain possibly attributable to sacroiliacjoint dysfunction.

LEVEL OF EVIDENCE: Therapy, level 4.J Orthop Sports Phys Ther 2008;38(10):616-623.doi:10.2519/jospt.2008.2759

KEY WORDS: manipulation, manual therapy,pelvic girdle, sacroiliac joint

the ensuing intervention are likely to besuboptimal.

James21 and others9 have highlightedthe importance of a regional examinationspecifically for patients with knee pain.A thorough history intake, screening,and biomechanical assessment are es-sential components of a comprehensiveexamination.28 This is especially impor-

ankle/foot,32 or sacroiliac joint.8 In suchcases, the pain may be referred from amore proximal structure or be consequen-tial to a remotely located impairmentor dysfunction that produces excessivestresses on structures of the knee, withresulting pain generation. When thatremote source is not identified in an ex-amination of the patient, the results of

Isolated Knee Pain: A Case ReportHighlighting Regional Interdependence

DANIEL W. VAUGHN, PT, PhD, FAAOMPT1

1Associate Professor of Physical Therapy, Grand Valley State University, Grand Rapids, MI. Address correspondence to Dr Daniel W. Vaughn, Grand Valley State University,Physical Therapy, 301 Michigan Street, NE, Room 260, Grand Rapids, MI 49503. E-mail: vaughnd@gvsu.edu

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®

Dow

nloa

ded

from

ww

w.jo

spt.o

rg a

t on

Aug

ust 5

, 201

4. F

or p

erso

nal u

se o

nly.

No

othe

r us

es w

ithou

t per

mis

sion

. C

opyr

ight

© 2

008

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®. A

ll ri

ghts

res

erve

d.

journal of orthopaedic & sports physical therapy | volume 38 | number 10 | october 2008 | 617

graduate years in college. Her competi-tive events in track were the mile, whichshe raced at collegiate nationals, in ad-dition to other events ranging from 800m to 5 km.

She had completed the Detroit Mara-thon approximately 2 months prior to theonset of her symptoms without incidentand had taken a 2-week respite from run-ning before beginning training for theBoston Marathon. She began that train-ing at about 40 to 50 km/wk. She trainedon trails and pavement. Her weekly levelof training at the time leading up to herconsultation was 70 to 80 km/wk at anaverage pace of approximately 4.5 min/km (approximately 7 min 15 s/mile). Shewas running 5 to 6 d/wk at that juncture,with long runs of up to 2 hours. She wasslowly increasing her mileage on a weeklybasis.

The patient’s pain began without iden-tifiable cause 4.5 weeks prior to her phys-ical therapy examination. She had notseen a physician for her pain nor had shehad other consultations or interventions.The pain began at about 1.5 km into oneof her training runs on pavement. Shedescribed the pain as a “nuisance” and“dull ache.” She kept running for 2 weeksbeyond the onset date. Initially, she no-ticed that the pain would come on in thelatter stages of her runs. However, overtime, the pain progressively intensifiedand would start earlier in the run. Thepain was not present between trainingruns during the first few days. At about10 to 11 days after the initial episode, shewas on a 20-km run and noticed thather knee began to hurt rather notice-ably. Later that night her knee began toache while she was in bed. The next daythe knee was almost too sore for weightbearing. Subsequent efforts to run wereterminated at 2.5 to 3.0 km by intolerablepain. She ultimately stopped running 2weeks after the initial episode. Intermit-tent attempts to run over the next 2 to 2.5weeks resulted in a return of pain. Shenoted that the longer she took off fromrunning, the longer it would take for thepain to return on subsequent efforts to

begin training again. In addition to run-ning, she noted that descending stairsincreased her pain. She was using an el-liptical or cross-country ski machine tomaintain her cardiovascular fitness leveland was able to do so without pain.

She reported no prior episodes ofright knee pain. She did recall a singleepisode of pain during her junior yearof high school, when a physical therapisttold her that she had patellar trackingproblems and iliotibial band (ITB) tight-ness, causing pain inferior and lateralto the left knee joint. This resolved andnever returned following a 4-month re-spite from running. She denied any sig-nificant pain episodes of the proximal ordistal joints or segments. There was nohistory of low back pain. She was takingno medications at the time of consulta-tion. Her pain was not influenced by hermenstrual cycles, which she described asnormal. Her medical status and historywere unremarkable, by her account.

Her typical training routine includedwhat she described as “general lowerextremity stretches” for the ITB, ham-strings, quadriceps, triceps surae, andhip adductor muscles. Generally, shestretched after a run. Her pattern oftraining and stretching was unchangedfor an extended period, with one excep-tion. She recalled making 1 variation inher stretching routine the day before herpain began; it may have been significantin her case. The variation was the addi-tion of a lunge-stretch exercise that wasperformed without pain. She opted notto do this stretch again as a result of theinitial pain experience she had the fol-lowing day on her 20-km run. The pa-tient reported no change in her trainingshoes; she had worn one brand since hersophomore year of college. She also indi-cated there were no episodes of give-wayweakness, locking, crepitus, or swellingof the knee.

