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.
A blog by Amy Mathews Amos- See below
My symptoms started in January 2008, with deep pain in my bladder and the sense that I had to urinate constantly. I was given a diagnosis of interstitial cystitis, a chronic bladder condition with no known cure. But in the following months, pain spread to my thighs, knees, hips, buttocks, abdomen and back. By the time my condition was properly diagnosed three years later, I had seen two urogynecologists, three orthopedists, six physical therapists, two manual therapists, a rheumatologist, a neurologist, a chiropractor and a homeopath.
What was wrong? Something completely unexpected, given my symptoms: myofascial pain syndrome, a condition caused by muscle fibers that contract but don’t release. That constant contraction creates knots of taut muscle, or trigger points, that send pain throughout the body, even to parts that are perfectly healthy. Most doctors have never heard of myofascial pain syndrome and few know how to treat it.
In my case, trigger points in my pelvic floor — the bowl of muscle on the bottom of the pelvis — referred pain to my bladder. Points along my thighs pulled on my knee joints, creating sharp pain when I walked. Points in my hips, buttocks and abdomen threw my pelvis and lower spine out of alignment, pushing even more pain up my back. The pain was so severe at times that I could sit for only brief periods.
“Why didn’t anybody know this?” I asked my doctor, Timothy Taylor, soon after he correctly diagnosed the reason for my pain. “Because doctors don’t specialize in muscles,” he said. “It’s the forgotten organ.”
‘There’s no wire’
Most medical schools and physical therapy programs lack instruction in myofascial pain, in part because it involves referred pain, according to Robert Gerwin, an associate professor of neurology at Johns Hopkins University. Gerwin, who is also president of Pain and Rehabilitation Medicine in Bethesda, says that medicine has only recently come to understand this type of pain.
“I remember a long conversation with a neurosurgeon saying that [referred] pain is impossible because there’s no connection, there’s no wire, no string, no blood vessel, there’s no nerve, there’s no nothing connecting these two places,” Gerwin said. Of course, the surgeon was “not realizing that the mechanism of spread is through the spinal cord.”
Pain signals from taut muscle fibers travel to specific locations on the spinal cord that also receive signals from other parts of the body. Referred pain occurs when pain signals from muscles register in the nervous system as if they came from elsewhere.
Although physicians increasingly recognize referred pain today, diagnosis and treatment of myofascial pain often takes more time than most physicians can provide, according to Taylor. Practitioners need specific training to recognize trigger points. And they must examine and palpate patients carefully to identify and locate these taut bands of muscle fiber.
In a 2000 survey, more than 88 percent of pain specialists agreed that myofascial pain syndrome was a legitimate diagnosis, but they differed over the criteria for diagnosing it.
Norman Harden, the medical director of the Center for Pain Studies at the Rehabilitation Institute of Chicago, conducted that survey. He believes that practitioners need clear, validated criteria for diagnosing myofascial pain and identifying effective treatments. He recently conducted another survey to determine if the level of recognition among pain specialists has changed. Preliminary results suggest it has not.
According to Gerwin, myofascial trigger points often cause or contribute to problems such as chronic back pain, headaches and pelvic pain. Trigger points can form anywhere in the body after an injury or if muscles brace against pain or trauma for a long period. They also can result from chronic overuse of muscles due to stress or to poor posture that puts constant pressure on muscles not designed to withstand it.
Taylor understands this as both a physician and a patient. His myofascial pain started in 2003 during his daily run. “I felt a sharp pain in my rear that felt just like when my brothers used to shoot me with our BB gun,” he recalled. He checked himself for signs of injury but found none, then limped home, assuming it was a strained muscle that would heal after a few days. It didn’t.
He sought treatment first from his general practitioner. He then went to a battery of specialists: neurologists, rheumatologists, orthopedic surgeons, osteopathic physicians, physical medicine and rehabilitation specialists, and physical therapists.
Found it on the Internet
After three years, a physical medicine and rehabilitation specialist told him the source of his pain was his piriformis muscle, a pear-shaped muscle that runs diagonally across the buttocks. The doctor prescribed stretching and strengthening exercises to resolve it, but they only made things worse. Eventually, the pain reached down to Taylor’s knees, up to his head and out to his fingers on both sides of his body.
