Long gone are the days of performing a joint assessment that covers only the joint that the patient or client is worried about or has pain in! Well… hopefully they are. Evidence has repeatedly demonstrated that one dysfunctional joint has implications for the function of many surrounding joints, particularly for the completion of many weight-bearing tasks. For any clinician, a complaint of joint pain most likely leads to further assessment of at least one other surrounding joint, as either a primary or secondary site of dysfunction.
In the previous Blog post entitled, “Knee Osteoarthritis and the other knee”, there was a clear message that focusing only on the symptomatic knee joint in our treatments is a problem and does not fully address the overall burden of osteoarthritis (OA) on our population. As Michelle stated in her article, 30% of persons with radiographic evidence of knee OA are asymptomatic. While this does not mean they have OA, because there are many other criteria for a knee OA diagnosis, it may indicate that a slip or a trip to a little too long in a canoe may tip the scales. Certainly we know that reviewing a knee x-ray does not indicate if Mr. Smith is able to go up and down stairs, kneel down to play with his grandkids, or continue to participate in his weekly bowling club. By the time a client presents to the clinic with complaints of knee pain (potentially years after the beginning stages of OA), they are either demonstrating a potential progression of structural changes to the joint or further involvement of the tissues which support the joint, which could include the hips, trunk, or structures on the contralateral leg.
As clinicians, we have to consider the radiographic changes which are present, apply those to our clinical subjective and objective assessment, and produce a functional plan in response to the patient’s complaints. I commonly find myself prescribing exercises to address flexibility or strength issues in the contralateral knee, as well as the hips. With increasing evidence of contralateral joint involvement, it should make us more aware in our methods of assessment, exercise prescription as well as gait aid prescription.
With the incidence of knee OA and the need for total joint replacement on the rise, it would be wise to include management of surrounding joints in our practices on a daily basis to better the function of the entire bilateral lower kinetic chain. Educating our patients/clients on OA, it’s potential progression, as well as self-management/prevention strategies to maintain and improve overall lower extremity function can increase the impact physiotherapists can have on disease and injury prevention. Are there specific muscular weaknesses or ROM deficits or movement patterns which present in a radiographically confirmed but asymptomatic knees? Do these alterations contribute to future issues with joint function and overall limitations to activity? With the current research being done, will we eventually come upon methods of pre-screening / further disease prevention? I guess we all will stay tuned!
Physiotherapist, Ms. Natalie MacDonnell, contributed this clinician’s commentary. Natalie is a graduate of St FX and Dalhousie’s School of Physiotherapy. She has accumulated eight years in orthopaedic private practice and currently works in the public sector with a focus on hip and knee OA rehabilitation, pre-surgical preparation for total hip and knee replacement as well as Cardiac and Pulmonary Rehab.