Conservative Treatment of Bilateral Knee Pain in a Female Older Adult: A

Case Report
Sarah Padgett
Clemson University Clemson, SC
Objective: To present the case of bilateral knee pain in a 70-year-old female.
Background: The knee joint bears most of the weight of the human body. Many factors can
lead to osteoarthritis of the knee joint, including body weight, previous injuries, gender, age, and
physical activity.
Diagnosis: Bilateral knee pain, osteoarthritis of the knee.
Treatment: The patient received four weeks of physical therapy. The patient performed
treatment exercises and activities that increased the strength and flexibility of the knees and hips.
The goals were improving function and reducing pain.
Conclusions: Four weeks of physical therapy was an appropriate treatment for this type
of injury, and the patient responded well.
Bilateral knee pain is a common
compliant among elderly adults. There are
many factors attributed to bilateral knee
pain. The single most common cause of
disability in older adults is osteoarthritis,
often occurring in the knees. Osteoarthritis
of the knee is displayed with knee pain and
several other symptoms. Osteoarthritis is an
active disease process that includes cartilage
destruction, bone thickening, and new bone
formation.2 This condition is most often
diagnosed on an x-ray.
The knee joint is a synovial joint that
connects the femur to the tibia. The knee is
designed to bend and straighten, but also
rotate slightly. The knee joint bears most of
the weight of the human body. Therefore, it
is subject to great wear and tear from the
stress of the body.3
Risk factors for osteoarthritis in the
knee include body mass index of overweight
or obese and previous knee injury. Women
are more likely to develop knee
osteoarthritis than men.
The risk of
osteoarthritis also increases with age. In
addition, those who exercise regularly and
intensely are at a greater risk for developing
osteoarthritis.1

Treatments for knee osteoarthritis

include pharmaceuticals, applying warmth
or cold, injections, electrostimulation, knee
braces,
surgery,
and
strengthening
4
exercises. This is a chronic condition, but
treatment has been proven effective in
easing the symptoms and reducing pain.
CASE HISTORY
A 70-year-old female presented with
bilateral knee pain. The patient reported a
long history, 8 years, of bilateral knee pain.
The injury was attributed to a fall 12 years
ago. The patient reported no pain at rest but
an increase of pain with activity. Due to
pain, the patient has had 5-6 cortisone shots
in the left knee in the past several years.
The patient is limited with stairs and often
complains of pain. She is also limited with
squatting, ascending hills, hiking, extending
the left knee from a 90-degree bend, and
getting up from a low chair or the ground.
Although the patient has some limitations,
she remains active. She has purchased a
gym membership and has begun working
with a trainer. She also walks 30 minutes
each day.

At the initial evaluation, the patient

presented with point tenderness, crepitus,
decreased Achilles flexibility, and decreased
bilateral lower extremity strength. The
patient also displayed an altered posture and
gait. Her balance was decreased. In
addition, the patient presented with a
decreased functional status. This included
standing, walking, transfers off a low
surface, stair negotiation, and extending the
knee. The patient was not limited with knee
range of motion. The greatest strength
deficits were displayed in the patients left
quadriceps.
Left and right hip flexor
strength, right quadriceps strength, and left
and right hamstring strength presented as
normal. The limitations and functional
status of the patient were consistent with
those of osteoarthritis.
TREATMENT
Physical therapy sessions were
scheduled twice a week for 4 weeks. The
plan of care for these therapy sessions
included therapeutic exercise, therapeutic
activities, manual therapy, hot/cold pack,
unattended
electrostimulation,
neuromuscular
re-education,
patient
education, balance, and gait training.
The patient began therapy with
exercises focused on strengthening the hip
musculature and quadriceps. The patient
performed bilateral leg raises with flexion,
abduction, and extension to strengthen the
hips. She reported some difficulty and
aching with this exercise, but there was no
knee pain reported.
The patient also
performed leg press and closed kinetic chain
terminal knee extension to increase
quadriceps strength. Other exercises began
focusing on balance and increasing
flexibility in the Achilles tendon and
gastrocnemius. After one week of therapy,
the patient was showing an increase in
muscle strength and a decrease in knee pain.