But he finally had a useful piece of information. He did an Internet search for “piriformis muscle” — a common spot for trigger points — and “myofascial pain syndrome” popped up. “I had been to the bone doctor and the joint doctor and the nerve doctor and the rehab doctor, and none of them had really examined my muscles in great detail,” he said. And none of them identified trigger points. Taylor has since changed his focus from radiology to working toward understanding, diagnosing and treating the condition. When I met him in 2011 he had established a practice that specializes in pain syndromes.
A popular treatment is dry needling, which sounds like exactly what it is: Tiny needles are inserted into the skin to stimulate a twitch response in the heart of a trigger point, releasing it. Although similar to acupuncture, dry needling focuses directly on trigger points rather than on the meridians, or energy fields, recognized by Chinese medicine. Usually, each trigger point requires several treatments before it relaxes substantially. Between sessions, patients treat themselves each day by pressing the points against a hard surface with simple tools such as tennis balls and holding for a minute or two. Treatment also addresses posture-related strains on muscles and metabolic factors such as vitamin and mineral deficiencies, low thyroid and hormonal imbalances that can contribute to trigger points.
Though a few studies have been done, they have not adequately demonstrated the effectiveness of treatments for trigger points, according to a 2009 review published in the European Journal of Pain. Researchers at the Universities of Exeter and Plymouth and the British Medical Acupuncture Society reported that only one of the seven studies they reviewed found dry needling to be effective in reducing pain. Four other studies found no difference between dry needling and placebo treatment, and the two remaining studies had contradictory results.
The American Academy of Orthopaedic Manual Physical Therapists recognizes dry needling as a legitimate treatment. The group maintains that research shows that dry needling reduces pain and muscle tension and helps muscles with trigger points return to normal. Other studies are underway. Jay Shah of the National Institutes of Health and Lynn Gerber and Siddartha Sikdar of George Mason University are using ultrasound imaging to examine how dry needling changes the physiology of trigger points after treatment.
Gerwin says that proper training in finding the trigger points can lead to consistency in diagnosing them. He and physical therapist Jan Dommerholt of Bethesda Physiocare run Myopain Seminars, which help physicians and physical therapists learn how to diagnose and treat trigger points.
According to Harden at the Rehabilitation Institute of Chicago, without clearer diagnostic criteria accessible to general practitioners, experiences like mine will continue. “As awareness grows and doctors feel empowered to understand and make this diagnosis, then that endless and frustrating round of trying to find what I’ve got and what the answer is will stop,” he said.
Gerwin agrees that more research will help, but already he sees greater acceptance of trigger points in the medical community.
“I think the bottom line is simply that the
underlying pain physiology is understood now to explain why referred pain occurs, to understand why tenderness occurs,” he said. “And that explains a lot of what muscle pain is all about.”
In my case, through a combination of therapies, including dry needling, compression, stretching, postural changes and relaxation techniques, I feel much better. I no longer need dry needling, but I do need to practice the other techniques myself, regularly, to prevent trigger points from reforming or to release them myself when they do form.
Amy Mathews Amos, a science writer in Shepherdstown, W.V., blogs at amymathewsamos.com.
People who exercise have better mental fitness, and a new imaging study from UC Davis Health System shows why. Intense exercise increases levels of two common neurotransmitters — glutamate and gamma-aminobutyric acid, or GABA — that are responsible for chemical messaging within the brain.
Published in this week’s issue of The Journal of Neuroscience, the finding offers new insights into brain metabolism and why exercise could become an important part of treating depression and other neuropsychiatric disorders linked with deficiencies in neurotransmitters, which drive communications between the brain cells that regulate physical and emotional health.
“Major depressive disorder is often characterized by depleted glutamate and GABA, which return to normal when mental health is restored,” said study lead author Richard Maddock, professor in the Department of Psychiatry and Behavioral Sciences. “Our study shows that exercise activates the metabolic pathway that replenishes these neurotransmitters.”
