Jospt.2008 knee pain

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, known
as the regional-interdependence model,
has received attention in the literature.
In this examination framework, regions
remote to a patient’s primary site of pain
are considered for their potential contri-
bution to that pain.45,46
The patient in this case report was a
competitive runner who presented with
right knee pain that had prevented her
from training for several weeks. In this
case, limited findings at the knee led the
therapist to a broader examination of
the lower quarter, including the lumbar
spine, pelvis, hip, and ankle/foot. The
combination of the patient’s symptoms,
clinical findings, and response to inter-
vention seem to be unique in a review of
the literature.
The purpose of this case report is to
describe the clinical findings, interven-
tion and outcomes in a patient with me-
dial knee pain and to highlight the value
of a regional interdependence model of
patient examination.
CASE DESCRIPTION
History
A
25-year-old, Caucasian female
and third-year physical therapy
student self-referred for consulta-
tion regarding medial, right knee pain.
She was a cross-country and track athlete
throughout high school and her under-
T
here are an estimated 30 million runners in North America.32
Knee pain is a common complaint in this population. Overuse
injuries, 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
In
some cases, knee pain may be the sole presenting symptom when a
more 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 reported
in the literature. However, very little has been writ-
ten about pain localized to the knee joint for cases
involving sacroiliac dysfunction.
CASE DESCRIPTION: A 25-year-old female
runner was self-referred to physical therapy for
medial knee pain of 4½ weeks’ duration without
a significant onset event. The pain completely
curtailed her training for the Boston Marathon.
Examination of the patient’s knee and hip did not
reveal any abnormal findings and there was no
reproduction of pain with any test procedures ex-
cept for medial knee joint tenderness to palpation.
Additional, more proximal examination suggested
significant asymmetry of sacral bony landmarks of
the pelvic girdle without significant findings on the
provocation tests of the sacroiliac joint. A single
session of manual therapy procedures directed to
the pubic symphysis and sacroiliac joint ipsilateral
to the side of knee pain was provided.
OUTCOMES: The patient was able to return to
running without further incident of knee pain after
a single therapy session.
DISCUSSION: This case suggests the
importance of regional interdependence in the
examination of patients with an apparently
common clinical problem. Furthermore, the case
describes a previously unreported presentation of
local knee pain possibly attributable to sacroiliac
joint 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 be
suboptimal.
James21
and others9
have highlighted
the importance of a regional examination
specifically for patients with knee pain.
A thorough history intake, screening,
and biomechanical assessment are es-
sential components of a comprehensive
examination.28
This is especially impor-
ankle/foot,32
or sacroiliac joint.8
In such
cases, the pain may be referred from a
more proximal structure or be consequen-
tial to a remotely located impairment
or dysfunction that produces excessive
stresses on structures of the knee, with
resulting pain generation. When that
remote source is not identified in an ex-
amination of the patient, the results of
Isolated Knee Pain: A Case Report
Highlighting Regional Interdependence
DANIEL W. VAUGHN, PT, PhD, FAAOMPT1
1
Associate 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
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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, which
she raced at collegiate nationals, in ad-
dition to other events ranging from 800
m to 5 km.
She had completed the Detroit Mara-
thon approximately 2 months prior to the
onset of her symptoms without incident
and had taken a 2-week respite from run-
ning before beginning training for the
Boston Marathon. She began that train-
ing at about 40 to 50 km/wk. She trained
on trails and pavement. Her weekly level
of training at the time leading up to her
consultation was 70 to 80 km/wk at an
average pace of approximately 4.5 min/
km (approximately 7 min 15 s/mile). She
was running 5 to 6 d/wk at that juncture,
with long runs of up to 2 hours. She was
slowly increasing her mileage on a weekly
basis.
The patient’s pain began without iden-
tifiable cause 4.5 weeks prior to her phys-
ical therapy examination. She had not
seen a physician for her pain nor had she
had other consultations or interventions.
