Within weekends and college holidays. The boy was taking

Within this case
study I will be discussing the injury of a 17-year-old student (boy) complaining
of left knee pain and swelling. The individuals knee started to swell three
days ago, although the injury was not caused by sport, the boy had
however been helping his dad lay carpets at the weekend and often helps out during
weekends and college holidays. The boy was taking NSAIDS (Non-Steroidal
Anti-Inflammatory Drugs) in order to reduce the pain and swelling. This
consisted of taking 2xIbuprofen once a day over the past three days, however
these had done little to help. He also reported a history of left knee pain,
although an x-ray taken one year ago showed no abnormality detected. Apart from
this the boy had good general health and was taking no other types of


Upon assessment the left knee
was seen to be visibly swollen anteriorly, light red in colour and warmer than
the right knee, however the skin was intact. These were signs and symptoms
indicating that the injured knee was within the acute stage of tissue healing
known as the inflammation stage (Norris, 1998). The boy also showed an antalgic
gait with the left knee in -25 degrees of flexion. The individual will have taken
up this style of gait as it is a compensatory mechanism that prevents further
pain to the injured area. It is achieved by shortening the stance phase of
their gait, therefore reducing the contact time between the limb and the ground
(Sawyer and Kapoor, 2009). This indicated that the individual was hesitant to
fully weight bare giving the thought that they were experiencing an
uncomfortable level of pain. Passive range of movement at the knee was normal,
however the boy could only achieve (2/3) active ROM; this was due to patient
pain and fear. He also displayed bilateral pes planus which according to
Lakstein et al.
(2010) may be a contributing factor
towards anterior knee pain. Both the hip and ankle were clear.

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Looking at all of the
information present from this case study such as signs and symptoms, range of
movement and gait, the existing diagnosis was thought to be pre-patellar
bursitis. This diagnosis was thought to be due to the nature of the occupation
that the boy was taking part in, as carpet layers spend 75% of their time on
their knees, particularly applying force to the pre-patellar area of the knee
(Huang and Wu, 2012). The signs and symptoms that they presented such as the
swelling, pain and red colour are also typical factors of this pathology (Cardone
and Tallia, 2003).


Bursa’s are comprised of small
synovial lined sacs and have the role of reducing friction (Hutson, 2001). There
are bursa’s located all over the body, the knee has 14 on average and they are
located in areas that have high levels of friction, such as between muscle,
tendon, bone and skin (Norris, 1998). The pre-patellar bursa itself sit’s
overlying the kneecap which is very superficial to the skin. They are used when
exercising, crawling, laying carpets scrubbing floors etc. therefore giving it
the name of house maids knee, carpet-layers knee, miners knee etc. (Evans,
1986). However, when these movements are frequently used over a long period of
time the bursa will become over worked or repeatedly pressed. This results in the
bursa swelling, creating pain, becoming red in colour and producing a reduction
in range of movement, this is known as bursitis. As shown in the 17-year-old
boy’s case.


The occupation in which the boy
was working was a large contributor towards this bursitis diagnosis. A study by
Thun et al.
(1987) spoke about how there are only 0.06% of carpet layers in the United
States, yet they submit 6.2% of compensation claims for traumatic knee
inflammation. Compared with floor layers or tile setters, double the amount of
carpet layers complain of this injury and the incidence is so common that it
was given the nickname “carpet layer’s knee” (Huang and Wu, 2012). The cause of
this is due to spending a vast amount of time on their knees placing pressure
upon the pre-patellar bursa and also using a tool called a knee kicker which is
used to stretch and install carpet. This tool is used by hitting the padded end
of the device with knee (Mueller and Bhattacharya, 1984). When this action
happens the maximum impact of the kick exceeds between three to five times the
body weight of the individual (3000N) and during a working day this action can
be repeated up to 140 times per hour (Huang and Wu, 2012). It was also found
that the supporting non-kicking knee experiences around 894N when the opposing
knee is kicking. This applies an incredible amount of extrinsic force to the
bursa of knee and within a short amount of time the bursa can become inflamed and
will start give signs and symptoms of bursitis. This research supports the high
risk in which carpet layers take when working within their occupation and
maintains the thought that the boys weekend and holiday work with his dad will
have been a large factor towards this diagnosis.