The patient completed the LysholmScale, a knee-rating questionnaire com-monly used with athletic patients toevaluate the effects of therapeutic or sur-gical interventions.30 The instrument has

been shown to be reliable and valid, withgood responsiveness.1,30 The instrument’smaximum score of 100 indicates that apatient has no pain, atrophy, buckling,edema, limp, or need for an assistive de-vice. The patient had a score of 79 on herintake. Her visual analogue scale (VAS)score for highest level of pain was 6/10when running, with a 0/10 pain score,when at best, while resting.

Examination and EvaluationInformed consent for treatment was ob-tained and the case report had approvalthrough the Human Subjects ResearchReview Committee at Grand Valley StateUniversity.

A general screen of the patient re-vealed no significant gait abnormalities.Moving from sit to stand and tolerance toeither position was painless. She was ableto squat, heel or toe walk, and balance oneither lower extremity without difficulty.There were no apparent limitations tothoracolumbosacral movement in thestanding position. On visual inspection,there were no significant alignment ab-normalities noted in her lower extremi-ties. Likewise, her foot position appearedto be within normal limits (WNL) duringthe standing inspection.

Examination of the patient’s pain-ful right knee showed full range of mo-tion (ROM) of the joint. Manual muscletesting (MMT) of the quadriceps, ham-strings, ankle plantar flexors and dorsi-flexors, foot invertors and evertors, andhip flexors, extensors, abductors, and ad-ductors demonstrated strong (5/5) andpainless contractions. Palpation of theknee revealed that she had concordantpain along the medial joint line, over thevicinity of the medial collateral ligament,with no apparent edema or temperaturechanges. Her palpatory findings aroundthe knee were otherwise unremarkable.The following tests were also unremark-able: ligamentous valgus and varus stresstests (performed at 0° and 30°), Lach-man’s, the anterior and posterior drawersigns, McMurray’s and Apley’s tests formeniscal involvement, tests for rotary in-

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®

Dow

nloa

ded

from

ww

w.jo

spt.o

rg a

t on

Aug

ust 5

, 201

4. F

or p

erso

nal u

se o

nly.

No

othe

r us

es w

ithou

t per

mis

sion

. C

opyr

ight

© 2

008

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®. A

ll ri

ghts

res

erve

d.

618 | october 2008 | volume 38 | number 10 | journal of orthopaedic & sports physical therapy

[ CASE REPORT ]stability of the knee, and patellofemoraljoint (PFJ) tests. The latter tests includedprovocation tests of the subchondral re-gion, plica irritation tests, and patellarinstability and retinacular tests.29

Given that there was an absence of lo-cal trauma to the knee, or joint signs andsymptoms, such as edema, buckling, orlocking, a more comprehensive, regionalexamination was carried out. Biomechan-ical assessment of the lower extremitiesdemonstrated an 8° angle on Craig’s testfor femoral anteversion. This is below theaverage angle for women (18°).5 The testhas demonstrated accuracy to within 4° ofintraoperative measurements of femoralanteversion.39 No immediate concerns re-sulted from this measure because the an-gle was similar to the uninvolved side. Thepatient’s Q-angles were measured at 15°and 12° on the left and right, respectively.This measure was also slightly below nor-mal (18° for females).29 This, however, didnot have apparent implications in the fur-ther development of her case.

Muscle flexibility tests of the lower ex-tremities indicated that the patient hadrestricted extensibility of the gastrocne-mii, measured with the knee straight.Only 3° of active dorsiflexion was avail-able on the left, while 5° was present onthe involved right side.29 She also pre-sented minus 47° of hamstring flexibilityon the left and minus 41° on the right onthe 90-90 hip-knee angle test. Her Ober’stests for ITB tightness and the Thomastests for hip flexor tightness were unre-markable, as were length tests of the hipadductors and the quadriceps, includingthe rectus femoris.29

Inversion and eversion of the ankle,with the foot in subtalar neutral, shouldbe present at an approximate ratio of 2:1to 3:1.12,21,33 By this standard, the patient’sinversion and eversion were consideredto be WNL. The importance of evaluat-ing the hindfoot-forefoot relationshipwas reported by Jones22 and James.21

This assessment was made from a sub-talar neutral position with the patientin a prone-lying, figure-four position, asdescribed by Magee.29 A minor (4°) right

forefoot varus was measured from thisposition. This angle was 0° on the left.

Her medical history was unremark-able and there were no associated signs orsymptoms that caused concern. Her mainconcern was that she could not train forthe marathon. The local tenderness alongthe medial aspect of the knee joint waspotentially indicative of a local problembut may also have been referred pain, orpain associated with a remote impair-ment. Dural tests, including slump andstraight leg raise (SLR), did not provokeher symptoms. The supine SLR, especial-ly, has been shown to have good sensitiv-ity for reproducing radicular pain, withsupportive MRI findings, when that painis associated with discogenic pathology.Rabin et al37 reported kappa coefficientvalues of 0.67 (95% confidence interval[CI]: 0.53-0.79) on 58 patients withsigns of nerve root conduction problemsand supportive MRI. The combinationof the negative responses to dural ten-sion testing, in addition to the patient’sexcellent active spinal ROM, minimizedthe author’s consideration of a possiblediscogenic source for the patient’s pain.

