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Table of Contents
Year : 2020  |  Volume : 2  |  Issue : 1  |  Page : 61-65

A case report on novel integrated kinetic chain correction protocol for early osteoarthritis knee: A preventive prospect

Department of Orthopedic Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission09-Jul-2019
Date of Acceptance25-Sep-2019
Date of Web Publication03-Jul-2020

Correspondence Address:
Dr. Aarti Welling
Department of Orthopedic Physiotherapy, KAHER Institute of Physiotherapy, Nehru Nagar, Belagavi, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_53_19

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Current literature states the use of management protocols that target the entire kinetic chain of the lower limb rather than managing only the affected joint. An integrated therapist-designed corrective protocol may work effectively through changes make as in the myofascial kinetic chain on knee osteoarthritis (OA). In this case report, the effect of a novel integrated protocol for knee OA in a 49-year-old woman was studied. The outcome measures included pain intensity, functional affection, kinesiophobia, frontal plane projection angle, range of motion, gait velocity, and cadence. The patient was treated for 15 sessions over a period of 3 weeks along with physical agent application and exercises that targeted from core to ankle. Significant improvements were observed in the outcome measures postintervention. This novel structured protocol has proved to be effective in minimizing the early symptoms of knee OA.

Keywords: Integrated protocol, Kinesiotherapy, Kinetic chain, Knee osteoarthritis, Lower limb

How to cite this article:
Gurudut P, Welling A, Jaiswal R. A case report on novel integrated kinetic chain correction protocol for early osteoarthritis knee: A preventive prospect. Indian J Phys Ther Res 2020;2:61-5

How to cite this URL:
Gurudut P, Welling A, Jaiswal R. A case report on novel integrated kinetic chain correction protocol for early osteoarthritis knee: A preventive prospect. Indian J Phys Ther Res [serial online] 2020 [cited 2023 Jun 2];2:61-5. Available from: https://www.ijptr.org/text.asp?2020/2/1/61/288865

  Introduction Top

Knee joint malalignment is known to induce problems with the trunk, pelvis, and lower limb segments during movement and ground reaction force generated. Knee osteoarthritis (OA) has shown to disrupt the lower limb kinetic chain.[1] Literature suggests poor core stability as one of the contributing factors that lead to the development of knee OA as well as its progression.[2]

The degenerative changes in the knee joint may be delayed and prevented by maintaining the joint mobility and rectifying the imbalance in the lower limb muscles.[3] Therapeutic correction of the muscle imbalances may modify pathomechanics, resulting in decreased joint loading rate or localized stress in the articular cartilage, thereby playing an important role in delaying initiation and progression of knee OA.[4] There is a shifting trend of diagnosis and management protocols from targeting only the affected joint to treating the entire kinetic chain of the lower limb. One of the theories suggests interconnected myofascial pattern involved in the kinetic chain of the musculoskeletal system.

There is growing evidence supporting the involvement of the lower limb kinetic chain in OA knee.[1],[2],[4] However, studies conducted so far on OA knee have documented clinical effectiveness of regional exercise targeting knee muscles. Hence, a need arises to improvise kinetic chain function by correcting the muscles and myofascial imbalances through a holistic and integrated approach involving correction from the pelvis to the foot.

This case reports the novel structured and tailor-made kinetic chain correction program which included integration of therapies aiming toward the correction of pathomechanics involved in early OA on dynamic frontal knee angle and function.

  Case Report Top

A 49-year-old female, measuring 1.6-m tall and weighing 76 kg with the body mass index of 29.6 kg/m2 (preobese), gives a history of right knee pain since 1 month. The onset of pain reported was sudden, which initiated while traveling in a bus after prolonged sitting for 12 h. The pain gradually increased, and she developed difficulty in performing daily activities such as standing, walking, and stair climbing. An orthopaedic surgeon advised her complete bed rest for 1 month along with the prescription of anti-inflammatory drugs. However, the patient's pain remained the same even after rest and medications and was then referred to the physiotherapy outpatient department.

