Physical Therapist’s Guide to Knee Pain
Knee pain can be caused by disease or injury. The most common disease affecting the knee is osteoarthritis. Knee injuries can occur as the result of a direct blow or sudden movement that strains the knee beyond its normal range of movement. Knee pain caused by an injury is most often associated with knee cartilage tears, such as meniscal tears, or ligament tears, such as anterior cruciate ligament tears.
What is Knee Pain?
Knee pain can be caused by disease or injury. Knee pain can restrict movement, affect muscle control in the sore leg, and reduce the strength and endurance of the muscles that support the knee.
The most common disease affecting the knee is osteoarthritis, which is caused by the cartilage in the knee gradually wearing away, resulting in pain and swelling.
Knee injuries can occur as the result of a direct blow or sudden movement that strains the knee beyond its normal range of motion, as can happen in sports, recreational activities, a fall, or a motor vehicle accident. Knee pain caused by an injury often is associated with tears in the knee cartilage or ligaments. Knee pain also can be the result of repeated stress, as often occurs with the kneecap, also known as patellofemoral pain syndrome. Very rarely, with extreme trauma, a bone may break at the knee.
How Does it Feel?
You may feel knee pain in different parts of your knee joint, depending on the problem affecting you. Identifying the location of your pain can help your physical therapist determine its cause.
How Is It Diagnosed?
Your physical therapist will make a diagnosis based on your symptoms, medical history, and a thorough examination. X-ray and magnetic resonance imaging (MRI) results may also be used to complete the diagnosis.
To help diagnose your condition, your physical therapist may ask you questions like these:
•Where exactly on your knee is the pain?
•Did you twist your knee?
•Did you feel a “tearing” sensation at the time of injury?
•Do you notice swelling?
•Have you ever felt like your knee joint is “catching,” or “locking,” or will give way?
•Do you have difficulty walking up and down stairs?
•Do you have difficulty sitting with your knee bent for long periods, as on an airplane or at the movies?
•Does your pain increase when you straighten or bend your knee?
•Does your knee hurt if you have to twist or turn quickly?
The physical therapist will perform tests to find out whether you have:
•Pain or discomfort with bending or straightening your knee
•Tenderness at the knee joint
•Limited motion in your knee
•Weakness in the muscles around your knee
•Difficulty putting weight on your knee when standing or walking
The physical therapist also is concerned about how well you are able to use your injured knee in daily life. To assess this, the therapist may use such tests as a single-limb hop test, a 6-minute walk test, or a timed up and go test.
How Can a Physical Therapist Help?
Based on the evaluation, your physical therapist will develop a customized rehabilitation program, including a specific set of knee exercises, for you.
If you already have knee problems, your physical therapist can help with a plan of exercise that will strengthen your knee without increasing the risk of injury or further damage. As a general rule, you should choose gentle exercises such as swimming, aquatic exercise, or walking rather than jarring exercises such as jogging or high-impact aerobics.
Consult your physical therapist about specific ways to maintain your knee health following injury or surgery. Your physical therapist has the relevant educational background and expertise to evaluate your knee health and to refer you to another health care provider if necessary.
Depending on the severity of your knee problem, your age, and your lifestyle, the therapist may select such treatments as:
Strength training and functional exercises, which are designed to increase strength, endurance, and function of your leg muscles (quadriceps and hamstrings). This in turn helps support the knee and reduce stress to the knee joint.
Your physical therapist can determine just how much you may need to limit physical activity involving the affected knee. He or she also can gauge your knee’s progress in function during your rehabilitation.
How Can a Physical Therapist Help Before & After Surgery?
Your physical therapist, in consultation with your surgeon, will be able to tell you how much activity you can do depending on the type of knee surgery (such as total knee replacement) you undergo. Your therapist and surgeon also might have you participate in physical therapy prior to surgery to increase your strength and motion. This can sometimes help with recovery after surgery.
Following surgery, your physical therapist will design a personalized rehabilitation program for you and help you gain the strength, movement, and endurance you need to return to performing the daily activities you did before.
Can this Injury or Condition be Prevented?
Ideally, everyone should regularly get 3 types of exercise to prevent injury to all parts of the body, including the knees:
•Range-of-motion exercises to help maintain normal joint movement and relieve stiffness.
•Strengthening exercises to keep or increase muscle strength.
•Aerobic or endurance exercises (such as walking or swimming) to improve function of the heart and circulation and to help control weight. Weight control can be important to people who have arthritis because extra weight puts pressure on many joints, including the knee.
To keep knee pain and other musculoskeletal pain at bay, it’s important to maintain an overall healthy lifestyle, exercise, get adequate rest, and eat healthy foods. It’s also important for runners and other athletes to perform physical therapist-approved stretching and warm-up exercises on a daily basis—especially before beginning physical activity.
