The first thing in treating knee pain is understanding and knowledge of what is causing the pain. There are many conditions that can cause knee pain. Our goal with the book, as in the clinic, is to help people understand what is causing their pain and then give them tools to help them manage that condition. Each of the exercises and techniques found in the book focuses on a specific condition. At the start of each section, we dive into what is causing the pain and what structures are involved. After reading this, readers should have a clear understanding of what is causing their pain.
What is Knee Pain?
The knee is the largest and most complicated joint in the body. The knee joint is made up of four bones: the femur, which is the thighbone; the tibia, which is the shinbone; the fibula, which is the smaller bone in the lower leg; and the patella, which is the kneecap. There are four main ligaments in the knee, which are the ligaments that are most commonly injured. These ligaments are the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL). There are also two shock absorbers in the knee called the menisci. The larger bone in the lower leg is the tibia, which is commonly referred to as the shinbone. The end of the tibia is covered with a layer of cartilage. A piece of fibrocartilage called the medial meniscus and lateral meniscus sit between the tibia and the femur. Articular cartilage is also located on the femur. The remaining bone in the lower leg is the fibula. The joint is surrounded by synovium and a joint capsule. The synovium and joint capsule are the areas most affected by rheumatoid arthritis.
Importance of Physical Therapy for Knee Pain
Physical therapy is important for the speedy recovery and for preventing re-occurrence of knee pain. Physical therapy takes a two-part approach for treating knee pain. It first helps reduce the pain, and then works to prevent re-occurrence of pain in the future. This is done through reinforcing correct physical movements, and through strengthening the muscles that support the knee. It also helps in ensuring an individual is educated about the best body mechanics to take the stress off the knee(s). The ultimate goal is to fully restore the individual to their prior level of function. This is done through a detailed evaluation, which will allow the physical therapist to construct the optimal treatment plan for the individual. Treatment may consist of biomechanical training, weight reduction, utilization of an orthotic (braces, heel cups, etc), an exercise regimen, manual therapy or use of ice to decrease pain and inflammation. A study says that more researchers should look into physical therapy as a way to treat knee osteoarthritis, noting it has been proven effective and costs less than knee replacement surgery.
Common Exercises for Knee Pain
Endurance is the ability of a muscle to work over a long period. The exercise involves light resistance with many repetitions. It is beneficial to the legs to do this exercise for longer periods, for example, standing activities. A good way to improve the endurance of the muscles used in an activity is to try doing the activity for a little longer each day. Specific muscle endurance training can be done by doing the specific exercise for longer and longer periods. This may be very tiring at first, but it should become easier as the muscles get used to it.
There are two types of exercises that can be used to improve the ability of the muscles to do their job. They are called strengthening exercises and endurance exercises. Strengthening is the ability of a muscle to produce force. The exercise generally involves heavy resistance with fewer repetitions. Strengthening exercise can actually make some muscles sore. This is not unusual, especially if you haven’t been doing the right exercise for your problem. This will gradually improve as the muscle gets stronger. It should not last more than 48 hours after the exercise. It is not harmful to use sore muscles, providing you don’t overdo it. A support (e.g. stick or rail) may be needed for balance. As the stronger leg muscles improve, it will be possible to move the support nearer the leg to increase the force between the muscles. Different types of strengthening exercises are described in this section.
Range of Motion Exercises
Range of motion exercises promote movement in the knee and leg and are essential in the initial treatment phase for knee disorders or following surgery. This helps prevent muscle atrophy and the development of arthrofibrosis. Arthrofibrosis is a condition whereby the knee joint has less movement than is desirable, often due to pain and swelling, leading to further immobility and knee stiffness. This can create a detrimental cycle in delayed rehab and further pain and swelling. Therapist-supervised physiotherapy is vital in the first week following surgery, and it is the role of the physiotherapist to limit swelling and pain and increase the rate and extent of knee flexion and extension. This is commonly achieved through cold therapy (cryotherapy), elevation, soft tissue massage, and specific exercises to improve movement. These may include the patient sitting or lying with the leg elevated and the physiotherapist bending the knee to slide the heel towards the buttocks (knee flexion) or by using a towel to assist in bending and straightening the knee (knee flexion and extension). The amplitude of training must always adhere to the knee’s available pain-free range. High degrees of pain may increase muscle guarding and further decrease in pain-free knee range. Static quadriceps contractions with the knee fully straight are encouraged to maintain/develop VMO strength, an important factor in preventing knee subluxations during later range of motion exercises.
