Different standardized tests are helpful when assessing the functional ability and fall risk in a patient.
Hip pain and knee pain are very common reasons for patients to seek physical therapy. Many different conditions can cause pain in the hip and/or knee. Often, patients with more chronic conditions have pain in both areas, and bilateral presentations are common. What considerations should physical therapists take when working with patients needing hip and knee rehabilitation?
Recommended course: An Overview of Hip and Knee Rehabilitation for the Physical Therapist, Updated
Evaluating hip and knee pain
If a non-surgical patient presents with knee or hip pain, our evaluation needs to help us understand the primary cause of the joint pain. Is it a joint dysfunction? Is it tendinopathy? Is it referred pain from the Lumbar spine?
If the patient is post-surgical, the problem is easy to spot. Consider any specific treatment protocols the surgeon may have provided. That protocol will initially dictate knee rehabilitation treatment, but it often leaves room for selecting the right exercises and the right intensity of those exercises.
Regardless of surgical status, most physical therapists use standardized outcomes to establish a baseline and to track progress during the treatments. The Lower Extremity Functional Scale (LEFS) is a good place to start for hip and/or knee evaluations. The LEFS assesses the patient’s difficulties and helps set realistic goals. For example, if a patient who wants to get back to playing soccer has severe difficulty making sharp turns and running, it's helpful to know how the patient progresses in those two areas.
Assessing functional ability
Different standardized tests are helpful when assessing the functional ability and fall risk in a patient with post-operative lower extremity pain. Depending on how well they ambulate and their post-operative status, therapists should consider the following:
- 6-minute walk test
- 4-square step test
- Timed single-leg stance test
Recommended course: Therapist's Guide to Joint Rehab for the Knee, Hip, and Shoulder
Post-surgical versus non-surgical knee evaluations
The rest of the evaluation is different for patients who have recently had surgery versus those who have not. If the patient had surgery, evaluation includes baseline measures including ROM, strength, and swelling. For non-surgical patients, the evaluation is more involved, as the therapist is looking for the root cause of their pain.
True joint dysfunction has a consistent presentation. Both Active Range of Motion (AROM) and Passive Range of Motion (PROM) will be similarly limited. Loaded and unloaded movement are consistently the same. Patients that have a soft-tissue injury might have limited AROM, but no restrictions with PROM.
Special tests are helpful, but they are more useful in providing a baseline than determining root causes. For the hip, consider using FABER, FADIR, and Thomas tests. For the knee, consider Anterior and Posterior draw, and medial and lateral gapping for the collateral ligaments. If the therapist suspects meniscus involvement, also use the Thessaly test.
Strength testing is very important during an evaluation. Not only does it help with a diagnosis, but also helps map out a plan for exercise therapy. Often muscles that present as “tight” are weak. Rather than stretching, they need strengthening.
Knee rehabilitation: regaining stability and mobility
In cases of hip and knee rehabilitation, therapists might find that hips need additional mobility, while knee patients need additional stability. Patients involved in activities like weightlifting and CrossFit, for example, will need evaluation of not only the knee and hip, but also the ankle and lumbar spine. In such instances, the spine will often need stability, while the ankle will need mobility.
When evaluating non-surgical hip and knee patients, look at their movement and their strength. Ask: What is restricted? What needs more control? Sometimes therapists need to stabilize first to gain mobility elsewhere.
Many patients present with tightness in their hip flexors. They’ve tried stretching. They use a foam roller, massage gun, etc., but the tightness remains. Patients like that may benefit from more core stability exercises like Transverse Abdominis activation drills, unilateral standing exercises, KB exercises, and even squats and deadlifts.
Exercise strategies for hip and knee rehabilitation
Key core exercises for patients with hip and knee pain include farmer carries and suitcase carries. Many patients with hip problems substitute and compensate through their lumbar spine. They can’t move their hip joint through full ROM without including some spine movements. Hip Controlled Articular Rotations, or CARs, are helpful in these cases. The patient focuses on controlled hip movement while engaging their core to prevent lumbar substitution.
In some cases, it’s important to mobilize first before focusing on stability. Lack of ankle dorsiflexion can cause lots of issues up the dynamic chain. Often the knee compensates with a valgus movement. If a patient presents with medially instability, or even lateral patella tracking, look at the ankle first. Look at their air squat and see how well they move and control their movement. Then repeat the squat while the patient’s heels are elevated and see if their squat improves, or their pain decreases. If so, check Ankle ROM and do some ankle mobilization drills and re-test their squat.
Knee treatment and evaluation
Physical therapists often find themselves providing treatments when evaluating patients with hip or knee pain, following the “test-treat-retest” method. For example, a therapist finds that the patient’s movements are restricted during the assessment. They might try manual therapy or a mobility drill to see how that affects the patient’s mobility. If those small, quick changes provide pain relief and increased ROM, it not only improves the prognosis but also encourages the patient to persevere.
Patients can gain a lot of mobility with loaded exercises by focusing on eccentrics. Most studies looking at improving mobility focus on the hamstrings, as those muscles are notoriously tight. Research shows that eccentric exercises can improve mobility, but often these exercises are neglected by therapists and patients.
Conclusion
Treating patients with knee and/or hip pain can be so rewarding. The key is not to focus on where the pain presents itself, but how their dynamic chain is functioning. The hip, or knee might be the “weakest link” and become symptomatic, but the root cause might be elsewhere and needs to be addressed to avoid re-injury.
This article was written by Pieter L. de Smidt, PT, DPT, Cert MDT, MTC.