Real Life Experiences
At age 56, Monica was in very good health—eating right, maintaining her weight, and exercising daily at home. One day she fell off her exercise equipment and twisted her knee. The pain was excruciating. Even though she could walk short distances, using her sore leg during her daily activities soon became impossible. Monica made an appointment with her physical therapist. The therapist reviewed her medical history, conducted a thorough examination, and consulted with Monica’s physician regarding the need for a series of X-rays to ensure no bones were broken in the fall.
Consultation with an orthopedic surgeon confirmed that there were no broken bones and no need for surgery. Monica’s physical therapist developed a program of strength training and functional exercises to increase her hip, knee, and ankle muscle strength and endurance. The physical therapist also recommended electrical stimulation of the knee to increase her quadriceps (thigh) muscle strength.
By following the physical therapist’s regimen, Monica decreased her knee pain, and her mobility improved dramatically. Regular ongoing strength-training knee exercises—and more careful use of her exercise equipment—have helped Monica remain free of knee pain.
What Kind of Physical Therapist Do I Need?
Although all physical therapists are prepared through education and experience to treat people with knee pain, you may want to consider:
•A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems
•A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship FCAMPT in orthopedic physical therapy, giving the therapist advanced knowledge, experience, and skills that may apply to your condition
General tips when you’re looking for a physiotherapist:
•Get recommendations from family and friends or from other health care providers.
•When you contact a physical therapy clinic for an appointment, ask about the physical therapist’s experience in helping people with TKR.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
At first it was just a niggle in your knee when you climbed stairs or were squatting. Then the pain and stiffness became more than a niggle and you began to feel it when walking, sitting and resting.
You may be hearing popping or cracking sounds in your knee, and notice that your knee “gives out” every now and again.
The knee is an amazing but complicated joint and knee pain is one of the most common reasons that people visit a physiotherapist.
Pain behind the kneecap is commonly called runner’s knee because it is often seen in athletes and people with an active lifestyle, although it can also be seen in everyone from the young adolescents during growth spurts to elderly people.
The medical term is patellofemoral pain syndrome. It is pain behind the kneecap where your patella (kneecap) slides along the groove in your femur (thighbone) beneath.
Pain and stiffness occurs when the kneecap does not slide smoothly and misaligns causing it to rub against your femur. Repeated mis-tracking causes pain, stiffness, and ultimately can cause damage to your kneecap joint surface.
Knee pain is most commonly noticed during activities that involve knee bending, jarring or weight bearing.
People most at risk are those whose sport or activity includes running, jumping or the need to land in a squatting position. Sports most commonly associated with knee pain include running, netball, volleyball, basketball, tennis, skiing and cycling. Many tradies such as tilers and carpet layers also have problems.
Causes of Runner’s Knee
Overuse – increased activity or increased duration and intensity of the activity
Changes in footwear or playing surfaces
Tight outer thigh muscles and weaker inner thigh muscles causing the kneecap to be pulled to one side
A twisting injury
Flat feet and lack of arch support
Weak hip control muscles
First aid for Runner’s Knee
Generally, knee pain is gradual onset, which means it gradually increases in severity over time.
As with most injuries, the best initial first aid is rest, ice packs (15 minutes at a time every 2-3 hours), and taking anti-inflammatory painkillers such as ibuprofen.
You do not need a referral from a doctor to see a physiotherapist. If the pain is moderate, then you can seek treatment with your Physiotherapist immediately.
Physiotherapy is a proven treatment for runner’s knee. Your physiotherapist may initially tape or strap your kneecap to help pull it back into alignment and reduce pain.
Massage and joint mobilisation techniques are also commonly used to reduce swelling and restore movement.
You will be prescribed exercises to stretch and strengthen muscles that may be contributing to the problem. These exercises will change as you heal and will gradually increase in intensity to match your recovery.
If you wish to continue exercising to maintain your fitness during your treatment, then explore swimming, deep-water running and low-impact gym equipment such as elliptical trainers.
Depending on your knee pain cause, you may also be advised to explore arch supports, orthotics or different footwear. You may also require postural or technique correction in your chosen sport to stop problems from recurring, as well as a strength and conditioning plan to get you back to full competitive fitness.
In our experience, over 90% of runner’s knee physiotherapy clients will be pain free within six weeks of starting treatment. However, for severely damaged joints or arthritic joints, surgery may be required.
Things to Remember
Runner’s knee or patellofemoral pain syndrome is a common cause of knee pain.
It is a gradual onset injury and is most commonly noticed during activities that involve knee bending, jarring or weight bearing.
Physiotherapy is a proven method to speed healing, and prevent recurrence of knee pain.
Future management may also involve assessment of your gait and posture during exercise, and prescription of arch support or custom made orthotics.
Hip strengthening exercises performed by female runners not only significantly reduced patellofemoral pain — a common knee pain experienced by runners — but they also improved the runners’ gaits, according to Indiana University motion analysis expert Tracy Dierks.