Slipman et al40 and others31 demon-strated that pain referred from the SIJcan be felt into the lower extremity. Theauthor considered this, as well as hipand/or other nondiscogenic lumbar spinepathologies, as possible sources for thepatient’s knee pain, if it was indeed re-ferred. The lower extremity flexibility im-pairments were also considered possiblecontributors to the clinical presentation.

Pain originating from the hip can re-fer to the knee yet knee pain may be thepatient’s only complaint with some hipinjuries.24,42 This is more common in ado-lescents. In adults, the presence of kneepain without concurrent complaints fromthe hip is not seen as often.20,25 In fact,Khan and Woolson25 found the absenceof hip pain in only 3% (n = 323 patients;358 hips) of patients with known hip dis-ease. Nonetheless, an examination of thehips was performed next. Patrick’s test,hip scouring, and the sign of the buttockwere all asymptomatic. All MMT scores

were 5/5 and painless. Her hip joint ROMfindings were unremarkable.

Her lumbar ROM, as noted earlier,was WNL and pain free in all directions.Posterior-anterior (PA) mobility tests ad-ministered through the lumbar spinousprocesses from L1 to L5 were pain freeand suggested normal mobility. Thus,the examiner directed his attention tothe sacroiliac joints and pelvic girdle. Al-though the author recognizes the very lowreliability and questionable validity of thepalpatory and motion tests of the pelvicgirdle,13,48 the lack of objective findings inthe hip, knee, or low back led the authorto investigate this region in an effort to becomplete in the examination.

The pelvic girdle examination beganwith the standing forward-flexion test,which was positive on the right (involvedside), meaning that the posterior supe-rior iliac spine moved superiorly furtherthan the left side in forward bending ofthe lumbopelvic region.17,18 Interexam-iner and intraexaminer reliability of thestanding forward-flexion test has beenreported at kappa coefficient values of0.052 and 0.46, respectively, in asymp-tomatic subjects (n = 9).44 Dreyfuss et al10

reported that 13% of 101 persons with-out back pain had a positive standingforward-flexion test. In spite of the stand-ing forward-flexion test’s popularity, theliterature is generally not supportive of itsreliability.13,27

There was no apparent leg length dis-crepancy from a supine visual inspection,either with the legs extended or in hooklying. Several palpatory and motion testanalyses appeared to indicate a posteri-orly rotated innominate on the right side.With the patient supine, her anterior su-perior iliac spine (ASIS) was apparentlyhigh on the right compared to the left.The pubic tubercles also appeared tohave an altered cephalocaudal relation-ship to one another, in that the right sidewas considered to be more cephalad thanits counterpart. With the patient prone,the examiner felt that the right poste-rior superior iliac spine (PSIS) was lowcompared to the left. Also in prone test-

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®

Dow

nloa

ded

from

ww

w.jo

spt.o

rg a

t on

Aug

ust 5

, 201

4. F

or p

erso

nal u

se o

nly.

No

othe

r us

es w

ithou

t per

mis

sion

. C

opyr

ight

© 2

008

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®. A

ll ri

ghts

res

erve

d.

journal of orthopaedic & sports physical therapy | volume 38 | number 10 | october 2008 | 619

ing, a positional analysis of the sacrumrevealed a torsion (rotation) as describedby Greenman,17 Mitchell,34 and Isaacsand Bookhout.18 The sacrum’s rotationwas identified by the inferior lateralangles (ILAs) at the level of the hiatus.The right side’s ILA was more posteriorthan its counterpart on the left, perhapsreflecting a rotation of the sacrum arounda vertical axis. Moreover, the right sacro-iliac joint was believed to be hypomobile,based on the results of the squish test, asdescribed by Magee.29 No reports on reli-ability or validity of this test have beenpublished. This finding was congruentwith the standing forward-bend test re-sults noted earlier. TABLE 1 summarizesthe patient’s impairments, as well as thepositive findings from the palpation andmobility components of the exam.

DiagnosisThe examiner considered the possibilitythat the patient developed a sacroiliacjoint dysfunction while performing thelunge exercise the day before her pain be-gan. A possible explanation as to why shedeveloped the purported sacroiliac jointdysfunction was that the deep-squat posi-tion attained during that lunge exercise(with the right hip flexed and left hip ex-tended) may have induced the positionalrelationships noted at the pubis and in-nominate. That is, a counterrotation ofthe innominates may have ensued withthe right one rotated backward and theleft one rotated forward. Correspond-ingly, the right pubic tubercle’s more ce-phalad position would be accounted forby the apparent innominate rotation. Al-ternatively, it is possible that the patient’sposterior innominate and cephalic pubictubercle may have developed as a result ofher hamstring tightness, combined withfactors related to the repetitive loadingthrough the ground reaction forces ofrunning. In either case, the author be-lieved that this impairment in flexibilitywould require attention for the long-termmanagement of this patient. Retrospec-tively, the author considered the possibil-ity that because the pain required loading

over a period of time, during running, tobecome manifest, isolated special testsapplied briefly in the clinic may havebeen insufficient to elicit her pain.