Another contributing factor
towards the diagnosis was the ROM that the boy presented. McAFEE and Smith
(1988) argue that upon clinical evaluation for this specific diagnosis, the
painless passive range of motion at the knee will be preserved rather than
increasing, unless the joint is extremely flexed putting pressure on the bursal
compartment. This was shown when the boy’s level of pain didn’t increase when
passively moving the knee, however when he was asked to flex the joint himself
he could only reach (2/3) of the full movement due to the bursa causing
pressure, pain and fear. Furthermore, in order for the boy to regain full ROM
the bursitis would have to be reduced in swelling and pain before full ROM can
be achieved. These types of tests also help narrow down the potential injury and
where the lesion lies because they can specify whether or not the contractile
or inert tissues are damaged. If there is pain upon active ROM and not passive,
then it indicates that the lesion most likely lies within the contractile
tissue. However, if there is pain within the passive movement and not the
active then the lesion is most likely to be within the inert tissue. Although
the boy experienced pain within the active movement of the knee he managed to
reach two thirds of the full flexion and if there was less swelling of the
bursa, pain and fear from the boy then it is expected that he would have been
able to reach full ROM. This implies that the important mechanisms of the knee
such as bones, ligaments, tendons, muscles, cartilage were most likely pathology
free; supporting the thought of pre patellar bursitis being the diagnosis.


The individual did not mention
any signs of locking, popping or giving away of the knee. Calmbach and Hutchens
(2003) considers locking of the knee to suggest a potential meniscal problem,
popping to suggest a potential ligamentous issue and giving away to represent
instability of the knee. The individual not presenting any of these signs draws
the attention away from potential articular cartilage, ligaments or bone diagnosis
and supports the thought of pre-patellar bursitis. A review of occupational
knee disorders by Reid et al. (2010) spoke about how there are other potential differential diagnosis
such as meniscal tears and osteoarthritis to workers that spend long hours on
their knees. To ensure that these other pathologies are ruled out there are
further specific tests that can be done such as the Mcmurrays test. If the test
is ruled out as negative, then it produces further evidence to support the bursitis
diagnosis. However, to diagnose osteoarthritis it would mean referring the boy
to a doctor to have either joint aspiration, an X-ray or an MRI scan. The McMurrays
test is used to evaluate the presence of a meniscal tear (Malanga and Nadler,
2006). It is carried out by having the patient laid on their back. The knee is
then flexed to ninety degrees and the foot is held by holding the heel whilst
the other hand is placed over the knee’s joint line. The tibia is then
externally rotated whilst producing a valgus force to test the medial meniscus
and extending the knee. To test the lateral meniscus, the tibia is internally
rotated whilst producing a varus force and extending the knee. If the test is
positive then the patient will experience pain, popping or clicking along the
joint line (Loudon et al.,
2008). For this case study the 17year old boy would have tested negative,
therefore enforcing the diagnosis of pre-patellar bursitis.


Mentioned earlier the boy’s knee
was presenting signs and symptoms of the inflammation stage of healing. Inflammation
is the second stage of a four stage healing process beginning with the
injury/bleeding through to inflammation, proliferation and remodelling (Hutson,
2001). These stages do not run one after the other but do partly overlap in
time. During the bleeding stage the capillaries around the wound contract in
order to reduce bleeding. Red blood cells and platelets then flood the wound in
order to try and form a clot to further reduce bleeding. This phase is followed
by the bodies way of protecting itself, inflammation. Inflammation is made up
of vascular, biomechanical and cellular events in order to repair or regenerate
a wound. There are five main signs and symptoms of inflammation these being, redness,
swelling, heat, pain and loss of function (Bahr and Mæhlum, 2004). This phase
begins through cells such as mast cells and platelets releasing chemical
mediators into the interstitial fluid and blood. These mediators cause local
vasodilation, increasing blood flow to the area. Capillary permeability is
increased allowing plasma proteins and fluid to move into the interstitial
space, this can be seen through an increase in heat and colour. Here exudate
fluid is formed which dilutes any toxic material, allowing blood clotting to
form a fibrous wall within the injury site. Leukocytes then move into the
injury site through attraction from chemotaxis, these then release neutrophils,
macrophages and monocytes that assemble along the walls of the capillaries
(Bahr, 2012). These leukocytes cells destroy any foreign objects within the
wound site, this process is called phagocytosis. This inflammatory process can
last can from 10 minutes to several days depending on the severity of the
injury sustained (Norris, 1998). During the inflammation stage the
proliferation stage will have begun, here the wound begins to rebuild new
granulation tissue through blood vessels delivering nutrients and oxygen to the
wound site. The new tissue builds collagen fibers which develop new blood
vessels and replace the old ones whilst damaged mesenchymal cells are
transformed into fibroblasts which aid the movement of cells around the
affected area (Bahr, 2012). The final stage would then be the remodelling