Strengthening Exercises
Knee Extension Knee extension is also a great way to strengthen the quadriceps without stressing the knee. But, you will have to use a resistance band. You can purchase these bands at any sporting goods store. To do the exercise: 1. Sit in a chair and tie one end of the band to the leg of the chair. 2. Place the other end of the band around the ankle of your injured knee. 3. The band will provide resistance as you extend your leg and try to straighten your knee. 4. For this exercise you will want to do 3 sets of 10-15 reps. This can be done every other day.
Straight Leg Raise One common exercise of strengthening the knee is the straight leg raise. The purpose of this exercise is to strengthen quadriceps (the muscle on the front of the leg, when it contracts the knee extends) without putting too much stress on the knee. To do this exercise correctly: 1. Lie on your back with one knee bent and the other leg straight. 2. Tighten the muscle on the top of your thigh of the straight leg, and then lift that leg up about 10 inches from the ground. 3. Keep in mind that you want your knee to be completely straight the entire time. If you have to prop your leg with something to do this exercise, do it. And remember, if you feel pain in the knee while doing this exercise, stop immediately. 4. The exercise is done when your leg has gotten tired or you have done 3 sets of 10-15 raises.
When you think about exercises, you probably think about lifting weights and using resistance bands. Actually, increasing the strength of your muscles around the knee can help decrease the pressure on the joint. But before doing any of these exercises, it is important to warm up. You may want to apply a warm pack to the knee or walk or ride a stationary bike for 5 minutes.
Balance and Stability Exercises
Specific balance and stability exercises should be included in every knee injury prevention and rehabilitation program. Balance exercises are designed to improve control of the limb and to prevent excessive joint movement that may result in further injury. Static balance exercises are performed on a stable surface and are useful in the early stages of rehabilitating injuries. Dynamic balance and landing pattern exercises are often sport-specific and are aimed at retraining reactions to a variety of perturbations. Balance should start easy and become more difficult as the person improves.
Strengthening muscles that support the knee with exercises done in a standing position will improve your knee stability for normal daily activities and sports. Closed kinetic chain exercises involve the foot being in a fixed position, in other words, standing on a firm surface. An example would be a squat with a theraband tied around the knees. Open kinetic chain exercises involve the foot moving freely.
Static balance is done on a stable surface. It is the ability to maintain a certain body position for a period of time. An example of this would be standing on one leg. Dynamic balance is the ability to move from one position to another. An example of this would be walking on a smooth, level surface. All of these aspects of balance can be practiced and improved with specific exercises. Balancing exercises should initially be performed with support. This can be a wall, table, or chair that you can hold onto. As you progress, doing the exercises without support will improve your balance more.
Proprioception is your body’s ability to sense its position in space and adjust in a manner to prevent falls. In people with knee pain, there is a delay in the muscles’ reaction times. For example, if you were to trip on something and start to fall, the muscles in a person with good proprioception would react and tighten to prevent the fall, whereas the muscles in a person with lessened proprioception would not tighten in time to prevent the fall.
Advanced Techniques for Knee Pain Management
Phase 1 knee OA occurs due to the breakdown of the hard tissue at the ends of joints. These are called the articular surfaces. This can lead to damage of the articular cartilage, which is designed to provide a smooth, lubricated surface for low friction movement of the knee joint. Damage to the cartilage causes increased pain and inflammation in the joint. Mild to moderate severity OA of the patella and femoral articulating surfaces responds well to joint surfaces. Joint surfaces are specific techniques designed to improve movement and decrease pain in areas of damaged hyaline cartilage.
In the treatment of increasing knee ROM, high and low-grade mobs and manipulations to the patella, tibio-femoral joint, and surrounding connective tissues are indicated. This is combined with soft tissue techniques to decrease any tension or contracture in the surrounding muscles. Once normal ROM is attained, functionality of the knee can be increased through a variety of strengthening exercises. Overall, manual therapy is an essential and highly effective technique in the treatment and management of knee OA.
Manual therapy is a highly specialized form of physical therapy that focuses on the use of ‘hands-on’ techniques to assess and treat soft tissue and joint injuries. The principal techniques include mobilizations, which are the movements of joints to increase range and normalize mechanical joint function, and manipulation, which uses a very specific, small movement to a joint to provide relief from pain and decreased function. The therapist performing manual therapy is highly skilled with a master understanding of anatomy and movement. They are able to locate the root of the symptoms and observe the movements of specific tissues or joints. Studies have shown that skilled manual therapy significantly improves pain, stiffness, and function in knee OA.