The pain began at about 1.5 km into one
of her training runs on pavement. She
described the pain as a “nuisance” and
“dull ache.” She kept running for 2 weeks
beyond the onset date. Initially, she no-
ticed that the pain would come on in the
latter stages of her runs. However, over
time, the pain progressively intensified
and would start earlier in the run. The
pain was not present between training
runs during the first few days. At about
10 to 11 days after the initial episode, she
was on a 20-km run and noticed that
her knee began to hurt rather notice-
ably. Later that night her knee began to
ache while she was in bed. The next day
the knee was almost too sore for weight
bearing. Subsequent efforts to run were
terminated at 2.5 to 3.0 km by intolerable
pain. She ultimately stopped running 2
weeks after the initial episode. Intermit-
tent attempts to run over the next 2 to 2.5
weeks resulted in a return of pain. She
noted that the longer she took off from
running, the longer it would take for the
pain to return on subsequent efforts to
begin training again. In addition to run-
ning, she noted that descending stairs
increased her pain. She was using an el-
liptical or cross-country ski machine to
maintain her cardiovascular fitness level
and was able to do so without pain.
She reported no prior episodes of
right knee pain. She did recall a single
episode of pain during her junior year
of high school, when a physical therapist
told her that she had patellar tracking
problems and iliotibial band (ITB) tight-
ness, causing pain inferior and lateral
to the left knee joint. This resolved and
never returned following a 4-month re-
spite from running. She denied any sig-
nificant pain episodes of the proximal or
distal joints or segments. There was no
history of low back pain. She was taking
no medications at the time of consulta-
tion. Her pain was not influenced by her
menstrual cycles, which she described as
normal. Her medical status and history
were unremarkable, by her account.
Her typical training routine included
what she described as “general lower
extremity stretches” for the ITB, ham-
strings, quadriceps, triceps surae, and
hip adductor muscles. Generally, she
stretched after a run. Her pattern of
training and stretching was unchanged
for an extended period, with one excep-
tion. She recalled making 1 variation in
her stretching routine the day before her
pain began; it may have been significant
in her case. The variation was the addi-
tion of a lunge-stretch exercise that was
performed without pain. She opted not
to do this stretch again as a result of the
initial pain experience she had the fol-
lowing day on her 20-km run. The pa-
tient reported no change in her training
shoes; she had worn one brand since her
sophomore year of college. She also indi-
cated there were no episodes of give-way
weakness, locking, crepitus, or swelling
of the knee.
The patient completed the Lysholm
Scale, a knee-rating questionnaire com-
monly used with athletic patients to
evaluate the effects of therapeutic or sur-
gical interventions.30
The instrument has
been shown to be reliable and valid, with
good responsiveness.1,30
The instrument’s
maximum score of 100 indicates that a
patient has no pain, atrophy, buckling,
edema, limp, or need for an assistive de-
vice. The patient had a score of 79 on her
intake. Her visual analogue scale (VAS)
score for highest level of pain was 6/10
when running, with a 0/10 pain score,
when at best, while resting.
Examination and Evaluation
Informed consent for treatment was ob-
tained and the case report had approval
through the Human Subjects Research
Review Committee at Grand Valley State
University.
A general screen of the patient re-
vealed no significant gait abnormalities.
Moving from sit to stand and tolerance to
either position was painless. She was able
to squat, heel or toe walk, and balance on
either lower extremity without difficulty.
There were no apparent limitations to
thoracolumbosacral movement in the
standing position. On visual inspection,
there were no significant alignment ab-
normalities noted in her lower extremi-
ties. Likewise, her foot position appeared
to be within normal limits (WNL) during
the standing inspection.
Examination of the patient’s pain-
ful right knee showed full range of mo-
tion (ROM) of the joint. Manual muscle
testing (MMT) of the quadriceps, ham-
strings, ankle plantar flexors and dorsi-
flexors, foot invertors and evertors, and
hip flexors, extensors, abductors, and ad-
ductors demonstrated strong (5/5) and
painless contractions. Palpation of the
knee revealed that she had concordant
pain along the medial joint line, over the
vicinity of the medial collateral ligament,
with no apparent edema or temperature
changes. Her palpatory findings around
the knee were otherwise unremarkable.
The following tests were also unremark-
able: ligamentous valgus and varus stress
tests (performed at 0° and 30°), Lach-
man’s, the anterior and posterior drawer
signs, McMurray’s and Apley’s tests for
meniscal involvement, tests for rotary in-

[ CASE REPORT ]
stability of the knee, and patellofemoral
joint (PFJ) tests. The latter tests included
provocation tests of the subchondral re-
gion, plica irritation tests, and patellar
instability and retinacular tests.29
Given that there was an absence of lo-
cal trauma to the knee, or joint signs and
symptoms, such as edema, buckling, or
locking, a more comprehensive, regional
examination was carried out. Biomechan-
ical assessment of the lower extremities
demonstrated an 8° angle on Craig’s test
for femoral anteversion. This is below the
average angle for women (18°).5
The test
has demonstrated accuracy to within 4° of
intraoperative measurements of femoral
anteversion.39
No immediate concerns re-
sulted from this measure because the an-
gle was similar to the uninvolved side. The
patient’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, did
not have apparent implications in the fur-
ther development of her case.