Hegedus et al. (2007) argues that knee pain has a prevalence of up to 45% and that 31% of
people with knee pain will consult a general practitioner in their lifetime. Taking
into consideration the high percentage of knee problems in a lifetime and the
fact that this is a reoccurring pathology for the boy, there will need to be preventative
measures put in place to treat or manage the injury, without it becoming worse.
Huang and Yeh (2011) argue that treatment and management of the bursitis is
primarily down to reducing the cause of the bursitis, in this case spending
long periods of time on his knees and by changing the pathology in the bursa. Within
this certain case aspiration of the knee is not required as the skin is intact
are there is a low chance of infection being present. PPE for carpet layers
such as knee pads have been mentioned within the literature as a preventative
measure, however a study by Porter et al. (2010) questions the reliability of the knee pads, arguing that
although the current knee pads sufficiently distribute the pressures of the
body weight across the knee and upper tibia, a significant amount of pressure
is still transmitted through the bursa sacs. Furthermore, for the mean time it
is best advised for the boy to look at RICE (Rest, Ice, Compression, Elevation),
trying to potentially have some time away from carpet laying until the
pathology has reduced or by adapting his work so that there is a reduction in
force on his knees. RICE can play an important and beneficial role within an acute
level injury. This occurs by taking the time out from what was causing the
injury, having the rest that you need in order to let the pain, swelling and
colour subside. In this case the boy was working at the weekends and
occasionally in the holidays meaning that when he works at the weekends there
is time after his working day and time within the week when he can rest. Although
when he works in the holiday for consecutive days he will have to look at
potentially having long enough rest time within breaks and between working days.
Alongside this resting, compression and elevation should be applied. Ice has
many beneficial factors, according to Madden et
al. (2017) ice or cryotherapy can decrease blood
flow to the area, decrease swelling, reduce inflammatory mediators and pain
producing substances and decrease muscle spasms etc. This will be very
beneficial for the boy as it will reduce his symptoms, hopefully increasing his
range of movement and reduce the antalgic gait that he presented. This type of
therapy can be applied through ice bags such as crushed ice in a plastic bag,
or through the use of ice packs, ice immersion, ice massage or an ice
circulating unit (Madden, 2010). For the young boy it would be most recommended
that he tried using either ice bags or ice packs after every day that he works
in order to try and alleviate the symptoms. Andrews et
al. (2012) believes that compression has several
physiological effects within acute injury. One of these being able to increase
the cooling efficiency of the cryotherapy, another being able to resist the
formation of edema and finally being able to lessen the bleeding from the
injured blood vessels. So the boy would need to lightly compress the injury
after icing it in order to amplify the effect of the cryotherapy and to further
the treatment process. This can be achieved by using a tube grip, bandage or a sock
with the end cut off and should be applied after the icing phase. Finally, the boy
should elevate the knee as gravity will limit the blood flow towards the
injured area. This can help control bleeding from the damaged vessels, limit edema
and hematoma formation, alter the trans capillary starling forced in the area
and will also limit the number of neutrophils to the injury site (Kolt and
Snyder-Mackler, 2003). However, if the injury persists even with the use of
RICE then the boy can look to potentially have a bursectomy where the bursa is removed,
or the option of corticosteroid injection could be taken into consideration (Madden,
2010). In relation to the NSAIDS that the boy was taking, they can have various
positive and negative effects on the body. Studies have shown that although NSAIDS
can mask the pain of injuries and post exercise fatigue, they can negative
effects on the healing process of injury’s (Tscholl et al., 2016). This negative effect is that the NSAIDS can inhibit the inflammation phase
and proliferation phase of tissue healing (Tscholl et al., 2016). Although therapists cannot advise a client whether or not they should
take NSAIDS, it is important that the individual understands this information
before doing so.


To conclude, after taking all of
the different factors influencing this case study into consideration it was
clear to see that the main diagnosis for the 17-year-old boy was pre-patellar
bursitis. This was made clear by the signs and symptoms, his reduction in range
of movement, the occupation he had been working in, the antalgic gait he
produced and the fact that the injury occurred out of sport. Although
differential diagnosis of osteoarthritis or a potential meniscal tear shouldn’t
be ruled out at this point and for further clarification of the diagnosis an
MRI scan should be undertaken. Being that knee pain within carpet layers is of
a high injury rate it is important that the boy takes up a management plan and
sustains it whilst in this field of work.