Initial clinical impression

The patient reported intensity of knee pain on Verbal Analog Scale to be 5/10 on rest and 9/10 on activity. The onset of pain was sudden, with precipitating factor being knee bending, standing for 10–15 min, and squatting position. She demonstrated antalgic gait on observation. Palpatory findings suggested tenderness on the medial joint line of the right knee and inferior angle of the patella with Grade I effusion. Range of motion of knee flexion was full but painful at the end range with the extension lag of 10°. According to Kendall's manual muscle testing grading the strength of the abdominals, quadriceps, gluteus maximus, gluteus medius, and vastus medialis obliquus was 3/5 and + 3/5 for back extensors on the contralateral side muscles graded with + 4/5. The popliteal angle of the right knee was 20°, while the left was 28°, indicating bilateral hamstring tightness (right > left). The Ely's test was positive, confirming the tightness of the rectus femoris and iliopsoas muscles. Besides, gastro-soleus, piriformis, and dorsolumbar fascia were also tight. Radiography of the right knee confirmed Grade II OA knee according to the Kellgren and Lawrence radiographic grading. Informed consent was obtained from the subject to participate in the present case study and to publish the findings with the hidden identity.

Physiotherapy intervention

The patient was treated for 15 sessions in total over a period of 3 weeks for her complain of right knee pain. [Table 1] presents the details of the novel structured kinetic chain correction protocol for OA knee designed by the physiotherapist in the format of frequency, intensity, time, and type determinant of exercise prescription. The protocol included the combination of exercise therapy and electrotherapy that aimed to correct kinetic chain muscle imbalance from the pelvis to the foot [Figure 1], [Figure 2], [Figure 3]. First two sessions of the treatment involved only electrotherapy to decrease her pain.[5],[6] From the third session of the treatment, stretching and strengthening exercises were started. Static exercises were progressed to dynamic strengthening. Along with these exercises, static cycling and treadmill training (forward walking and retro-walking) were added in the treatment plan.
Table 1: Novel structured integrated kinetic chain correction protocol for osteoarthritis knee

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Figure 1: Pilates exercises (a) Pelvic Bridging (left above) (b) Table top position (right above) (c) Scapular lifts (left below) (d) Obliques (right below)

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Figure 2: Stretching exercises: or add as sticker on the pictures (a) Hip flexor & adductors (top left) (b) Pyriformis (top right) (c) Hamstrings stretch (2nd row left) (d) Dorsolumbar fascia stretch (2nd row right) (e) TFL (3rd row left) (f) Calf (3rd row right) (g) RF & IP (bottom left)

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Figure 3: Elastic band exercise: (a) Quadriceps & Hip Abductors (Top left) (b) Hip extensors (Top Right) (c) Ankle Dorsiflexors (Bottom)

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Outcome data collection

The following data were collected on the first and last days of the treatment. Frontal plane projection angle for the knee [Figure 4], range of motion, gait velocity, and cadence were measured. The functional affection was assessed using the Western Ontario McMaster Osteoarthritis Index and Knee Injury and Osteoarthritis Outcome Score. Kinesiophobia was measured using the Tampa Scale.
Figure 4: Frontal plane projection angle for knee (FPPA)

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  Results Top

After the intervention, the patient reported a decrease in the pain, morning stiffness, and improvement in the functional level. [Table 2] demonstrates the progress in all the outcomes seen after 15 sessions of the protocol. There was a significant improvement in all outcome measures pre- and postintervention.
Table 2: Pre-and post-difference in outcome measures

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  Discussion Top

The present case report focused on correcting the whole muscular chain associated with early knee OA. It consisted of structured exercise protocol targeting the imbalances from the pelvis till the ankle. The protocol included correction of the entire kinetic chain with the prescription of stretching and strengthening exercises along with gait training using a treadmill. Structured exercise protocol consisted of core strengthening and correction of muscle imbalance of the hip, knee, and ankle with the strengthening weak muscles and stretching the tight muscles which helped the patient in alleviating the symptoms of knee OA.

