Our approach in the clinic as we try to say, “Where does it hurt? Why does it hurt there?” sometimes it’s very simple. We take a history and a physical examination and get the answer right away, or so the story is supposed to go. Actually our clinical exercise is merely a set of guesses in which we try to get down to some possible anatomic explanations for the pain and some possible notions about the processes that might be modified. In fact, the number of historical features that seem to have some weight in classic training about diagnosis really may not tell us much. For instance, locking; which is supposed to be quite indicative of a meniscal derangement, was looked at among hundreds and hundreds of possible symptoms in a systematic way. In normal knees and knees that underwent arthroscopy and had these derangements shown and locking was not predictive of a torn meniscus. A buckling, for instance, was not indicative of a cruciate ligament. So we are merely making guesses here. We are beyond what the orthopedists had to do and really judge whether or not an operation needed to be done. We need to make guesses and what we can do about it.
Our physical examination likewise. It goes somewhat beyond simply ascertaining whether or not there is inflammation there or not, to make us think of an inflammatory process or if there is crepitus and bony enlargement or not to make us think of osteoarthritis. We also need to carefully look for areas of focal tenderness, look for instability, for laxity, for muscle power, for muscle wasting and so on. Things that might eventually influence what we ask of our physical therapy recommendation. So the patient leaves the physician’s office with possibly some assessment about what anatomic problems might be in the knee and why they might be hurting, and what else is wrong. Then the therapist takes over and assesses how these things go together.
Okay, this therapist is ready to take over, however you are going to see an extemporaneous show of teamwork here since I don’t have a remote control, so Bob is in charge of this. As we look for effective methods to evaluate and treat the knee, it’s necessary to think of the lower extremity as a whole and in terms of its biomechanics and as a working unit or a kinetic chain. We look at this chain in terms of alignment and posture, muscular action and muscular length and flexibility. It’s impossible to understand the sources of knee pain or remedies for it without considering all of these components. However, let me assure you, a lecture on biomechanics is not coming up next. Just a few, hopefully, memorable reasons why we must look beyond the knee when we think about knee pain.
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