Establishing a diagnosis based on theosteopathic model has to be viewed withcaution because there is little evidence tosupport its validity. This is especially truefor sacroiliac joint dysfunction, wheremany diagnostic conclusions are basedon palpatory findings.15,26 The interraterreliability of these findings has been

shown on several occasions to be poorat best.35,48 Consequently, the results ofseveral tests were combined to establisha working diagnosis. The sacroiliac jointmobility tests, as well as the boney land-mark positional findings described above,combined with the limited number of lo-cal findings at the patient’s painful knee,led the examiner to a working diagnosisof sacroiliac joint dysfunction. The authorbelieved that the knee pain was referredfrom, or at least related to, the sacroiliac

TABLE 1Summary of the Patient’s Impairments,

Positive Motion Tests,

and Relevant Palpatory Findings

Abbreviations: B, bilateral; ILA, inferior lateral angle; L, left; R, right; SIJ, sacroiliac joint.

Impairments Motion Tests Palpatory Findings

8° femoral anteversion (B) Positive standing Medial (R) kneeforward-flexion test (R) tenderness (concordant)

Q angles of 15° (L) and 12° (R) Hypomobile (R) SIJ (squish test) Cephalad position of (R) pubic ramus

Ankle dorsiflexion of 3° Posterior rotation of (R) innominate(L) and 5° (R)

Hamstring flexibility of –47° (R) sacral ILA more posterior(L) and –41° (R)

Forefoot varus of 4° (R)

TABLE 2

Summary of the Differential Diagnostic

Considerations for the Patient’s Knee Pain

and the Rationales for Their Elimination as

Primary Contributors to the Presentation

Abbreviations: ITB, iliotibial band; MOI, Mechanism of injury; ROM, range of motion; SLR, straight-leg raise; WNL, within normal limits.

Potential Pain Sources at Knee21 Rationale for Diagnostic Exclusion

Patellar tracking Q-angle WNL

Patellar instability No history of subluxation or locking

Quadriceps and patellar tendinopathy Location of pain

Pathological plica No patellar stuttering; location of pain; no fibrotic thickening

Meniscal lesions No locking, buckling; history did not support with MOI

Bursitis Location of pain; no swelling

Stress fractures No abrupt change in training regimen

Osteoarthritis Age of patient

ITB friction syndrome Location of pain

Popliteal tenosynovitis Location of pain

Ligamentous instability Stress tests were negative

Possible Sources of Referred Pain Rationale for Diagnostic Exclusion

Hip Negative special tests, normal ROM

Lumbar spine discogenic Negative SLR, excellent ROM

Lumbar spine nondiscogenic Negative spring tests, excellent ROM

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®

Dow

nloa

ded

from

ww

w.jo

spt.o

rg a

t on

Aug

ust 5

, 201

4. F

or p

erso

nal u

se o

nly.

No

othe

r us

es w

ithou

t per

mis

sion

. C

opyr

ight

© 2

008

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®. A

ll ri

ghts

res

erve

d.

620 | october 2008 | volume 38 | number 10 | journal of orthopaedic & sports physical therapy

[ CASE REPORT ]joint dysfunction or its associated impair-ments. There is essentially no literatureto support the validity of the tests thatled to this clinical impression. However,because the proposed mechanism (lungeexercise) for the SIJ impairment was con-sistent with the palpatory and mobilityfindings, the author proceeded with thisworking diagnosis. If the osteopathic bio-mechanical model were applied to labelthis dysfunction, the palpatory findingswere consistent with a right-sided pu-bic elevation and backward rotation ofthe ilium, along with a rotated sacrum.Other differential diagnostic possibilitiesand the rationale for giving them reducedconsideration are shown in TABLE 2.

InterventionThe author decided to mobilize the pubicsymphysis, first using a method describedby Greenman.17 The rationale for this de-cision was based on Greenman’s17 andIsaac’s18 contention that pubic symphysisdysfunction should be addressed prior tomost dysfunctions in the sacroiliac joint.Undoubtedly, given the ring structure ofthe pelvis, treatment directed at eitherarticulation will influence the other.

For this initial intervention, the pa-tient was positioned in a supine, hook-lying position, as shown in FIGURE 1A. Theauthor used the hip adductors to articu-late the pubic symphysis. Some authorscontend that this can reposition the jointsurfaces into a better cephalocaudal re-lationship.17,18 Two 6-second isometriccontractions of hip abduction and exter-nal rotation were utilized to reciprocallyinhibit the adductor muscle group. Theseinitial contractions were carried out atthe lower extremity position shown inFIGURE 1A. Additional contractions wereresisted at 2 larger hip abduction/exter-nal rotation angles. The third and fourthcontractions were carried out in the samefashion with the knees separated fromone another at approximately 50%, then75%, of the patient’s available hip abduc-tion/external rotation ROM (FIGURES 1B

and 1C). The patient’s feet remained side-by-side throughout the 4 contractions. At

this juncture, the author placed his rightelbow on the inside of the patient’s knee

closest to him, while the right hand wasplaced inside the patient’s left knee (FIG-

URE 1D). The patient then squeezed herknees together isometrically at 50% to75% of her hip adductors’ available con-tractile force. An audible click was heardat the pubic symphysis, perhaps indicat-ing a successful gapping of the articula-tion. Subsequent palpation of the pubiclandmarks demonstrated an apparentlylevel relationship of the right and left pu-bic tubercles.