Muscle flexibility tests of the lower ex-
tremities indicated that the patient had
restricted 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 on
the involved right side.29
She also pre-
sented minus 47° of hamstring flexibility
on the left and minus 41° on the right on
the 90-90 hip-knee angle test. Her Ober’s
tests for ITB tightness and the Thomas
tests for hip flexor tightness were unre-
markable, as were length tests of the hip
adductors and the quadriceps, including
the rectus femoris.29
Inversion and eversion of the ankle,
with the foot in subtalar neutral, should
be present at an approximate ratio of 2:1
to 3:1.12,21,33
By this standard, the patient’s
inversion and eversion were considered
to be WNL. The importance of evaluat-
ing the hindfoot-forefoot relationship
was reported by Jones22
and James.21
This assessment was made from a sub-
talar neutral position with the patient
in a prone-lying, figure-four position, as
described by Magee.29
A minor (4°) right
forefoot varus was measured from this
position. This angle was 0° on the left.
Her medical history was unremark-
able and there were no associated signs or
symptoms that caused concern. Her main
concern was that she could not train for
the marathon. The local tenderness along
the medial aspect of the knee joint was
potentially indicative of a local problem
but may also have been referred pain, or
pain associated with a remote impair-
ment. Dural tests, including slump and
straight leg raise (SLR), did not provoke
her symptoms. The supine SLR, especial-
ly, has been shown to have good sensitiv-
ity for reproducing radicular pain, with
supportive MRI findings, when that pain
is associated with discogenic pathology.
Rabin et al37
reported kappa coefficient
values of 0.67 (95% confidence interval
[CI]: 0.53-0.79) on 58 patients with
signs of nerve root conduction problems
and supportive MRI. The combination
of the negative responses to dural ten-
sion testing, in addition to the patient’s
excellent active spinal ROM, minimized
the author’s consideration of a possible
discogenic source for the patient’s pain.
Slipman et al40
and others31
demon-
strated that pain referred from the SIJ
can be felt into the lower extremity. The
author considered this, as well as hip
and/or other nondiscogenic lumbar spine
pathologies, as possible sources for the
patient’s knee pain, if it was indeed re-
ferred. The lower extremity flexibility im-
pairments were also considered possible
contributors to the clinical presentation.
Pain originating from the hip can re-
fer to the knee yet knee pain may be the
patient’s only complaint with some hip
injuries.24,42
This is more common in ado-
lescents. In adults, the presence of knee
pain without concurrent complaints from
the hip is not seen as often.20,25
In fact,
Khan and Woolson25
found the absence
of hip pain in only 3% (n = 323 patients;
358 hips) of patients with known hip dis-
ease. Nonetheless, an examination of the
hips was performed next. Patrick’s test,
hip scouring, and the sign of the buttock
were all asymptomatic. All MMT scores
were 5/5 and painless. Her hip joint ROM
findings 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 spinous
processes from L1 to L5 were pain free
and suggested normal mobility. Thus,
the examiner directed his attention to
the sacroiliac joints and pelvic girdle. Al-
though the author recognizes the very low
reliability and questionable validity of the
palpatory and motion tests of the pelvic
girdle,13,48
the lack of objective findings in
the hip, knee, or low back led the author
to investigate this region in an effort to be
complete in the examination.
The pelvic girdle examination began
with the standing forward-flexion test,
which was positive on the right (involved
side), meaning that the posterior supe-
rior iliac spine moved superiorly further
than the left side in forward bending of
the lumbopelvic region.17,18
Interexam-
iner and intraexaminer reliability of the
standing forward-flexion test has been
reported at kappa coefficient values of
0.052 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 standing
forward-flexion test. In spite of the stand-
ing forward-flexion test’s popularity, the
literature is generally not supportive of its
reliability.13,27
There was no apparent leg length dis-
crepancy from a supine visual inspection,
either with the legs extended or in hook
lying. Several palpatory and motion test
analyses appeared to indicate a posteri-
orly rotated innominate on the right side.
With the patient supine, her anterior su-
perior iliac spine (ASIS) was apparently
high on the right compared to the left.