The research also helps solve a persistent question about the brain, an energy-intensive organ that consumes a lot of fuel in the form of glucose and other carbohydrates during exercise. What does it do with that extra fuel?
“From a metabolic standpoint, vigorous exercise is the most demanding activity the brain encounters, much more intense than calculus or chess, but nobody knows what happens with all that energy,” Maddock said. “Apparently, one of the things it’s doing is making more neurotransmitters.”
The striking change in how the brain uses fuel during exercise has largely been overlooked in brain health research. While the new findings account for a small part of the brain’s energy consumption during exercise, they are an important step toward understanding the complexity of brain metabolism. The research also hints at the negative impact sedentary lifestyles might have on brain function, along with the role the brain might play in athletic endurance.
“It is not clear what causes people to ‘hit the wall’ or get suddenly fatigued when exercising,” Maddock said. “We often think of this point in terms of muscles being depleted of oxygen and energy molecules. But part of it may be that the brain has reached its limit.”
To understand how exercise affects the brain, the team studied 38 healthy volunteers. Participants exercised on a stationary bicycle, reaching around 85 percent of their predicted maximum heart rate. To measure glutamate and GABA, the researchers conducted a series of imaging studies using a powerful 3-tesla MRI to detect nuclear magnetic resonance spectra, which can identify several compounds based on the magnetic behavior of hydrogen atoms in molecules.
The researchers measured GABA and glutamate levels in two different parts of the brain immediately before and after three vigorous exercise sessions lasting between eight and 20 minutes, and made similar measurements for a control group that did not exercise. Glutamate or GABA levels increased in the participants who exercised, but not among the non-exercisers. Significant increases were found in the visual cortex, which processes visual information, and the anterior cingulate cortex, which helps regulate heart rate, some cognitive functions and emotion. While these gains trailed off over time, there was some evidence of longer-lasting effects.
“There was a correlation between the resting levels of glutamate in the brain and how much people exercised during the preceding week,” Maddock said. “It’s preliminary information, but it’s very encouraging.”
These findings point to the possibility that exercise could be used as an alternative therapy for depression. This could be especially important for patients under age 25, who sometimes have more side effects from selective serotonin reuptake inhibitors (SSRIs), anti-depressant medications that adjust neurotransmitter levels.
For follow-up studies, Maddock and the team hope to test whether a less-intense activity, such as walking, offers similar brain benefits. They would also like to use their exercise-plus-imaging method on a study of patients with depression to determine the types of exercise that offer the greatest benefit.
“We are offering another view on why regular physical activity may be important to prevent or treat depression,” Maddock said. “Not every depressed person who exercises will improve, but many will. It’s possible that we can help identify the patients who would most benefit from an exercise prescription.”
Our spinal columns are made of twenty four vertebrae stacked one above another on the pelvis. They are joined together at the front by discs and at the back by facet joints. When we bend forward, the vertebra above tilts and slides forward, compressing the disc and stretching the facet joints at the back of the vertebrae. When we bend backward, the disc compression is reduced at the front and the facet joints are compressed at the back. In the upper neck and thoracic areas we tend to have more facet joint strains and in the lower cervical spine and lumbar spine areas, disc injuries are more frequent. This is because our upper spine joints allow us to turn our heads to see, hear and smell, so they need mobility but do not support much weight. Our lumbar spine bears around half our body weight and as we move and sit, there are huge, sustained, compressive loads on our discs.
CAUSES OF BACK PAIN
Disc injuries are the most common cause of low back pain and can range in severity from a mild intermittent ache, to a severe pain where people cannot move. Disc injuries occur mainly during sudden loading such as when lifting, or during repetitive or prolonged bending forces such as when slouching, rowing, hockey and while cycling. They are often aggravated by coughing and running. A flexed posture during slouching, bending or lifting is a frequent cause of disc damage because of the huge leverage and compression forces caused by gravity pulling down on the mass of the upper body.