The patient was then retested in pronefor sacral and innominate positions,which demonstrated persistent asym-metry of the sacral (ILA) and ilial land-marks (PSIS). Greenman17 and Flynn etal14 described a manipulative procedureused for either a lumbar or sacral mobil-ity restriction. Flynn et al14 described thetechnique for management of nonradicu-lar low back pain and validated its use forcases that fit a clinical prediction rule.

The next intervention was applied tothe patient’s right side innominate, withthe patient lying supine. The side to bemanipulated was selected according tothe protocol used by Flynn et al14—that is,the side (right) with the symptoms. Theauthor stood on the patient’s left side.The patient placed her hands behind herneck with the fingers laced together. Hertorso and lower extremities were pas-sively placed in side flexion, away fromthe author, putting her in right side bend-ing. The author then laced his right armthrough the patient’s arms, as shown inFIGURE 2. The patient was rotated to theleft and flexed down through and includ-ing the lumbosacral junction. A quickthrust through the ASIS was applied in aposterior and inferior direction.

The patient was then placed prone,and her iliac and sacral positional anal-yses were considered normal throughlandmark palpations of the PSISs, sacralbases, and sacral ILAs. No further treat-ment was administered at this initial con-sult. The patient’s subjective response tothe intervention was considered normalalthough the influence on her painfulknee was unknown at this juncture.

FIGURE 1. (A) Starting position for the interventiondirected to the pubic symphysis. Isometric resistanceis provided by the therapist to the patient’s hipabductors/external rotators (AB/ER). (B) Position forthe third AB/ER isometric contraction. (C) Positionfor the final AB/ER isometric contraction. (D)Therapist positioning and hand placement for theisometric contraction of the hip adductors/internalrotators (AD/IR).

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®

Dow

nloa

ded

from

ww

w.jo

spt.o

rg a

t on

Aug

ust 5

, 201

4. F

or p

erso

nal u

se o

nly.

No

othe

r us

es w

ithou

t per

mis

sion

. C

opyr

ight

© 2

008

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®. A

ll ri

ghts

res

erve

d.

journal of orthopaedic & sports physical therapy | volume 38 | number 10 | october 2008 | 621

The patient was instructed to ice thelumbosacral region as needed during theremainder of the day and evening. Shewas also given instruction to attemptrunning or walking at her discretion, ifthere was no adverse response to the ma-nipulative procedures.

OUTCOMES

The patient was seen for follow-up 1 week later. She had no pain onstairs and had returned to running

with only minimal sacroiliac joint sore-ness (VAS score, 1/10) reported on herlonger runs (15-20 km). These symptomsresolved without further intervention insubsequent weeks, and the patient wasable to return to her running routinewithout further interruptions. The kneepain was fully resolved (VAS score, 0/10)after the single treatment session. HerLysholm score at 1 week postinterven-tion was 100. She was encouraged tocontinue her flexibility regimen for thelower extremities, with precaution not todo the lunge stretch. The patient’s goal ofreturning to her training for the BostonMarathon was achieved. She ultimatelycompleted the marathon successfully ap-proximately 4 months later.

DISCUSSION

The patient’s history, specifi-

cally the proposed mechanism ofinjury, as well as the palpation and

mobility findings at the sacroiliac jointand pubis, were significant factors in

establishing the working diagnosis inthis case. The author acknowledges thatthe evidence to support these findings ismarginal. Laslett et al26 and others6 stressthe importance of establishing workingdiagnoses in potential sacroiliac jointdysfunctions from the results of a batteryof tests and/or historical elements. Thecurrent author based his impressions onan analysis of the palpatory findings, thelunge incident in the patient’s history,and the mobility tests of the sacroiliacjoint. While this does not establish thepathology in this case as a sacroiliac jointdysfunction, the summated elements ofthe examination pointed most clearly inthat direction, in the author’s opinion.

Others have investigated the link be-tween the sacroiliac joint and the knee.Suter et al41 established an apparent linkbetween sacroiliac joint pathology andinhibition of the quadriceps muscles inpatients with anterior knee pain. Cook-son8 presented a case involving anothermarathon runner with knee pain, wheresacroiliac joint dysfunction was appar-ently a part of the clinical picture. Finally,Matthews31 provided indirect evidencefor a link between the sacroiliac joint andknee pain in an elderly population withdegenerative arthritis (DJD) of the knees.He assessed 16 patients with radiographicevidence of DJD of the knee and notableROM loss. Using prolotherapy to theipsilateral sacroiliac ligaments, he “suc-cessfully treated” 14 of 16 patients. At 4months, the patients that were character-ized as successful outcomes in the Mat-thews study31 were subjectively “muchbetter” to completely pain free.31 All of thepatients had failed previous interventionsof physical therapy, surgery, medications,and/or local steroid injections.