The pubic tubercles also appeared to
have an altered cephalocaudal relation-
ship to one another, in that the right side
was considered to be more cephalad than
its counterpart. With the patient prone,
the examiner felt that the right poste-
rior superior iliac spine (PSIS) was low
compared to the left. Also in prone test-

ing, a positional analysis of the sacrum
revealed a torsion (rotation) as described
by Greenman,17
Mitchell,34
and Isaacs
and Bookhout.18
The sacrum’s rotation
was identified by the inferior lateral
angles (ILAs) at the level of the hiatus.
The right side’s ILA was more posterior
than its counterpart on the left, perhaps
reflecting a rotation of the sacrum around
a vertical axis. Moreover, the right sacro-
iliac joint was believed to be hypomobile,
based on the results of the squish test, as
described by Magee.29
No reports on reli-
ability or validity of this test have been
published. This finding was congruent
with the standing forward-bend test re-
sults noted earlier. TABLE 1 summarizes
the patient’s impairments, as well as the
positive findings from the palpation and
mobility components of the exam.
Diagnosis
The examiner considered the possibility
that the patient developed a sacroiliac
joint dysfunction while performing the
lunge exercise the day before her pain be-
gan. A possible explanation as to why she
developed the purported sacroiliac joint
dysfunction 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 positional
relationships noted at the pubis and in-
nominate. That is, a counterrotation of
the innominates may have ensued with
the right one rotated backward and the
left one rotated forward. Correspond-
ingly, the right pubic tubercle’s more ce-
phalad position would be accounted for
by the apparent innominate rotation. Al-
ternatively, it is possible that the patient’s
posterior innominate and cephalic pubic
tubercle may have developed as a result of
her hamstring tightness, combined with
factors related to the repetitive loading
through the ground reaction forces of
running. In either case, the author be-
lieved that this impairment in flexibility
would require attention for the long-term
management of this patient. Retrospec-
tively, the author considered the possibil-
ity that because the pain required loading
over a period of time, during running, to
become manifest, isolated special tests
applied briefly in the clinic may have
been insufficient to elicit her pain.
Establishing a diagnosis based on the
osteopathic model has to be viewed with
caution because there is little evidence to
support its validity. This is especially true
for sacroiliac joint dysfunction, where
many diagnostic conclusions are based
on palpatory findings.15,26
The interrater
reliability of these findings has been
shown on several occasions to be poor
at best.35,48
Consequently, the results of
several tests were combined to establish
a working diagnosis. The sacroiliac joint
mobility 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 diagnosis
of sacroiliac joint dysfunction. The author
believed that the knee pain was referred
from, or at least related to, the sacroiliac
TABLE 1
Summary 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) knee
forward-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

[ CASE REPORT ]
joint dysfunction or its associated impair-
ments. There is essentially no literature
to support the validity of the tests that
led to this clinical impression. However,
because the proposed mechanism (lunge
exercise) for the SIJ impairment was con-
sistent with the palpatory and mobility
findings, the author proceeded with this
working diagnosis. If the osteopathic bio-
mechanical model were applied to label
this dysfunction, the palpatory findings
were consistent with a right-sided pu-
bic elevation and backward rotation of
the ilium, along with a rotated sacrum.
Other differential diagnostic possibilities
and the rationale for giving them reduced
consideration are shown in TABLE 2.
Intervention
The author decided to mobilize the pubic
symphysis, first using a method described
by Greenman.17
The rationale for this de-
cision was based on Greenman’s17
and
Isaac’s18
contention that pubic symphysis
dysfunction should be addressed prior to
most dysfunctions in the sacroiliac joint.
Undoubtedly, given the ring structure of
the pelvis, treatment directed at either
articulation will influence the other.
For this initial intervention, the pa-
tient was positioned in a supine, hook-
lying position, as shown in FIGURE 1A. The
author used the hip adductors to articu-
late the pubic symphysis. Some authors
contend that this can reposition the joint
surfaces into a better cephalocaudal re-
lationship.17,18
Two 6-second isometric
contractions of hip abduction and exter-
nal rotation were utilized to reciprocally
inhibit the adductor muscle group. These
initial contractions were carried out at
the lower extremity position shown in
FIGURE 1A. Additional contractions were
resisted at 2 larger hip abduction/exter-
nal rotation angles. The third and fourth
contractions were carried out in the same
fashion with the knees separated from
one another at approximately 50%, then
75%, 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 right
elbow on the inside of the patient’s knee
closest to him, while the right hand was
placed inside the patient’s left knee (FIG-
URE 1D). The patient then squeezed her
knees together isometrically at 50% to
75% of her hip adductors’ available con-
tractile force. An audible click was heard
at the pubic symphysis, perhaps indicat-
ing a successful gapping of the articula-
tion. Subsequent palpation of the pubic
landmarks demonstrated an apparently
level relationship of the right and left pu-
bic tubercles.