Manual Therapy Techniques
A recent RCT by Deyle, Allison, Matekel, Ryder, Stang and Gohdes (2005) compared manual physical therapy to a home exercise program for patients with knee osteoarthritis. The authors hypothesized that manual therapy in conjunction with supervised exercise would produce significantly greater improvements in knee pain, stiffness, function and aerobic capacity compared to a home exercise program. After 4 weeks of treatment, the manual therapy group had significantly greater improvements in WOMAC pain and function and stair climb performance compared to the home exercise program group. Both groups showed equal improvements in the 6-minute walk test and self-reported global knee function. These findings suggest that manual therapy combined with exercise provides superior improvements in pain and functional ability compared to exercise alone in a short-term period for individuals with mild to moderate knee osteoarthritis. This supports the research from Vicenzino and Wright (1995) which mentions that patients with patellofemoral pain have achieved positive clinical outcomes after manual therapy treatment but requires further research to draw a definitive statement.
Manual therapy is a hands-on treatment by clinicians to treat musculoskeletal pain and disability. Techniques comprise of mobilization (slow movements to improve access to joint function) and manipulation (a thrust technique to improve joint function). Manual therapy has been proven to be an effective and cost efficient treatment for musculoskeletal conditions. A 2007 systematic review by the American Physical Therapy Association (APTA) found strong evidence that manual therapy improved clinical and intermediate outcomes for knee osteoarthritis. Juhl, Christensen, Roos, Zhang and Lund (2007) found manual therapy to be the only physical therapy intervention that improved pain and clinical changes in knee osteoarthritis. This was just one of the positive outcomes from recent literature for using manual therapy techniques to treat knee pain.
Electrical Stimulation
Electrical stimulation (ES) is a valuable form of treatment for various different conditions, one of which is knee pain. ES works by mimicking the body’s natural mechanism for muscle contraction, applying electrical impulses to the motor nerves that cause muscles to contract. The impulses are generated by a device and delivered through electrodes to the skin in direct proximity to the target muscles. The use of ES for muscle strengthening has been widely researched, and it has been found that it can assist in increasing the strength of a weak muscle, maintaining or increasing strength during periods of inactivity, and preventing muscle inhibition while increasing muscle mass. ES has also been argued to assist in providing symptomatic relief of knee pain. This is thought to offer the patient an increased ability to exercise and undertake other forms of rehabilitation to further improve their condition. Furthermore, study findings suggest that ES in combination with exercise therapy can be more effective than exercise therapy alone for patients with osteoarthritis, improving muscle strength and functional performance. ES has many other uses, including quadriceps re-education and prevention of muscle wasting, which can commonly occur in those with knee pain due to traumatic injury or surgery. Overall, the vast amount of research on ES supports the view that it is a highly beneficial form of treatment for knee pain.
Ultrasound Therapy
Widespread use of therapeutic ultrasound as a treatment for musculoskeletal conditions has occurred only in the last 10-15 years. The most popular use of ultrasound is for its potential to enhance tissue healing. Ultrasound does this by increasing blood flow to the injured area. This can help reduce swelling and decrease pain. Once the injury has entered the subacute or chronic phase, ultrasound can help to realign collagen fibers which, if allowed to heal on their own, will remain disorganized and form scar tissue. This will lead to a mechanical weakness in the tissue. It is in the treatment of chronic injuries that the use of ultrasound is most beneficial. The reason for this is that the intensity of the treatment and duration of the treatment cause more of a biological response. This, coupled with the fact that chronic injuries usually have a lower rate of tissue metabolism, means that the ultrasound is more likely to have a positive impact.
Cold and Heat Therapy
Heat packs will increase blood flow, relax tight and sore muscles, and also ease joint stiffness. It is best used for chronic, sub-acute conditions and before exercise. For chronic pain, heat packs can be applied for a longer period of time, up to 2 hours. Caution should be taken to avoid burns for patients with decreased skin sensation or poor paralysis. Step-by-step instructions can be provided to avoid patient confusion.
Contrast bath therapy is the intermittent use of both heat and cold therapy. It involves immersion of the limb and quickly changing from hot to cold water and back. An increased circulatory effect is achieved from the vasodilation and vasoconstriction. This is a usual treatment for conditions such as osteoarthritis. This needs to be done in a safe environment and generally not recommended for patients with neurological deficits.
Cold packs cause vasoconstriction in the skin and muscle, reducing blood flow to the area thus decreasing inflammation and swelling. It also slows down pain signals along nerves. An example of when to use cold therapy includes acute injuries, during flare-ups or after exercise. Precautions must be taken with patients who have sensory deficits, poor circulation, or are hypersensitive to cold. This should be applied for 10-20 minutes.
There are different types and advantages of using cold and heat therapy for knee pain. It is important to understand when and how to utilize these techniques to maximize outcomes for knee therapy.