“The results indicate that the strengthening intervention was successful in reducing pain, which corresponded to improved mechanics,” said Dierks, associate professor of physical therapy in the School of Health and Rehabilitation Sciences at Indiana University-Purdue University Indianapolis. “The leg was going through more motion, suggesting that the (pain) guarding mechanism was reduced, and coordination or control of many of these peak or maximum angles in the leg were improved in that they were getting closer to occurring at the same time.”
Only in recent years have researchers begun studying the hips as a possible contributor to patellofemoral pain (PFP). This study is the first to focus on hip strength and gait changes during prolonged running. Dierks, director of the Motion Analysis Research Laboratory at IUPUI, discussed his findings at the American College of Sports Medicine annual meeting in Denver.
The runners in Dierks’ study received no training or coaching on proper running form, which makes the improvements more notable. The improvements in mechanics resembled those of uninjured runners, when muscles, joints and limbs move economically and in synch with each other.
About the study
The study involved four runners and a control group comprising another four runners. Hip strength measurements and kinematic data — minute measurements of how the women’s hips, knees and shin bones moved and rotated while they ran — were taken before and after the runners in the control group maintained their normal running schedule for six weeks. The measurements were repeated for all of the runners before and after the next six-week period in which they all performed the hip-strengthening exercises.
The exercises, performed twice a week for around 30 to 45 minutes, involved single-leg squats and exercises with a resistance band, all exercises that can be performed at home. This study is part of an ongoing study involving hip exercises and PFP pain, with 10 runners successfully using the intervention.
After the six-week program, the movement of the hips and knees in relation to each other improved for both groups of runners, demonstrating increases in joint angles between the foot, shin and thigh.
The study used a pain scale of zero to 10, with 3 representing the onset of pain and 7 representing very strong pain — the point at which the runners normally stop running because the pain is too great. The injured runners began the six-week trial registering pain of 7 when they ran on a treadmill and finished the study period registering pain levels of 2 or lower; i.e. no onset of pain.
PFP, one of the most common running injuries, is caused when the thigh bone rubs against the back of the knee cap. Runners with PFP typically do not feel pain when they begin running, but once the pain begins, it gets increasingly worse. Once they stop running, the pain goes away almost immediately. Dierks said studies indicate PFP essentially wears away cartilage and can have the same effect as osteoarthritis. His study participants showed many of the classic signs of PFP, the most prominent being their knees collapsing inward when running or doing a squat exercise move.
Co-authors of “The Effect Of Hip Muscle Strengthening On Pain and Running Mechanics In Females With Patellofemoral Pain” are Rebecca L. Phipps, Ryan E. Cardinal, Peter A. Altenburger, IUPUI.
The above post is reprinted from materials provided by Indiana University.
Dry needling involves the application of very fine sterilised acupuncture needles into muscle and surrounding tissues to assist in the release of myofascial trigger points, reduce tightness and spasm, improve muscle function and relieve pain. It is commonly used as an adjunct to physiotherapy and myotherapy techniques to improve treatment outcomes.
There are two types of Dry Needling, the first called Superficial Dry Needling (SDN) works by inserting the needle only 5-10mm under the skin. Secondarily is Deep Dry Needling (DDN) where the needle is inserted to the depth required to penetrate the targeted myofascial trigger point.
How does it work?
Myofascial trigger points are hyper-irritable, taut bands within muscles, which are painful to touch and can contribute to muscle shortening, weakness and pain (both locally and referred). They often develop following muscle, joint or nerve injury and sometimes persist well after the initial tissue injured has healed. This leads to persistent pain and discomfort.
Dry needling releases these trigger points by encouraging local blood flow to the trigger point and by modulating nerve pathways that erroneously cause them to persist. The needling also stimulates your body’s own endorphin system to provide pain relief and help allow the muscle to relax.
Dry needling can be extremely effective in the treatment of:
Needles used in dry needling are much thinner than those you receive when you see your GP for an injection and so usually cause much less discomfort. This does vary depending on what techniques your therapist uses. You may also experience the very satisfying response of the muscle twanging and releasing quickly. A sure sign of a successful trigger point release.
The initial treatment is conservative to determine the patient’s response. This varies from person to person. It is expected that there will be some post treatment soreness during the first 24-48hrs and sometimes minor bruising is experienced.
What sorts of conditions can Dry Needling be beneficial for?
Dry needling can produce excellent results as an adjunct to standard physiotherapy and manual therapy treatment. It can be used in both acute and chronic painful conditions.
Dry needling can be extremely effective in the treatment of:
Back, neck and shoulder pain
Hand and wrist pain
Tendinopathy pathologies i.e. Tennis elbow, Achilles pain
Many other musculoskeletal injuries (You can discuss dry needling with your therapist to see if it may be useful for your condition)
What is the difference between Dry Needling and Acupuncture?
Dry needling revolves around Western Medicine philosophy and involves inserting needles into muscular trigger points palpated by your therapist and consistent with your area of pain.
Acupuncture is based on ancient Eastern Medicine, with needle placement over specific points along meridian lines or ‘energy’ lines which are thought to associate with particular illness and disease.