The patient was then retested in prone
for sacral and innominate positions,
which demonstrated persistent asym-
metry of the sacral (ILA) and ilial land-
marks (PSIS). Greenman17
and Flynn et
al14
described a manipulative procedure
used for either a lumbar or sacral mobil-
ity restriction. Flynn et al14
described the
technique for management of nonradicu-
lar low back pain and validated its use for
cases that fit a clinical prediction rule.
The next intervention was applied to
the patient’s right side innominate, with
the patient lying supine. The side to be
manipulated was selected according to
the protocol used by Flynn et al14
—that is,
the side (right) with the symptoms. The
author stood on the patient’s left side.
The patient placed her hands behind her
neck with the fingers laced together. Her
torso and lower extremities were pas-
sively placed in side flexion, away from
the author, putting her in right side bend-
ing. The author then laced his right arm
through the patient’s arms, as shown in
FIGURE 2. The patient was rotated to the
left and flexed down through and includ-
ing the lumbosacral junction. A quick
thrust through the ASIS was applied in a
posterior and inferior direction.
The patient was then placed prone,
and her iliac and sacral positional anal-
yses were considered normal through
landmark palpations of the PSISs, sacral
bases, and sacral ILAs. No further treat-
ment was administered at this initial con-
sult. The patient’s subjective response to
the intervention was considered normal
although the influence on her painful
knee was unknown at this juncture.
FIGURE 1. (A) Starting position for the intervention
directed to the pubic symphysis. Isometric resistance
is provided by the therapist to the patient’s hip
abductors/external rotators (AB/ER). (B) Position for
the third AB/ER isometric contraction. (C) Position
for the final AB/ER isometric contraction. (D)
Therapist positioning and hand placement for the
isometric contraction of the hip adductors/internal
rotators (AD/IR).

The patient was instructed to ice the
lumbosacral region as needed during the
remainder of the day and evening. She
was also given instruction to attempt
running or walking at her discretion, if
there was no adverse response to the ma-
nipulative procedures.
OUTCOMES
T
he patient was seen for follow-
up 1 week later. She had no pain on
stairs and had returned to running
with only minimal sacroiliac joint sore-
ness (VAS score, 1/10) reported on her
longer runs (15-20 km). These symptoms
resolved without further intervention in
subsequent weeks, and the patient was
able to return to her running routine
without further interruptions. The knee
pain was fully resolved (VAS score, 0/10)
after the single treatment session. Her
Lysholm score at 1 week postinterven-
tion was 100. She was encouraged to
continue her flexibility regimen for the
lower extremities, with precaution not to
do the lunge stretch. The patient’s goal of
returning to her training for the Boston
Marathon was achieved. She ultimately
completed the marathon successfully ap-
proximately 4 months later.
DISCUSSION
T
he patient’s history, specifi-
cally the proposed mechanism of
injury, as well as the palpation and
mobility findings at the sacroiliac joint
and pubis, were significant factors in
establishing the working diagnosis in
this case. The author acknowledges that
the evidence to support these findings is
marginal. Laslett et al26
and others6
stress
the importance of establishing working
diagnoses in potential sacroiliac joint
dysfunctions from the results of a battery
of tests and/or historical elements. The
current author based his impressions on
an analysis of the palpatory findings, the
lunge incident in the patient’s history,
and the mobility tests of the sacroiliac
joint. While this does not establish the
pathology in this case as a sacroiliac joint
dysfunction, the summated elements of
the examination pointed most clearly in
that 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 link
between sacroiliac joint pathology and
inhibition of the quadriceps muscles in
patients with anterior knee pain. Cook-
son8
presented a case involving another
marathon runner with knee pain, where
sacroiliac joint dysfunction was appar-
ently a part of the clinical picture. Finally,
Matthews31
provided indirect evidence
for a link between the sacroiliac joint and
knee pain in an elderly population with
degenerative arthritis (DJD) of the knees.
