Complex knee pain patient case study – Sonal

As one of the UK’s leading London physiotherapists, I regularly write about injuries, treatment and assessment techniques.

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Where do you go if you have a long-term or complex knee problem, you don’t need or want surgery right now, but you aren’t responding to your current physiotherapy treatment?

This is the story of one of my patients, I’ll call her Sonal, though that’s not her real name, and I have changed a few details so that she’s not easily identifiable.

A sore knee…

In 2012, Sonal was a 40 year old lawyer.  Out with her husband one day, he asked her why she was limping.  She hadn’t really noticed, but once her attention was drawn to it, she realised that actually she couldn’t control it, and her right knee was feeling stiff and sore.

A few months later – still stiff and sore – Sonal limped into her GP’s surgery.  He referred her to see a local physiotherapist, who prescribed some standard knee exercises, to strengthen her thigh and buttock muscles.

But unfortunately, Sonal’s knee didn’t respond.  She carried on limping with a stiff, sore right knee – and gradually her left knee started to join in!  She bought some knee supports and eventually started using crutches to get around.

Knee surgery…

After a year of frustration with treatment, Sonal’s physio sent her to see a knee surgeon.  He did an MRI scan which showed some torn cartilage.  She needed surgery to repair the cartilage and clean out the joint.  Clearly this was the issue, so she had the surgery and then went back to her physio for rehab.

It didn’t work.

Another year later, Sonal was still on crutches, still trying to do her knee exercises, and still in pain in both knees.

In desperation, she went back to her surgeon to ask if he would operate on the left knee, because it was becoming so sore and stiff.

Instead, her surgeon sent her to see me.

Sonal came into my clinic, using her crutches, and accompanied by what felt like her whole family: her mother, her sister and her daughter.  They all sat in the reception area as quiet as mice, being made cups of tea by my reception team, while Sonal and I went into the treatment room for a 90-minute assessment session, to see if I could help her.

But… was it really about the knee?

I didn’t look only at Sonal’s knees, or at her scans and her diagnosis.  I looked at her whole body.

One thing that was immediately obvious was that both of her knees were collapsing inwards, and when I looked more closely, I realised that this was actually happening because of her feet!  Her foot muscles had become so weak that her arches weren’t supporting her any more, and over time her feet had actually stiffened into that collapsed position.  They weren’t completely rigid though – they actually collapsed further when she was standing on one foot compared to standing on both feet.

Of course, when you’re walking, you stand on first one foot and then the other, so being able to stand on one foot is quite key!  When Sonal’s arches collapsed, her shins dropped down on the inside and twisted inwards, so each step was putting a terrific strain through her knees – no wonder she was in pain!

At the point when I first met Sonal, even if she’d managed to build the world’s strongest buttock and thigh muscles – which she hadn’t – then she still wouldn’t have been able to overcome the twist coming from her feet, and to support her knees properly.

Treating the body in the right order

The difference when we started working on Sonal’s feet was dramatic.  Bear in mind that by this time she’d had two years of physiotherapy and crutches.

In that first session, I got my hands on her feet. I got her foot bones and joints moving a little bit better, and I taught her some exercises to try to wake up the foot muscles.

Even after just that, the change was so dramatic that when we returned from the treatment room to reception, for the first time in two years, Sonal wasn’t using her crutches!  Her mother, sister and daughter were waiting for her, and they couldn’t believe what they were seeing.  As she walked towards them, slowly and carefully but without using walking aids, they all burst into tears of joy.

I ended up working with Sonal for 12 sessions over the space of 9 months.  In between the sessions, she worked really hard on improving her foot mobility, control and strength; and I made her some temporary insoles which she wore for a few months until she didn’t need them any more.

Within two months, she was able to use an exercise bike, and her new butt exercises were starting to take effect.

Two months later, she went dancing in high heels at a friend’s wedding.

And by the time we finished working together, 9 months later, she was regularly going to the gym and swimming.  Two years later, she still hasn’t needed any more treatment on her legs, and definitely hasn’t needed any more knee surgery!

What makes the difference?

What made the difference?  It was the fact that I didn’t just home straight in on her knees – I analysed her whole body to work out why they were so twisted.

Everything in your body is connected.  I’ve seen knee pain arising from issues in the ribcage.  I’ve seen back pain arising from problems in the feet.  I’ve seen ankle pain arising from problems in the neck.  So just because your knee hurts, if it’s not getting better, please don’t settle for a therapist or doctor who only looks at your knee and doesn’t consider it in the context of the rest of your body! Call my team on 0207 175 0150 and come and see me, so that we can work out not just what hurts, but why.

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