Clinical Examination and Therapeutic Exercise Resources for Treating Common Knee Pathologies

By: Keerat Chawla, SPT

 

Background

As I progressed through the DPT program and completed clinical rotations, one area that I felt underprepared in was exercise interventions for various pathologies. Upon returning from rotations I came to know that other students in my cohort and students from prior years shared similar feelings. From faculty members and alumni, we have often heard that exercise interventions are something that we will learn on our clinical rotations. However, many of us have experienced that we are still expected to have some ideas regarding therapeutic interventions or that we should be able to create and teach exercise programs. This is an area that I had identified as a personal weakness time and time again on rotations because I did not enter PT school with a fitness background. Therefore, I chose to create evidence-based therapeutic exercise resources for physical therapy students and entry-level clinicians that can be referenced for treating the following knee pathologies: knee osteoarthritis, iliotibial band syndrome, and patellar tendinopathy. We have been educated on the anatomy and etiology of the pathologies in our coursework, but it is also important that we know how to treat these conditions.

I hope that my exercise charts help broaden our “toolbox” of interventions and can serve as a resource for individuals who may not know where to begin when treating patients with these pathologies. The exercises provided are evidence-based, and individuals are encouraged to use clinical reasoning when choosing exercises, as all of these exercises provided may not be appropriate for an individual with a specific diagnosis. I believe that by creating these resources, students will gain more confidence in their abilities while on rotations and as new clinicians. 

 

Statement of Need

We will undoubtedly see common knee pathologies including knee osteoarthritis, patellar tendinopathy, and iliotibial band syndrome in outpatient orthopedic clinics. In our program’s coursework we learn about the etiology of these conditions, but there is a lack of focus on treatment and exercise intervention. On clinical rotations, we are expected to have a knowledge base of therapeutic interventions when treating patients with these common conditions. Additionally, every PT student will complete a clinical rotation in an outpatient orthopedic setting. However, many students do not have a fitness background or may not have worked as a PT technician prior to entering school and may not have a basic understanding of exercises to perform to strengthen specific muscles or treat specific pathologies or injuries. Therefore it is important that students have supplementary resources available regarding treatment interventions for common pathologies to reference and learn from. Making these resources available to UNC students will help improve preparedness for rotations and continue to expand their “toolbox” of interventions.

 

Purpose

The purpose of this project was to create evidence-based resources to help aid clinical examination and therapeutic exercise prescription for patients with common knee pathologies: knee osteoarthritis, patellar tendinopathy, and iliotibial band syndrome. The resources are intended for use by PT students and entry-level clinicians to improve clinical preparedness and increase confidence in treatment skills.

 

Health Literacy

DPT students and entry-level clinicians are the target audience for this project. Therefore, the therapeutic exercise resources and reference handouts were created to cater towards this specific audience. There was a logical flow of content in the resources, and physical therapy specific language was utilized to make the resources easy to understand.

 

Products

Evidence Table: 

• • Exercise Prescription for Knee Pathologies Evidence Table

Therapeutic Exercise Charts:

• • Knee Osteoarthritis Exercises
  • Patellar Tendinopathy Exercises
  • Iliotibial Band Syndrome Exercises

Reference Handouts

• • Knee Osteoarthritis Handout
  • Patellar Tendinopathy Handout
  • Iliotibial Band Syndrome Handout

The therapeutic exercise charts provide evidence-based exercise interventions along with progression and regression options to help students and entry-level clinicians with treatment of the listed knee pathologies. The charts are not intended to be a protocol for treatment, and they may guide students or clinicians in their clinical reasoning based on patient presentation.

The reference handouts are intended to serve as a brief “cheat sheet” of each pathology to assist with clinical diagnosis. Hopefully the handouts will help students and clinicians be able to better explain the conditions and the associated deficits of impairments to their patients. 