It is important to understand that damage from small disc injuries is cumulative if discs are damaged at a faster rate than they can heal and the damage will eventually increase until it becomes painful. Pain sensing nerves are only on the outside of the disc, so by the time there is even small pain of disc origin, the disc is already significantly damaged internally where there are no nerve endings to feel pain with.
There may be a previous history of pain coming and going as the damaged area has become inflamed, perhaps was rested or treated, settled for a while but as the underlying problem was not fixed, the pain has flared up repeatedly since. This type of disc injury responds very well to Physiotherapy treatment.
A marked disc injury causes the outer disc to bulge, stretching the outer disc nerves. In a more serious injury, the central disc gel known as the nucleus, can break through the outer disc and is known as a disc bulge, prolapse or extrusion.
Spinal muscles are often blamed as the cause of spinal pain but this is rarely the cause of the pain. Muscle pain may develop as the muscles contract to prevent further damage as they protect the primary underlying painful structures. This muscle pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture etc, there is temporary relief but the pain will often come back, as the muscles resume their protective bracing. Treatment must improve the structure and function in the tissues which the muscles are trying to protect. The most common sources of primary pain are the discs, facet joints and their ligaments.
There are four facet joints at the back of each vertebra, two attaching to the vertebra above and two attaching to the vertebra below. A facet joint strain is much like an ankle sprain and the joints can be strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged and will then produce pain.
Facet joint sprains can occur during excessive bending but typically occur with backward, lifting or twisting movements. Trauma such as during a car accident or during repetitive or prolonged forces such as when slouching or bowling at cricket.
There are many other sources of back pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will examine your back and advise you should further investigation be necessary.
SYMPTOMS OF BACK PAIN
Symptoms of structural back pain are always affected by movement. This is important to understand. Symptoms, usually pain but perhaps tingling and pins and needles, are often intense and may be sudden in onset but also may be mild and of gradual onset. There are other conditions which can produce back pain such as abdominal problems, ovarian cysts and intestinal issues. If you have symptoms in these areas which are not affected by movement, you must consult with your doctor. If you have chest, jaw or upper limb pain which is unaffected by movement, you must attend your doctor or hospital immediately.
Facet joints, discs, muscles and other structures are affected by our positions and movements. More minor problems produce central low back pain. With more damage, the pain may spread to both sides and with nerve irritation, the pain may spread down into the thigh or leg. As a general rule, disc pain is worse with bending, lifting and slouching and facet joint strains are worse twisting and bending backward or sideways. A severe disc problem is often worse with coughing or sneezing and on waking in the morning.
DIAGNOSIS OF BACK PAIN
Diagnosis of back injuries is complex and requires a full understanding of the onset history and a comprehensive physical examination. It is important for your Physiotherapist to establish a specific and accurate diagnosis to direct the choice of treatment. In some cases, the pain may arise from several tissues known as co-existing pathologies and each of these are treated as they are identified. Where the Physiotherapist requires further information or the management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.
UPPER BACK AND LOWER BACK PAIN RELIEF
Eighty percent of adults will experience severe spinal pain at some time in their life. Much of this pain is called non-specific low back pain and is treated with generic non-specific treatment. This type of treatment often fails to provide lasting relief. However, Musculoskeletal Physiotherapists have developed specific diagnostic skills and specific treatment techniques, targeted to specific structures. We identify the structure and cause of the pain producing damage and develop specific advice and strategies to prevent further damage and promote healing.
Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education. As normal tissue structure and function returns, there is a reduction in the inflammation and the pain will subside.
When normal movement has been achieved, the inflammation has settled and the structures have healed, your new strategies will reduce the possibility of the problem recurring. We use this specific approach to reduce or stop chronic pain.
While we have the choice to manipulate, adjust or click joints, patients with ongoing pain will seldom benefit from repeating these techniques. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost, as the elastic tissues tighten and shorten again. Adjustments of this type have little long term benefit and often lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safer and more appropriate treatment for you.
PROGNOSIS OF BACK PAIN
Physiotherapy for back pain can provide outstanding results but it is a process, not magic. The damage which produces pain in a back takes time to develop and also time to repair and heal. You will understand there are often several interacting factors to deal with and patient compliance is necessary.