He assessed 16 patients with radiographic
evidence of DJD of the knee and notable
ROM loss. Using prolotherapy to the
ipsilateral sacroiliac ligaments, he “suc-
cessfully treated” 14 of 16 patients. At 4
months, the patients that were character-
ized as successful outcomes in the Mat-
thews study31
were subjectively “much
better” to completely pain free.31
All of the
patients had failed previous interventions
of physical therapy, surgery, medications,
and/or local steroid injections.
It is also conceivable that the patient’s
pain was influenced by peripheral and/
or central neurological mechanisms. A
mounting volume of evidence would
support that possibility.23,36,43,50
Both neu-
romechanical and neurophysiologic influ-
ences have been associated with manual
therapy interventions. Among these are
extremity hypoalgesia following spinal
mobilization or manipulation,16
potential
descending neuromodulation of nocicep-
tor input,43
sympathoexcitatory effects,36
or afferent input modulation through
spinal mechanoreceptors in close prox-
imity to the applied manual therapy
procedures.7
Zusman50
elegantly sum-
marized, for example, the influence of
descending, inhibitory pathways from the
brainstem and higher cortical centers on
spinal nociceptive pathways in the dorsal
horn. The author outlines how mechani-
cal stimuli, acquired in the current case
through the manipulative procedures, are
among a host of physical and psychologi-
cal factors that effectively desensitize the
nervous system to a constant or incon-
stant bombardment of nociceptive input
conducted over nonmyelinated C-fibers
or thinly myelinated A- afferents.50
Bialosky et al2
proposed that certain
nonspecific influences might alter pain
levels as a result of manual therapy in-
terventions. These influences include
responses related to the placebo effect or
patient expectations. Powers addressed
the importance of taking the placebo ef-
fect into consideration in his invited com-
mentary on a published study by Iverson
et al,19
which was relatively similar to the
current case report in terms of the pa-
tients’ pain presentation (knee pain) and
the subsequent lumbopelvic intervention.
Considering the current case in light of
the results of the Iverson et al19
study,
it is conceivable that a subgroup of pa-
tients with knee pain may exist that will
respond to lumbopelvic intervention. Ka-
laoukalani et al23
demonstrated the influ-
ence of patient expectations on treatment
outcomes in patients with low back pain.
In their study, patients who had higher
outcome expectations for their ran-
domized intervention (acupuncture or
massage) reported better functional out-
comes (86%) than those who had lower
expectations (68%). This may have been
a factor in the present case, as a physical
therapy student might have preconceived
notions about the effectiveness of spinal
manual therapy.
Any conclusions drawn from this
FIGURE 2. Positioning for the manipulative thrust to
the right innominate through the anterior superior
iliac spine.

[ CASE REPORT ]
case report have to be evaluated within
the context of the poor reliability inher-
ent in the examination procedures, most
notably as they pertain to the sacroiliac
joint and the pelvis.15,26,27,35,48
However, if
the patient’s atypical knee pain presenta-
tion was related to the sacroiliac joint, it
would be unique in the literature for this
age group. The theoretical constructs of
regional interdependence do not say that
pain is actually referred or radiating from
a proximal source, only that it is some-
how related to the remotely located dys-
function or impairment.46
The Lysholm instrument used in this
study 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 best
outcome scale to use, retrospectively.
However, given the outstanding results
of the case, it is unlikely that the use of
another instrument would have added
much to an assessment of this patient’s
outcome.
Finally, it is interesting to consider
why the patient was able to use the
cross-country and elliptical exercise ap-
paratuses without provoking her symp-
toms prior to the initial physical therapy
visit. If the cause of her symptoms was
related to repetitive trauma, then the
low-impact nature of these machines
may have eliminated the painful stimuli
of running’s ground reaction forces. If
the pain was produced by an alteration
in the positional relationships of the pel-
vic ring structures, then either the low-
impact factor or avoidance of potentially
provocative end-range positions might
account for her ability to painlessly use
these devices.
CONCLUSION
T
his case report describes the
elimination of knee pain in a run-
ner following manual therapy in-
terventions for the sacroiliac region and
symphysis 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 to
lumbopelvic interventions. While a case
report cannot define definitive relation-
ships of cause and effect, this patient’s
case provides anecdotal evidence of a
relationship between sacroiliac joint
dysfunction and knee pain. The case also
highlights the importance of considering
regional interdependence in the exami-
nation of patients.
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