 

Evaluation

Tool: https://forms.gle/zoMeV7aCSwGToLMz9 

The form above was completed by 11 3rd-year UNC physical therapy students who were asked to evaluate the quality and usefulness of the following resources: exercise charts and reference handouts for knee osteoarthritis, iliotibial band syndrome, and patellar tendinopathy.

100% of the evaluators found the charts to be clear, organized, and easy to understand. Additionally, they all strongly agreed that it would be a beneficial resource to have while on clinical rotations or as an entry-level clinician. A number of individuals mentioned that they liked the inclusion of regressions and progressions of exercises. Others stated that the exercise charts were clear, easy to follow, and a great resource. A few evaluators suggested that the formatting could be improved, as the exercises were displayed in a continuous running chart. The documents posted reflect the changes I made regarding this feedback, and it should be easier to understand which progressions and regressions go with which exercise. 

When assessing the reference handouts, all 11 students strongly agreed that the resources were clear, organized, easy to understand, they offered a quick review of knee pathologies, and that they would help facilitate clinical reasoning. Many of these individuals made positive statements regarding what they liked, rather than providing suggestions for improving this resource. One of the students said: “I really enjoyed how they are filled with the most pertinent information in a compacted manner. I think this will make it a true “quick cheat sheet” for clinical scenarios!” This was a wonderful response to receive, because this was my goal for the reference handouts. All of the evaluators provided excellent feedback regarding my products.

 

Self Reflection

Having an interest in outpatient orthopedics has made me want to improve my skills and knowledge in this setting. During my clinicals throughout the program, I identified a personal weakness in coming up with exercise interventions for patients. Therefore, I chose this project with the goal of furthering my own knowledge of therapeutic exercise interventions and with the hope of creating products which can aid my classmates in the same way. Although there are many common knee-related pathologies, I chose 3 to focus on so that I could perform literature searches and create quality resources. The 3 diagnoses that I chose involve different structures and I tried to find different evidence-based exercises interventions for them to enhance my resources.

At the start of this project, I wanted to focus on literature regarding EMG studies, but I quickly realized that a lot of the studies were finding the same results or looked at similar exercises. Therefore, I decided to broaden my search and then was able to find a variety of exercises. 

Throughout the past year in Evidence Based Practice courses and while working on my capstone project, I feel that my skills of reviewing and understanding literature have improved significantly. I have gained a better understanding of knee osteoarthritis, iliotibial band syndrome, and patellar tendinopathy and I am pleased with the products I created. I also feel much more confident in my clinical reasoning skills and my ability to come up with treatment ideas for knee pathologies. I hope that these products can help other students and entry-level clinicians in a similar manner.

 

Acknowledgments:

To Dr. Bria Dunn, PT, DPT: Thank you for being my primary capstone advisor. I appreciate the expert knowledge and guidance that you shared with me throughout this process. Thank you for your support and patience over the past several months!

To Dr. Sarah McAuliffe, PT, DPT: Thank you for your timely feedback during this process. Your recommendations directed me to be more concise in my products. I am grateful for the time you spent reviewing my drafts! 

To Dr. Kiersten Flynn, PT, DPT: Thank you for providing thoughtful and detailed feedback on my work. I truly appreciate the time you took out of your busy schedule to review drafts of my products. You are an incredible resource and I look forward to staying in touch in the future!

To my fellow classmates in the Class of 2023, thank you so much for your endless motivation and support, not only with my capstone project, but also over the last 3 years. We have been through so much together and you all are some of the most intelligent and outstanding people I know. I am so excited to see all the great things you all will accomplish in your careers!

