Here we explain why with two examples of knee pains, with both diagnosed by a GP as the same condition, but requiring very different physiotherapy.

When we see patients at the clinic seeking a solution to their pains, they often expect a quick analysis, diagnosis and treatment to resolve the issue.

We are happy to say that, via a thorough assessment, questioning of the patient to determine the background behind the problem, and a complete analysis of the condition in the treatment room, we have a very high success rate.

However, this article will aim to highlight how no two people are the same, regardless of how similar their symptoms may appear at first, and thus an entirely individual approach to each and every part of a patient’s source of pain is necessary to assess exactly what the problem is.

Caroline Hennigan, one of our five strong team of physiotherapists at the clinic, recently saw two ladies independently of each other, both suffering with pains in their right knee.

However, after delving deeper into their symptoms, assessing the site of the pain and the surrounding area, and asking a number of specific questions directly related to their issue, it was clear that the cause of their pain was very different, even if the official diagnosis by their GP was the same by name.

Let’s meet Caroline’s first lady.

“Patient A, a lady aged 55, came to the clinic with a right knee problem that had recently developed - she described the pain as a dull, low grade ache that she felt after periods of prolonged sitting. This quickly eased if she got up and moved around. She also found that she couldn’t kneel down to garden anymore, and that when she got up in the morning she couldn’t ‘get going’ until after she had had a shower and got dressed.

“On examination the knee looked normal and the patient was moving around the clinic well. When the knee movements were tested, the knee wouldn’t bend or straighten fully, and these movements provoked a feeling of discomfort. When I felt at how the surfaces of the knee joint were sliding on each other there was some resistance but this didn’t provoke any pain. The muscles around the knee were strong and functioning well.

"Treatment involved vigorous manual therapy, where I worked on the knee in various positions to fully restore the normal smooth feeling movement in the knee, which the patient was then able to maintain with a couple of simple stretches at home.”

Then let’s move onto Caroline’s second lady, who also came to the clinic with knee pain.

“Patient B, also a 55-year-old lady, came to the clinic with a recently developed right knee problem. She described the pain as throbbing pain deep within the knee, it was constant, and she struggled to gain any relief from it, although she felt sometimes Ibuprofen ‘took the edge off it’.

“Walking for just a few minutes aggravated the pain, as did bending and straightening the knee. She had also lost confidence in the knee and felt that it might give way. Because of the throbbing pain she was finding it difficult to get to sleep at night and was woken intermittently through the night.

“On examination the patient B was walking slowly and with a limp. The knee itself looked red and swollen, and she couldn’t bend or straighten the knee fully because it hurt too much. When I felt at how the surfaces of the knee joint were sliding on each other it was painful, and the muscles around the knee weren’t functioning well and had lost some of their bulk.

“Treatment for this lady involved gentle manual therapy, where I worked on the knee in a comfortable position to relieve the knee pain and sooth the joint. A self management programme was set up with the patient, involving an effective medication plan, ice and gentle home mobilisations to control the pain that was limiting movement and inhibiting muscle activity. As the pain settled, movement and muscle strength were gradually restored.”

Now to the really interesting part - both ladies’ had x-rays that revealed arthritis, with the same arthritic changes.

Caroline explained how essential the differences are between the two ladies’ conditions.

“If we are experiencing pain and dysfunction then of course we need to know the cause, and most people seek a name, a label and a diagnosis, with the implication being that if we can give something a name or definitive diagnosis, then the solution (which is what we are really seeking) will be obvious and straightforward.

“Unfortunately, this area of medicine (the field of neurosmusculoskeletal dysfunction) doesn’t work like that, and those that try to make it fit into a ‘test-diagnose-treat’ model don’t enjoy a high level of successful outcomes.

“These two case studies are a perfect example of this. Both patients have an arthritic knee – but what different presentations! If in treating these patients we simply embarked on employing the recipe for treating ‘arthritic knees’, then neither would be likely to do very well, and this is why labelling and diagnosing isn’t typically very useful.

“Both patients could have been spared the x-ray exposure and still experienced a good recovery because:

In the case of patient A, we were treating a ‘stiff knee that lacked a bit of movement’, and in the case of patient B, we were treating a ‘painful, inflamed knee’.”