It is also conceivable that the patient’spain was influenced by peripheral and/or central neurological mechanisms. Amounting volume of evidence wouldsupport that possibility.23,36,43,50 Both neu-romechanical and neurophysiologic influ-ences have been associated with manualtherapy interventions. Among these areextremity hypoalgesia following spinal

mobilization or manipulation,16 potentialdescending neuromodulation of nocicep-tor input,43 sympathoexcitatory effects,36

or afferent input modulation throughspinal mechanoreceptors in close prox-imity to the applied manual therapyprocedures.7 Zusman50 elegantly sum-marized, for example, the influence ofdescending, inhibitory pathways from thebrainstem and higher cortical centers onspinal nociceptive pathways in the dorsalhorn. The author outlines how mechani-cal stimuli, acquired in the current casethrough the manipulative procedures, areamong a host of physical and psychologi-cal factors that effectively desensitize thenervous system to a constant or incon-stant bombardment of nociceptive inputconducted over nonmyelinated C-fibersor thinly myelinated A- afferents.50

Bialosky et al2 proposed that certainnonspecific influences might alter painlevels as a result of manual therapy in-terventions. These influences includeresponses related to the placebo effect orpatient expectations. Powers addressedthe importance of taking the placebo ef-fect into consideration in his invited com-mentary on a published study by Iversonet al,19 which was relatively similar to thecurrent case report in terms of the pa-tients’ pain presentation (knee pain) andthe subsequent lumbopelvic intervention.Considering the current case in light ofthe results of the Iverson et al19 study,it is conceivable that a subgroup of pa-tients with knee pain may exist that willrespond to lumbopelvic intervention. Ka-laoukalani et al23 demonstrated the influ-ence of patient expectations on treatmentoutcomes in patients with low back pain.In their study, patients who had higheroutcome expectations for their ran-domized intervention (acupuncture ormassage) reported better functional out-comes (86%) than those who had lowerexpectations (68%). This may have beena factor in the present case, as a physicaltherapy student might have preconceivednotions about the effectiveness of spinalmanual therapy.

Any conclusions drawn from this

FIGURE 2. Positioning for the manipulative thrust tothe right innominate through the anterior superioriliac spine.

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®

Dow

nloa

ded

from

ww

w.jo

spt.o

rg a

t on

Aug

ust 5

, 201

4. F

or p

erso

nal u

se o

nly.

No

othe

r us

es w

ithou

t per

mis

sion

. C

opyr

ight

© 2

008

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®. A

ll ri

ghts

res

erve

d.

622 | october 2008 | volume 38 | number 10 | journal of orthopaedic & sports physical therapy

[ CASE REPORT ]case report have to be evaluated withinthe context of the poor reliability inher-ent in the examination procedures, mostnotably as they pertain to the sacroiliacjoint and the pelvis.15,26,27,35,48 However, ifthe patient’s atypical knee pain presenta-tion was related to the sacroiliac joint, itwould be unique in the literature for thisage group. The theoretical constructs ofregional interdependence do not say thatpain is actually referred or radiating froma proximal source, only that it is some-how related to the remotely located dys-function or impairment.46

The Lysholm instrument used in thisstudy is generally acknowledged as hav-ing more utility for patients with liga-mentous injuries at the knee.1 Inasmuch,the Lysholm may not have been the bestoutcome scale to use, retrospectively.However, given the outstanding resultsof the case, it is unlikely that the use ofanother instrument would have addedmuch to an assessment of this patient’soutcome.

Finally, it is interesting to considerwhy the patient was able to use thecross-country and elliptical exercise ap-paratuses without provoking her symp-toms prior to the initial physical therapyvisit. If the cause of her symptoms wasrelated to repetitive trauma, then thelow-impact nature of these machinesmay have eliminated the painful stimuliof running’s ground reaction forces. Ifthe pain was produced by an alterationin the positional relationships of the pel-vic ring structures, then either the low-impact factor or avoidance of potentiallyprovocative end-range positions mightaccount for her ability to painlessly usethese devices.

CONCLUSION

This case report describes the

elimination of knee pain in a run-ner following manual therapy in-

terventions for the sacroiliac region andsymphysis pubis. The current case report,coupled with the work of Iverson et al,19

suggests the existence of a subgroup of

patients with knee pain who respond tolumbopelvic interventions. While a casereport cannot define definitive relation-ships of cause and effect, this patient’scase provides anecdotal evidence of arelationship between sacroiliac jointdysfunction and knee pain. The case alsohighlights the importance of consideringregional interdependence in the exami-nation of patients.

REFERENCES

1. Bengtsson J, Mollborg J, Werner S. A studyfor testing the sensitivity and reliability of theLysholm knee scoring scale. Knee Surg SportsTraumatol Arthrosc. 1996;4:27-31.

2. Bialosky JE, Bishop MD, George SZ. Regional in-terdependence: a musculoskeletal examinationmodel whose time has come. J Orthop SportsPhys Ther. 2008;38:159-160; author reply 160.http://dx.doi.org/10.2519/jospt.2008.0201

3. Brukner P, Khan K. Clinical Sports Medicine.Sydney, Australia: McGraw-Hill; 1993.

4. Calmbach WL, Hutchens M. Evaluation ofpatients presenting with knee pain: Part II.Differential diagnosis. Am Fam Physician.2003;68:917-922.

5. Cibulka MT. Determination and significanceof femoral neck anteversion. Phys Ther.2004;84:550-558.

6. Cibulka MT, Koldehoff R. Clinical usefulness of acluster of sacroiliac joint tests in patients withand without low back pain. J Orthop SportsPhys Ther. 1999;29:83-89; discussion 90-82.

