Knee injuries are one of the most common injuries we see at the clinic. They are either the result of an acute traumatic event or an overuse type injury that occurs from repetitive sport or activities.
In the acute phase of a traumatic injury the body responds with inflammation, swelling, pain and often a loss of movement.
The treatment at this stage is RICE (relative rest, ice, compression and elevation). After 36-48 hours with good management this usually settles, but the underlying damage can still cause on-going problems. If the injury has been particularly traumatic and a fracture is suspected, then this needs to be determined by x-ray and appropriate management started.
There can be many causes for on-going symptoms, such as fractures, ligament injuries, meniscal damage, tendon injuries, patella dislocation or overuse pain such as ITB syndrome and degenerative joint changes (arthritis).
The ligaments go from bone to bone and provide support and stability to the joint. If the ligaments have been strained this can limit joint movement and cause pain. In the knee there are 2 collateral ligaments which run either side of the knee, inside is the medial collateral ligament and the outside one is the lateral collateral ligament.
The cruciate ligaments are inside the joint and are referred to as the intra-articular ligaments and prevent forward and backward movement of knee. The anterior cruciate ligament (ACL) stops the forward movement of the tibia and is frequently injured in sports such as netball and rugby. The ACL is typically injured in a non-contact situation, often with a sudden change in direction or a jumping and landing mechanism causing hyperextension and twisting motion of the knee. Sometimes people hear an audible popping sound as the ligament ruptures.
The posterior cruciate ligament prevents backward movement of the tibia and is not injured as often as the ACL. Injury most often occurs when a force is applied to the front of the tibia when knee is bent, with a hyperextension (forced over straightening), or a twisting motion to the knee.
The meniscus act as a cushioning mechanism for the knee and helps aid in the preservation of the joint surfaces. They help in the transfer of forces across the knee joint during movement and help to balance the changes to the joint surfaces that occur with various loads and activities.
The meniscus is most often injured with activities that involve a twisting motion to the knee, more commonly in a bent position and with the foot planted. The degree of damage can vary and cause a variety of symptoms. The most severe being a tear large enough to cause the knee to lock and prevent full movement. These injuries are always painful. The smaller tears or multiple small splits don’t have quite the same severity of symptoms but are still painful and often prevent people from doing the activities they love.
Surgery is usually required for moderate to larger tears which are restricting joint movement. Smaller tears are generally managed relatively conservatively to see how they respond. They often take some time to settle, but usually respond well to light exercise – with cycling being the most effective.
The quadriceps tendon runs across the top of the patella (knee cap) and the patella tendon is at the bottom end and attaches just below the knee at a bony prominence.
Tendons can be acutely injured causing a rupture or suffer from an overuse type injury resulting in tendinopathy. These injuries tend to occur with sports that have a high rate of jumping and landing and fast acceleration-deceleration activities such as basketball, netball and volleyball.
There has been a lot of recent research into the treatment of these structures and specific exercises can be helpful.
The hamstring (muscles at the back of the leg) have tendinous structures that attach to the tibia on either side of the knee and bend the knee. These can also be torn or strained with various sporting activities, football being one of these.
The patella (knee cap) can be acutely injured through dislocation where it pops to the outside of the knee causing significant pain and loss of movement. The knee cap can also be fractured through falling with force onto the knee.
Pain around the patella (knee cap) can develop soon after a knee has been traumatised and swelling has occurred. The trauma has a detrimental impact on the muscles around the knee, particularly the inside quadriceps muscle known as the vastus medialis (VMO). The pain, swelling and inflammation cause the muscle signals to ‘switch off’ and for the muscle to become weak, which can cause the patella to track in a less than ideal position, resulting in pain.
These conditions are created with repetitive and often weight bearing activity across a variety of sports and can cover a myriad of injuries. Running, walking and cycling are just a few repetitive sports that cause overuse knee pain.
Overuse conditions include retropatella pain or patellofemoral pain, Iliotibial band syndrome (ITB for short), tendinopathies and bursal involvement.
1.Patellofemoral or retropatella pain
Patellofemoral or retropatella pain is often associated with poor tracking of the knee cap causing pain anywhere around the knee cap and even to the back of the knee. It can be further complicated by influencing biomechanics around the pelvis, hip, knee and ankle. Strengthening and stretching of various muscle groups help unload the knee region. Technique and training load and progression are major contributors to the development of this problem.
The Iliotibial band is a wide band of fascia (or ligament) that runs down the side of the upper leg from the outside hip region to the outside of the knee. Imbalance between these two points can cause problems. If some of the muscles around the pelvic/hip region are not doing their job particularly well, then the ITB tends to take up the slack which can cause tension and sub-optimal movement range resulting in knee pain.
This can be particularly noticeable with downhill running control or running on uneven ground. Biomechanics as well as training load and progression also influence this problem and there’s often more than one component that needs addressing.
Although not overly common at the knee, they can occur with repetitive movement and overloading of the tissue, resulting in severe pain.
Degenerative joint changes (arthritis)
When there has been an injury, often years ago or a gradual build-up of wear on the knee there can be a thinning of the cartilage that lines the joint and a narrowing of the joint space. This causes pain, swelling and sometimes limitation of movement and decreased muscle strength around the knee. An example is the person who years ago had an ACL rupture who then develops a symptomatic knee. Regardless of whether an ACL rupture is repaired or not, it has been shown that the joint will develop arthritis.
This can be distressing but if caught early enough, physiotherapy can improve symptoms and function. If surgery is required then an exercise programme can be helpful to give the best post-operative outcome.
Active young athletes can develop overuse type injuries in the knee affecting the bony compartments of the knee. Osteochondral changes can occur and need to be diagnosed and managed early to prevent major problems to the growing joint. Osgood Schatters disease is another relatively common condition for the young growing athlete, causing pain at the front of the knee at the bony prominence (tibial tubercle) just below the knee cap.
As you can see, knee pain covers a myriad of conditions and injuries. For the most part, injured knees generally respond well to prescribed exercises with some form of stretching and strengthening components. Physiotherapy is a valuable part of the rehabilitation process and with our on-site gym we are able to provide individualised and progressive programmes to help people return to form as soon as possible.
Book your appointment at Ponsonby Physio
Ph: 09 378 6890