We would like to appraise you of a real case scenario of an avid female football player aged 11and her physiotherapy management at The Sherwood Clinic. We shall address her as Ms MT. Here is a case study describing Ms MT’s journey from the initial assessment, diagnosis to improvement of her symptoms and finally achieving her goals.
Presenting Complaint
MT presented to The Sherwood Clinic Sports Physio team, with left knee pain which had bothered her for the past 6-7 weeks.
Background
MT, a young school student and member of a local football club trains hard and plays football, four times a week. She also is an enthusiastic theatre dancer and a performer.
MT reported her pain Intensity on Visual Analogue Scale (VAS) as 4-7/10. Her pain was around the outer knee and around and under the kneecap (patella).
Functional Limitation: Difficulty straightening the knee fully for weight-bearing activities. Playing football and dancing aggravated her pain. The only relieving factor was rest.
Clinical Presentation
Key symptoms included:
- Pain Localization: Anterior and lateral aspects of the knee, particularly around the patella and below.
- Pain Pattern: Pain worsened during jogging and running, and occasionally with weight-bearing tasks.
- Functional Limitation: Inability to fully straighten the knee, particularly when bearing weight.
Clinical Findings and Examination
| Examination Finding | Left Side | Right Side | Clinical Significance |
| Hip Abductor Strength | 3+ | 4+ | Reduced strength on the left may contribute to knee valgus |
| Knee Extensor/Flexor Strength | Reduced(4) | Normal(5) | Reduced quadriceps strength contributes to difficulty with knee extension |
| Adductors | Weak(4) | Weak(4) | Bilateral weakness may affect knee alignment and function |
| Straight Leg Raise (SLR) | Weak (more on left) | Normal | Reduced quad strength, more pronounced on the left side |
| Hip Extensor Strength | Weak | Normal | Weak hip extensors may result in compensatory low back motion |
| Dorsiflexion Range of motion | Reduced (neutral) | Normal | Reduced dorsiflexion may affect squat mechanics and knee loading |
| Hip rotator (IR and ER) | IR: ROM- reduced, strength: weak; ER: ROM: reduced, strength- good | IR: ROM- normal, strength: weak; ER: ROM: reduced, strength- good | Reduced external rotation range in hip may lead to |
| Tenderness | Lateral knee, Gerdy’s tubercle, patella tendon, distal ITB, calf | Not applicable | Tenderness in these areas points towards PFPS and muscle spasm in ITB |
| Single Leg Squat | Pain below the knee cap and around the patellar tendon | Pain-free | Indicates inflammation of patellar tendon |
| Muscle Spasm | Present in ITB and calf | Not applicable | Indicates muscle tightness contributing to knee pain |
| Special Ligament Tests | Negative | Not applicable | Knee joint stability not compromised |
Differential Diagnosis (Rathleff & Collins, 2025; Horii et al., 2022)
| Diagnosis | Key Symptoms | Clinical Signs |
| Patellofemoral Pain Syndrome (PFPS) | Anterior knee pain, exacerbated by running, squatting, stairs | Tenderness over patella, quadriceps weakness, knee valgus during squat |
| Iliotibial Band Syndrome (ITBS) | Lateral knee pain during running or squatting | Tenderness over ITB, pain during running |
| Osgood-Schlatter Disease | Pain at tibial tuberosity, aggravated by jumping | Swelling or tenderness over tibial tuberosity |
| Patellar Tendinopathy (Jumper’s Knee) | Anterior knee pain, exacerbated by jumping or running | Tenderness at patellar tendon insertion |
| Juvenile Idiopathic Arthritis (JIA) | Joint pain, swelling, morning stiffness, possible systemic signs | Joint swelling, systemic signs (fever, rashes) |
| Hip/Sacroiliac Joint Referral | Referred knee pain from hip or pelvis, aggravated by certain positions | Hip or pelvic tenderness, altered posture |
Clinical Impression: Acute Patellar Tendonitis
Management Plan
- Pain Management
MT was advised to apply ice for 15-20 minutes post-activity to reduce inflammation and muscle spasm. Recommended every 1-2 hours during acute episodes. She was treated with kinesiology taping (K Tape)to improve patellar tracking and reduce pain. Her parent was instructed in the use of K Tape for MT.