 

References

Evidence Table & Therapeutic Exercise Charts:

1. Al Amer HS, Sabbahi MA, Alrowayeh HN, Bryan WJ, Olson SL. Electromyographic activity of quadriceps muscle during sit-to-stand in patients with unilateral knee osteoarthritis. BMC Res Notes. 2018;11(1):356. Published 2018 Jun 5. doi:10.1186/s13104-018-3464-9
2. Yuenyongviwat V, Duangmanee S, Iamthanaporn K, Tuntarattanapong P, Hongnaparak T. Effect of hip abductor strengthening exercises in knee osteoarthritis: a randomized controlled trial. BMC Musculoskelet Disord. 2020;21(1):284. Published 2020 May 7. doi:10.1186/s12891-020-03316-z
3. Singh S, Pattnaik M, Mohanty P, Ganesh GS. Effectiveness of hip abductor strengthening on health status, strength, endurance and six minute walk test in participants with medial compartment symptomatic knee osteoarthritis. J Back Musculoskelet Rehabil. 2016;29(1):65-75. doi:10.3233/BMR-150599
4. ​​Brosseau L, Taki J, Desjardins B, et al. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs. Clin Rehabil. 2017;31(5):596-611. doi:10.1177/0269215517691084
5. Brosseau L, Taki J, Desjardins B, et al. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part one: introduction, and mind-body exercise programs. Clin Rehabil. 2017;31(5):582-595. doi:10.1177/0269215517691083
6. Reiman MP, Bolgla LA, Loudon JK. A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises. Physiother Theory Pract. 2012;28(4):257-268. doi:10.3109/09593985.2011.604981
7. Bishop BN, Greenstein J, Etnoyer-Slaski JL, Sterling H, Topp R. Electromyographic Analysis of Gluteus Maximus, Gluteus Medius, and Tensor Fascia Latae During Therapeutic Exercises With and Without Elastic Resistance. Int J Sports Phys Ther. 2018;13(4):668-675.
8. THERABAND Resistance Band Beginner Kit | Performance Health. Accessed April 7, 2023. https://www.performancehealth.com/theraband-resistance-band-beginner-kit
9. Jahanshahi M, Nasermelli MH, Baker RL, Rabiei P, Moen M, Fredericson M. Comparing Functional Motor Control Exercises With Therapeutic Exercise in Wrestlers With Iliotibial Band Syndrome. J Sport Rehabil. 2022;31(8):1006-1015. Published 2022 Jun 25. doi:10.1123/jsr.2020-0541
10. Morgan S, Janse van Vuuren EC, Coetzee FF. Causative factors and rehabilitation of patellar tendinopathy: A systematic review. S Afr J Physiother. 2016;72(1):338. Published 2016 Nov 29. doi:10.4102/sajp.v72i1.338
11. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277-1283. doi:10.1136/bjsports-2014-094386
12. Breda SJ, Oei EHG, Zwerver J, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. Br J Sports Med. 2021;55(9):501-509. doi:10.1136/bjsports-2020-103403

Images:

• HEP2go – Build a HEP < Home Exercise Program> For Free. Accessed April 8, 2023. https://www.hep2go.com/exercise_editor.php?exId=49444&userRef=gciaake
• Reverse Lunges To Knee Hops Home Exercise Guidance. Lunges To Knee Drive Young Woman Does Fitness. Stock Vector – Illustration of girl, physical: 233236027. Accessed April 9, 2023. https://www.dreamstime.com/reverse-lunges-to-knee-hops-home-exercise-guidance-lunges-to-knee-drive-young-woman-does-fitness-reverse-lunges-to-knee-hops-home-image233236027
• UW Medicine Sports Medicine Clinic. Isometric Exercises for Patellar Tendinopathy. Accessed April 6, 2023. https://healthonline.washington.edu/sites/default/files/record_pdfs/Isometric-Exercises-Patellar-Tendinopathy.pdf

Knee Osteoarthritis Reference Handout

1. Bullock J, Rizvi SAA, Saleh AM, et al. Rheumatoid Arthritis: A Brief Overview of the Treatment. Med Princ Pract. 2018;27(6):501-507. doi:10.1159/000493390

2. Ekim AA, Hamarat H, Musmul A. Relationship Between Q-Angle and Articular Cartilage in Female Patients With Symptomatic Knee Osteoarthritis: Ultrasonographic and Radiologic Evaluation. Arch Rheumatol. 2017;32(4):347-352. Published 2017 Jun 5. doi:10.5606/ArchRheumatol.2017.6145