The theory of interconnected myofascial intricacies during complex human motion supports the improvement demonstrated in this case report. It is a suggested fact that myofascial chain is a global method to an integrated kinetic chain that explains biotensegrity system design, suggesting that human movements occur in the fascial pattern of musculoskeletal systems. According to this theory, the musculoskeletal system is connected in entirety through viscoelastic properties of the myofascial chain. A dysfunction like a dynamic knee valgus suggests that there is an abnormal pathomechanical pattern across the three planes of movements extending from the pelvis to the femur, knee, and ankle.[7]

Referring to the above-mentioned pathomechanics, the structured physiotherapy protocol focused on correcting the kinetic chain of the lower limb soft tissue from the pelvis till the foot, as the biomechanics of the proximal and distal joints are also affected along with the knee joint. Maintaining the strength of particular muscles around the knee joint is a common approach to the treatment of knee OA. However, this may not be as effective as correcting the whole kinetic chain. The gradual increase in the resistance during the prescription of resistance exercise is also a vital component in the treatment of knee OA.[8] Hence, elastic resistance bands and weights were used and the resistance of which was progressively increased every 5th day.

The novelty of the integrated protocol used in this case report focused on strengthening of the whole limb including back and abdomen and correcting the muscle imbalance present from lumbar to the ankle muscles indirectly targeting the entire kinetic chain. Hence, correcting the biomechanical defects of the whole limb helped in decreasing the mechanical stress and improving the physical functions of the OA knee.

  Conclusion Top

The present novel structured kinetic chain correction protocol has demonstrated to be effective in correcting muscles imbalances and pathomechanics associated in the kinetics of the lower limb, thereby decreasing the pain, disability, and kinesiophobia along with improvement in gait parameters in case of early OA knee prolonging and preventing future degeneration of the knee. However, a clinical trial is suggested in future to study the effectiveness of the protocol.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflict of interest.

  References Top

Kinoshita K, Ishida K, Hashimoto M, Yoneda Y, Naka Y, Kitanishi H, et al. Relationship between trunk function evaluated using the trunk righting test and physical function in patients with knee osteoarthritis. J Phys Ther Sci 2017;29:996-1000.  Back to cited text no. 1
Daud DM, Razak NR, Lasimbang H. Core stability deficits in female knee osteoarthritis patients. Acad J Sci 2015;4:117-24.  Back to cited text no. 2
Van Manen MD, Nace J, Mont MA. Management of primary knee osteoarthritis and indications for total knee arthroplasty for general practitioners. J Am Osteopath Assoc 2012;112:709-15.  Back to cited text no. 3
Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee: A Cochrane systematic review. Br J Sports Med 2015;49:1554-7.  Back to cited text no. 4
Ulus Y, Tander B, Akyol Y, Durmus D, Buyukakıncak O, Gul U, et al. Therapeutic ultrasound versus sham ultrasound for the management of patients with knee osteoarthritis: A randomized double-blind controlled clinical study. Int J Rheum Dis 2012;15:197-206.  Back to cited text no. 5
Das P, Dan MK. Comparative study of the effectiveness of therapeutic ultrasound versus interferential therapy to reduce pain and improve functional ability in osteoarthritis of Knee. Indian J Phys Med Rehabil 2017;28:100-5.  Back to cited text no. 6
Dischiavi SL, Wright AA, Hegedus EJ, Bleakley CM. Biotensegrity and myofascial chains: A global approach to an integrated kinetic chain. Med Hypotheses 2018;110:90-6.  Back to cited text no. 7
Vincent KR, Vincent HK. Resistance exercise for knee osteoarthritis. PMR 2012;4:S45-52.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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