Case Study; The Stubborn Knees and the Stubborn Man

A Note on Confidentiality

This case study is shared with the full awareness of the patient, who, for privacy reasons, will remain anonymous. He understands that this is not a gossip column about his knees but a professional reflection on how physiotherapy can transform lives—even when the knees are as stubborn as the patient himself. His only request? "Tell them I’m still standing."

Case Study: The Stubborn Knees and the Stubborn Man

Patient Profile

• Name: Confidential (but if you see a sharply dressed man who refuses to sit down, you didn’t hear it from me.)
• Age: 67 years
• Primary Complaint: Severe knee pain and difficulty walking
• Diagnosis: Advanced bilateral knee osteoarthritis (OA) with genu valgum (knock-knees)
• Co-morbidities: Hypertension, Type 2 Diabetes Mellitus
• Patient Goal: "I will NOT use a wheelchair. Over my very mobile body."

Background Story

My patient was a retired school principal, and discipline was second nature to him. Unfortunately, his knees didn’t get the memo. They had turned inward like they were conspiring against him, making every step a struggle. Yet, the very mention of a wheelchair made him react as if I had suggested he move to Mars. "God forbid!" he exclaimed, waving his cane dramatically.

Initial Assessment (Month 1: The Battle Begins)

Subjective Assessment

The patient, a retired school principal in his late 60s, presented with chronic bilateral knee pain that had progressively worsened over the past five years. He described the pain as deep and aching, aggravated by prolonged standing or walking, with morning stiffness lasting up to 30 minutes. He reported difficulty climbing stairs, rising from chairs, and maintaining balance on uneven surfaces.

Despite medical recommendations to use a wheelchair for longer distances, he was adamantly opposed and insisted on maintaining his mobility. He had a history of hypertension and type 2 diabetes mellitus, both managed with medication. There was no history of trauma, but he reported a long-standing knock-kneed posture (genu valgum).

Objective Assessment

General Observation

• Posture: Increased bilateral knee valgus, mild forward trunk lean.

Gait Analysis

• Antalgic gait with a wide base of support.
• Reduced push-off strength and increased lateral trunk sway.
• Reduced stance phase on both lower limbs, compensating for pain.

Range of Motion (ROM)

• Knee flexion: Right - 90° (pain-limited) Left - 95° (pain-limited)
• Knee extension: Lacked full extension by 10° bilaterally (fixed flexion deformity).

Muscle Strength (Oxford Scale)

• Quadriceps: 3/5 bilaterally (weak, affecting stability and knee control).
• Hamstrings: 4/5 bilaterally (relatively stronger).
• Hip Abductors: 3/5 bilaterally (contributing to lateral instability in gait).

Joint Integrity and Stability

• Valgus Stress Test: Mild instability in the medial knee compartment, bilaterally.
• Varus Stress Test: Negative.
• Patellar Grind Test: Positive bilaterally (suggesting patellofemoral joint involvement).

Pain and Functional Limitations

• Pain Scale: 8/10 during movement. 6/10 at rest.
• Increased pain with prolonged standing, walking, or stair climbing.
• Functional Assessment: Timed Up and Go (TUG): 23 seconds (indicating high fall risk).

Treatment Plan: "Operation No Wheelchair"

The goal? Reduce pain, improve mobility, and keep him walking—on his own terms. Upon initial consultation, he insisted that correcting the genu valgum was his main goal with physiotherapy. The reality of that was explained.

Phase 1 (Months 1-3): Laying the Foundation

Strength training focused on quadriceps and hamstrings, including seated leg raises and mini squats (if tolerated). Hip abductor activation exercises like side-lying leg raises and clamshells were introduced. His response? "So you want me to train like an athlete now?"

Pain management included TENS therapy and shortwave diathermy.

Gait training involved heel-to-toe walking and weight-shifting drills. He still insisted on wearing his favorite shoes during sessions.

Progress Report (Month 3: The First Victory)

• Pain reduced to 6/10 (but he still exaggerated for dramatic effect).
• Quadriceps showed mild improvement, but he was still hesitant to fully commit to the comeback.
• Gait was slightly less wobbly, though he continued to hold onto furniture for "security reasons."

Phase 2 (Months 4-6): The Stubborn Knees Start to Listen

Strength training intensity increased with squats against a wall ("youthful nonsense") and resistance band exercises ("This one feels like real training, sha.").

Functional training included sit-to-stand drills and step-ups to mimic climbing stairs. He also upgraded to a more stable cane—only after I convinced him it made him look like a "big man."

Progress Report (Month 6: Small Wins, Big Confidence)

• Pain down to 5/10 (but still refused to admit he was improving too much).
• Strength improvement noticeable: Quadriceps no longer "asleep on duty."
• Gait more stable: Less wobbling, more control.
• Still NO wheelchair.

Phase 3 (Months 7-9): The Turning Point

Advanced strength training included leg presses on low resistance and walking drills on uneven surfaces to simulate real-life terrain.

Manual therapy techniques were introduced for pain management, which he found "strangely relaxing."

Gait training intensified, focusing on longer walking distances without excessive breaks.

Progress Report (Month 9: The Comeback Team Rises)

• Pain at 4/10 on most days.
• Stronger muscles, better posture.
• No longer clung to furniture for balance.
• Could walk short distances without his cane.

Phase 4 (Months 10-12): Wrapping Up the Journey

Final functional training included longer walks with confidence and independent stair climbing. Pain management was maintained with heat therapy and home exercises.

Discharge planning focused on a home exercise program to sustain progress and encouraging social walking activities (which he called "waka waka nonsense.").

Final Progress Report (Month 12: The Last Session)

• Pain now a manageable 3/10.
• Could walk independently for longer periods.
• Knees were still knock-kneed but far more stable.
• Never used a wheelchair—not once.
• Patient Feedback: "You tried. I won’t clap for you, but you tried. Maybe I’ll even miss these sessions… a little."

Final Reflection

His genu valgum remained, a structural reality that no amount of exercise alone could fully correct. But his functionality improved dramatically. He learned to navigate his world with more stability and less pain, understanding that while surgery might offer further correction, his current progress gave him a renewed sense of independence.

By the final months, he was taking his medications regularly, checking his blood pressure without argument, and even admitting (begrudgingly) that a well-managed condition is better than a neglected one. His knees may still grumble, but he walks—proudly, defiantly, and on his own terms.

And as he put it best: "My knees may be old, but my determination is young."