- Activity Modification
MT was advised to Refrain from high-impact activities such as football and running to reduce stress on the knee. Replace with low-impact activities like swimming or cycling.
She was advised to avoid activities such as repetitive stair climbing and squatting as these would exacerbate symptoms until her pain subsided. She was advised to gradually reintroduce these activities with proper form and progression.
- Rehabilitation and Strengthening Program
Progressive Exercise Protocol
| Week | Exercise | Sets/Reps | Goal |
| 1-4 | Quad Sets | 3 sets of 10 reps (hold 5 seconds) | Strengthen quadriceps with minimal load |
| Straight Leg Raise (SLR) | 3 sets of 10 reps | Improve quadriceps strength, more emphasis on left side | |
| Bridges | 3 sets of 10-15 reps | Strengthen glutes and hip extensors | |
| Clamshells | 3 sets of 15 reps | Strengthen hip abductors and correct valgus collapse | |
| 5-8 | Wall Squats | 3 sets of 10-15 reps | Improve squatting mechanics and quadriceps strength |
| Step-ups | 3 sets of 10 reps | Increase knee stability and strength | |
| Single-Leg Squats | 3 sets of 8 reps | Improve unilateral stability and strengthen quads and hip abductors | |
| Lunges | 3 sets of 10 reps per leg | Strengthen glutes and quads, correct knee valgus | |
| Calf Stretches | Hold for 30 seconds, 3 times | Improve ankle dorsiflexion and calf mobility |
- Biomechanical Correction
MT was assessed for appropriate footwear and potential orthotics to support arch collapse. She was asked to Focus on exercises to reduce knee valgus, such as squats and lunges with proper form.
- Neuromuscular Control and Proprioception
To improve proprioception, MT was given single leg balance exercises on an unstable surface (wobble board) to improve knee stability. Gradual introduction of low impact plyometrics (e.g., jump squats) to improve dynamic stability once symptoms improve.
Response to treatment
Following two weekly sessions, MT refrained from playing football but engaged in 45 minutes of netball, during which pain was felt on the lateral side of the knee, with a VAS rating of 6.5/10 the following morning.
MT’s Pain typically emerged after physical activity and persisted for up to 3 hours. She was pain-free during walking but her aggravated during descending/ascending stairs and with squatting, which she avoided.
Return to Sport Protocol
| Phase | Activities | Progression |
| Phase 1 | Low-impact sports (e.g., swimming, cycling) | Gradually increase intensity and duration as tolerated without pain. |
| Phase 2 | Football (gradual introduction) | Begin with light drills, progressing to more intense activity as strength and mobility improve. |
| Phase 3 | Full Return | Full return to sport with continued strength maintenance and regular monitoring for pain recurrence. |
Following eight weeks of treatment, MT showed remarkable improvement with a structured rehabilitation program with periodic exercise progression. Return to sport phase is termed as one of the most important aspect of knee rehabilitation with maximum chances of re-injury if the transition is not planned properly. Hence prior to inception of the training, MT underwent sport specific conditioning using the exercises like single leg squats, balance training on stability trainer, agility and sprint training. The tailored routine along with well-designed warm up helped her achieve the best possible outcomes leading to timely return to sport. As a young athlete it is important to continue the strength and conditioning program to reduce the risk of injuries and have an enhanced sporting performance.
References
Rathleff MS, Collins NJ. Physiotherapy management of patellofemoral pain in adolescents. J Physiotherpy. 2025 Jan;71(1):8-17. doi: 10.1016/j.jphys.2024.11.018. Epub 2024 Dec 14. PMID: 39675948.
Horii, M., Akagi, R., Takahashi, S., Watanabe, S., Ogawa, Y., Kimura, S., Yamaguchi, S., Ohtori, S., & Sasho, T. (2022). Risk factors for the occurrence and protraction of patellar and patellar tendon pain in children and adolescents: a prospective cohort study of 3 years. BMC musculoskeletal disorders, 23(1), 389. https://doi.org/10.1186/s12891-022-05349-y
