Clinical Decision Making and Physical Therapy Management of Knee Pain Following Total Hip Arthoplasty: A Case Report

BACKGROUND AND PURPOSE: The diagnostic process for determining the source of lateral knee pain in active individuals is difficult. This process is made considerably more challenging in a patient with a complicated surgical history. The purpose of this case report is to illustrate the diagnostic process in the development of a plan of care for a patient whose lateral knee pain was suspected to be a result of ITBS and whose case was complicated by undergoing bilateral THA’s and a meniscectomy prior to referral to outpatient physical therapy. CASE DESCRIPTION: A 55 year old patient was referred by this orthopedic surgeon to an outpatient physical therapy clinic with complaints of left knee and left hip pain after MRI of the left knee revealed no significant pathology. The patient described increasingly bothersome hip pain that had never completely resolved after his THA, in addition to left lateral knee. Activity limitations included antalgic gait, difficulty with walking long distances and pain with stair climbing. The specific source of the knee pain was not apparent based on the physical therapy examination, so a treatment plan addressing the patient’s general physical impairments was adopted. OUTCOMES: Over the course of eleven treatment sessions the patient made gains in lower extremity strength and soft tissue mobility in the affected leg and met his functional goals. However, his pain did not resolve with treatment. Several clinical impressions regarding the cause of the patient’s pain, with an increasing focus on impairments at the hip, were adopte4d during the episode of care and modifications to the plan of care were made accordingly. Over time, after considering the lack of success in reducing pain, a final clinical impression was formed that the cause of the patient’s pain was consistent with greater trochanteric pain syndrome (GTPS). The patient was referred back to his orthopedic physician for a re-evaluation and was eventually treated with cortisone injection t the lateral hip, which completely resolved both his left knee and hip pain. DISCUSSION: This case study describes how physical therapists’ ability to use clinical decision making when considering alternative physical therapy clinical impressions can lead to a better outcome for patients who make therapeutic improvements but continue to experience pain