7. Colloca CJ, Keller TS, Gunzburg R. Neurome-chanical characterization of in vivo lumbarspinal manipulation. Part II. Neurophysi-ological response. J Manipulative Physiol Ther.2003;26:579-591. http://dx.doi.org/10.1016/j.jmpt.2003.08.004

8. Cookson L. Atypical knee pain: the biomechani-cal and neurological relationship between thepelvis, hip, and knee--a case report. Clin Chiro-pract. 2003;6:63-66.

9. Davis WL, Fulkerson JP. Initial evaluation of theathlete with anterior knee pain. Op Tech SportsMed. 1999;7:55-58.

10. Dreyfuss P, Dryer S, Griffin J, Hoffman J, WalshN. Positive sacroiliac screening tests in asymp-tomatic adults. Spine. 1994;19:1138-1143.

11. Duffey MJ, Martin DF, Cannon DW, Craven T,Messier SP. Etiologic factors associated withanterior knee pain in distance runners. Med SciSports Exerc. 2000;32:1825-1832.

12. Dutton M. Orthopaedic Examination, Evaluation,and Intervention. New York, NY: McGraw-Hill;2004.

13. Egan D, Cole J, Twomey L. The standing forwardflexion test: an inaccurate determinant of sacro-

iliac dysfunction. Physiother. 1996;82:236-242.14. Flynn T, Fritz J, Whitman J, et al. A clinical

prediction rule for classifying patients withlow back pain who demonstrate short-termimprovement with spinal manipulation.Spine. 2002;27:2835-2843. http://dx.doi.org/10.1097/01.BRS.0000035681.33747.8D

15. Freburger JK, Riddle DL. Using published evi-dence to guide the examination of the sacroiliacjoint region. Phys Ther. 2001;81:1135-1143.

16. George SZ, Bishop MD, Bialosky JE, Zeppieri G,Jr., Robinson ME. Immediate effects of spinalmanipulation on thermal pain sensitivity: anexperimental study. BMC Musculoskelet Disord.2006;7:68. http://dx.doi.org/10.1186/1471-2474-7-68

17. Greenman PE. Principles of Manual Medicine.3rd ed. Philadelphia, PA: Lippincott, Williams &Wilkins; 2003.

18. Isaacs ER, Bookhout MR. Bourdillon’s SpinalManipulation. 6th ed. Boston, MA: Butterworth-Heinemann; 2002.

19. Iverson CA, Sutlive TG, Crowell MS, et al.Lumbopelvic manipulation for the treatmentof patients with patellofemoral pain syndrome:development of a clinical prediction rule. JOrthop Sports Phys Ther. 2008;38:297-309;discussion 309-212. http://dx.doi.org/10.2519/jospt.2008.2669

20. Jacobs B. Diagnosis and natural history ofslipped capital femoral epiphysis. Instr CourseLect. 1972;21:167-175.

21. James SL. Running injuries of the knee. InstrCourse Lect. 1998;47:407-417.

22. Jones DC, James SL. Foot orthoses. In: BaxterED, eds. The Foot and Ankle in Sport. St Louis,MO: Mosby; 1995:

23. Kalauokalani D, Cherkin DC, Sherman KJ,Koepsell TD, Deyo RA. Lessons from a trial ofacupuncture and massage for low back pain:patient expectations and treatment effects.Spine. 2001;26:1418-1424.

24. Khan AM, McLoughlin E, Giannakas K,Hutchinson C, Andrew JG. Hip osteoar-thritis: where is the pain? Ann R Coll SurgEngl. 2004;86:119-121. http://dx.doi.org/10.1308/003588404322827518

25. Khan NQ, Woolson ST. Referral patterns of hippain in patients undergoing total hip replace-ment. Orthopedics. 1998;21:123-126.

26. Laslett M, Aprill CN, McDonald B, Young SB.Diagnosis of sacroiliac joint pain: validity ofindividual provocation tests and composites oftests. Man Ther. 2005;10:207-218. http://dx.doi.org/10.1016/j.math.2005.01.003

27. Levangie PK. Four clinical tests of sacroiliac jointdysfunction: the association of test results withinnominate torsion among patients with andwithout low back pain. Phys Ther. 1999;79:1043-1057.

28. Lun V, Meeuwisse WH, Stergiou P, StefanyshynD. Relation between running injury and staticlower limb alignment in recreational runners. BrJ Sports Med. 2004;38:576-580. http://dx.doi.org/10.1136/bjsm.2003.005488

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®

Dow

nloa

ded

from

ww

w.jo

spt.o

rg a

t on

Aug

ust 5

, 201

4. F

or p

erso

nal u

se o

nly.

No

othe

r us

es w

ithou

t per

mis

sion

. C

opyr

ight

© 2

008

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®. A

ll ri

ghts

res

erve

d.

journal of orthopaedic & sports physical therapy | volume 38 | number 10 | october 2008 | 623

29. Magee DJ. Orthopedic Physical Assessment. 4thed. Philadelphia, PA: Saunders; 2002.

30. Marx RG, Jones EC, Allen AA, et al. Reliability,validity, and responsiveness of four knee out-come scales for athletic patients. J Bone JointSurg Am. 2001;83-A:1459-1469.