During week two of therapy, the

patient continued with initial therapeutic
exercises and began several new therapeutic
exercises. Stepping up on a 4 step was
introduced. The patient also began lunges
onto a 6 step to increase quadriceps
strength.
These exercises targeted the
patients difficulty with stairs. Improved
balance was noted, and the patient began
balancing on foam without much difficulty.
Additional flexibility exercises included a
seated bilateral piriformis stretch. There
was no complaint of knee pain from the
patient. However, the patient requested to
discontinue therapy for the day after
reporting fatigue from hip strengthening
exercises.
The patient displayed great progress
with three weeks of therapy. The patient
reported that she noticed improvement in the
things she was doing in the community. The
patient reported that she could perform 4
step-ups without pain, but normal steps still
caused pain in the left knee. The patient
continued with previous strengthening
exercises, increasing the resistance with
several. The patient progressed to 6 stepups and 100 pounds on the leg press. The
patient also began heel raises to improve
tendon flexibility and gastrocnemius
strength. A seated hamstring stretch was
added to the patients therapy.
Four weeks completed the patients
first prescription for therapy. The patient
still reported difficulty with the left knee
when climbing stairs.
Otherwise, she
reported no pain. The patients progress was
measured and documented for her doctor.
The patient showed decreased pain levels,
improved range of motion, and improved
functional strength. However, the therapist
requested four more weeks of therapy for
functional strength gains. The patient has
chosen to continue treatment to gain desired
levels of strength.

DISCUSSION
Knee osteoarthritis is the most
common disability among older adults.2 In
this case, the patient presented several risk
factors for osteoarthritis.1 Age may be the
greatest contributing risk factor to the
patients diagnosis. The patient is 70 years
old and has experienced great wear and tear
of the knees. The patient is also female,
which makes her of greater risk for
osteoarthritis of the knee compared to males.
In addition, the patient is overweight. Higher
body weight adds more stress to the loadbearing knee joints.3 The patient had an
earlier knee injury and has also recently
increased her level of physical activity. All
of these factors increased the likelihood that
the patient would experience osteoarthritis
of the knees.
The symptoms of
osteoarthritis may be reduced, but the
patient will continue to be at risk of these
issues as she ages.
Major areas of focus for the patients
plan of care included therapeutic exercises,
therapeutic activities, patient education,
home exercise program instruction, and
balance. Cortisone shots have failed to have
lasting effects for the patient. Physical
therapy has proven a very effective
intervention method for the patient.4 She has
gained flexibility, range of motion, and
strength with therapeutic activities and
exercises.
Her pain has substantially
decreased with activity. The patient showed
a deficit in quadriceps strength at the initial
evaluation. As treatment progressed, that
deficit was reduced. The patient also added
2-3 degrees of active range of motion in
each knee. She has responded well to
treatment and is eagerly continuing her
home exercise program.
The prognosis for the patient is good.
The patient has lost about 11 pounds and
seems to be changing her lifestyle. She is
becoming more conscious of her health and
is excited to be under the guidance of her

new trainer. As the patient continues, she

will reduce her physical limitations. The
patient is expected to gain confidence in her
community activities, including climbing
stairs and hills.
The patient returned to the doctor to
receive another prescription for therapy.
After four weeks of physical therapy, she
had increased her flexibility, range of
motion,
and
strength
substantially.
However, the patient was not completely
where she wanted to be. She is currently
continuing therapy to gain functional
strength.
REFERENCES
1. Blagojevic, M., Jinks, C., Jeffery, A.,
& Jordan, K. (2009, October 7). Risk
factors for onset of osteoarthritis of
the knee in older adults: A systematic
review and meta-analysis. Retrieved
November
30,
2015,
from
http://www.oarsijournal.com/article/
S1063-4584(09)00225-8/fulltext
2. Peat, G., McCarney, R., & Croft, P.
(2000, July 25). Knee pain and
osteoarthritis in older adults: A
review of community burden and
current use of primary health care.
Retrieved November 30, 2015, from
http://ard.bmj.com/content/60/2/91.f
ull
3. Schmidler, C. (2015, March 10).
Knee Joint Anatomy, Function and
Problems. Retrieved November 30,
2015,
from
http://www.healthpages.org/anatomy
-function/knee-joint-structurefunction-problems/
4. What treatments are there for
osteoarthritis of the knee? (n.d.).
Retrieved November 30, 2015, from
http://www.arthritisresearchuk.org/ar
thritisinformation/conditions/osteoarthritisof-the-knee/treatments.aspx