3. Guide | Physical Therapy Guide to Knee Osteoarthritis | Choose PT. Accessed February 24, 2023. https://www.choosept.com/guide/physical-therapy-guide-osteoarthritis-of-knee

4. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee [published correction appears in Arthritis Care Res (Hoboken). 2021 May;73(5):764]. Arthritis Care Res (Hoboken). 2020;72(2):149-162. doi:10.1002/acr.24131

5. Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2264-2274. doi:10.1007/s00167-013-2759-6

6. Primorac D, Molnar V, Rod E, et al. Knee Osteoarthritis: A Review of Pathogenesis and State-Of-The-Art Non-Operative Therapeutic Considerations. Genes (Basel). 2020;11(8):854. Published 2020 Jul 26. doi:10.3390/genes11080854

7. Samuel AJ, Kanimozhi D. Outcome measures used in patient with knee osteoarthritis: With special importance on functional outcome measures. Int J Health Sci (Qassim). 2019;13(1):52-60.

8. van Doormaal MCM, Meerhoff GA, Vliet Vlieland TPM, Peter WF. A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis. Musculoskeletal Care. 2020;18(4):575-595. doi:10.1002/msc.1492

Patellar Tendinopathy Reference Handout

1. Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. J Orthop Sports Phys Ther. 2015;45(11):887-898. doi:10.2519/jospt.2015.5987

2. Morgan S, Janse van Vuuren EC, Coetzee FF. Causative factors and rehabilitation of patellar tendinopathy: A systematic review. S Afr J Physiother. 2016;72(1):338. Published 2016 Nov 29. doi:10.4102/sajp.v72i1.338

3. Maffulli N, Oliva F, Loppini M, Aicale R, Spiezia F, King JB. The Royal London Hospital Test for the clinical diagnosis of patellar tendinopathy. Muscles Ligaments Tendons J. 2017;7(2):315-322. Published 2017 Sep 18. doi:10.11138/mltj/2017.7.2.315

4. Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2264-2274. doi:10.1007/s00167-013-2759-6

5. Santana JA, Mabrouk A, Sherman A l. Jumpers Knee. In: StatPearls. StatPearls Publishing; 2020.

Iliotibial Band Syndrome Reference Handout

1. Bishop BN, Greenstein J, Etnoyer-Slaski JL, Sterling H, Topp R. Electromyographic Analysis of Gluteus Maximus, Gluteus Medius, and Tensor Fascia Latae During Therapeutic Exercises With and Without Elastic Resistance. Int J Sports Phys Ther. 2018;13(4):668-675.

2. Guide | Physical Therapy Guide to Iliotibial Band Syndrome (ITBS or “IT Band Syndrome”)  | Choose PT. Accessed February 24, 2023. https://www.choosept.com/guide/physical-therapy-guide-iliotibial-band-syndrome-itbs

3. Hutchinson LA, Lichtwark GA, Willy RW, Kelly LA. The Iliotibial Band: A Complex Structure with Versatile Functions. Sports Med. 2022;52(5):995-1008. doi:10.1007/s40279-021-01634-3

4. Shamus J, Shamus E. THE MANAGEMENT OF ILIOTIBIAL BAND SYNDROME WITH A MULTIFACETED APPROACH: A DOUBLE CASE REPORT. Int J Sports Phys Ther. 2015;10(3):378-390.

5. Speers CJ, Bhogal GS. Greater trochanteric pain syndrome: a review of diagnosis and management in general practice. Br J Gen Pract. 2017;67(663):479-480. doi:10.3399/bjgp17X693041

6. Yaras RJ, O’Neill N, Yaish AM. Lateral collateral ligament knee injuries. In: StatPearls. StatPearls Publishing; 2022.

Top Image: Medial Knee Pain Exercises. Accessed April 26, 2023. https://www.verywellhealth.com/medial-knee-pain-exercises-5120563