31. Matthews JH. A new approach to the treatmentof osteoarthritis of the knee: prolotherapy of theipsilateral sacroiliac ligaments. Am J Pain Man-agement. 1995;5:91-93.

32. McKenzie DC, Clement DB, Taunton JE. Run-ning shoes, orthotics, and injuries. Sports Med.1985;2:334-347.

33. Menadue C, Raymond J, Kilbreath SL, Ref-shauge KM, Adams R. Reliability of two gonio-metric methods of measuring active inversionand eversion range of motion at the ankle. BMCMusculoskelet Disord. 2006;7:60. http://dx.doi.org/10.1186/1471-2474-7-60

34. Mitchell FL, Mitchell PKG. The Muscle EnergyManual. East Lansing, MI: MET Press; 1999.

35. O’Haire C, Gibbons P. Inter-examiner and intra-examiner agreement for assessing sacroiliacanatomical landmarks using palpation and ob-servation: pilot study. Man Ther. 2000;5:13-20.http://dx.doi.org/10.1054/math.1999.0203

36. Paungmali A, O’Leary S, Souvlis T, Vicenzino B.Hypoalgesic and sympathoexcitatory effects ofmobilization with movement for lateral epicon-dylalgia. Phys Ther. 2003;83:374-383.

37. Rabin A, Gerszten PC, Karausky P, Bunker CH,Potter DM, Welch WC. The sensitivity of the

seated straight-leg raise test compared with thesupine straight-leg raise test in patients present-ing with magnetic resonance imaging evidenceof lumbar nerve root compression. Arch PhysMed Rehabil. 2007;88:840-843. http://dx.doi.org/10.1016/j.apmr.2007.04.016

38. Reinking MF, Hayes AM. Intrinsic factors associ-ated with exercise-related leg pain in collegiatecross-country runners. Clin J Sport Med.2006;16:10-14.

39. Ruwe PA, Gage JR, Ozonoff MB, DeLuca PA.Clinical determination of femoral anteversion. Acomparison with established techniques. J BoneJoint Surg Am. 1992;74:820-830.

40. Slipman CW, Jackson HB, Lipetz JS, ChanKT, Lenrow D, Vresilovic EJ. Sacroiliac jointpain referral zones. Arch Phys Med Rehabil.2000;81:334-338.

41. Suter E, McMorland G, Herzog W, Bray R.Conservative lower back treatment reducesinhibition in knee-extensor muscles: a random-ized controlled trial. J Manipulative Physiol Ther.2000;23:76-80.

42. Tippett SR. Referred knee pain in a young ath-lete: a case study. J Orthop Sports Phys Ther.1994;19:117-120.

43. Vicenzino B, Collins D, Benson H, Wright A. Aninvestigation of the interrelationship betweenmanipulative therapy-induced hypoalgesia andsympathoexcitation. J Manipulative Physiol Ther.1998;21:448-453.

44. Vincent-Smith B, Gibbons P. Inter-examiner and

intra-examiner reliability of the standing flexiontest. Man Ther. 1999;4:87-93. http://dx.doi.org/10.1054/math.1999.0173

45. Wainner RS, Flynn TW, Whitman JM. Spinal andExtremity Manipulation: The Basic Skill Set forPhysical Therapists. San Antonio, TX: SpinalPublications; 2001.

46. Wainner RS, Whitman JM, Cleland JA, Flynn TW.Regional interdependence: a musculoskeletalexamination model whose time has come. J Or-thop Sports Phys Ther. 2007;37:658-660. http://dx.doi.org/10.2519/jospt.2007.0110

47. Walter SD, Hart LE, McIntosh JM, Sutton JR. TheOntario cohort study of running-related injuries.Arch Intern Med. 1989;149:2561-2564.

48. Waters N. Static palpation tests of the sacroiliacjoint--a systematic review. Physiother Ireland.2003;24:3-9.

49. Wen DY, Puffer JC, Schmalzried TP. Lower ex-tremity alignment and risk of overuse injuriesin runners. Med Sci Sports Exerc. 1997;29:1291-1298.

50. Zusman M. Forebrain-mediated sensitization ofcentral pain pathways: ‘non-specific’ pain and anew image for MT. Man Ther. 2002;7:80-88.

@ MORE INFORMATIONWWW.JOSPT.ORG

VIEW Videos on JOSPT’s Website

Videos posted with select articles on the Journal’s website (www.jospt.org)show how conditions are diagnosed and interventions performed. For alist of available videos, click on “COLLECTIONS” in the navigation bar in theleft-hand column of the home page, select “Media”, check “Video”, andclick “Browse”. A list of articles with videos will be displayed.

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®

Dow

nloa

ded

from

ww

w.jo

spt.o

rg a

t on

Aug

ust 5

, 201

4. F

or p

erso

nal u

se o

nly.

No

othe

r us

es w

ithou

t per

mis

sion

. C

opyr

ight

© 2

008

Jour

nal o

f O

rtho

paed

ic &

Spo

rts

Phys

ical

The

rapy

®. A

ll ri

ghts

res

erve

d.