Knee Pain - What We Can Do For You
Knee pain is extremely debilitating and can be complex. You may have arthritis to injuries sustained from day-to-day life, sports fall and post-surgery knee pain. Thankfully a combination of manual therapy and rehabilitation/strengthening exercises is usually a good regime to get your knee pain under control.
In order to understand and differentiate what might be going on with your knee, here are a few of the main conditions that can impact the knee and how to make it easier for yourself before and after your treatment.
In the case of acute knee pain, there is a treatment protocol that can help manage the condition.
Below is a recap of the protocol. In the first few days post-injury use P.E.A.C.E. After the first few days have passed start using L.O.V.E. What does this entail? Take a look below.
PEACE & LOVE Protocol to ease knee pain.
The above poster is taken from an article published in 2019 in the British Journal of Sports and medicine (the full title can be found in the reference section). There is stated in the article evidence that icing should be avoided as it could disrupt tissue repair.
However, it has to be said that ice has been used successfully for a long time. If you are going to choose between anti-inflammatory medications (which in the protocol should also be avoided) and ice, ice should definitely be the first choice. At the end of the day, listen to your body and do what feels right for you.
THE OTTAWA KNEE RULES:
What is this? This is a protocol that helps clinicians identify if someone needs a scan or further medical referral (you can read our blog on scans). According to the rules you should seek a scan (most probably an x-ray to start with) or will be referred for one if:
Ø You are aged 55 or older
Ø Have tenderness on the head of the fibula (the outside bone on your lower leg, the head of which is a little nobble on the outside and slightly below your knee)
Ø Have isolated tenderness on the patella (kneecap)
Ø Cannot bend the knee past 90 degrees
Ø Cannot stand on your affected knee (seen as the inability to take four steps or two steps on each leg even with limping).
Disclaimer: Please note that this article is purely informative and should not be used as a means to self-diagnose but to try and get a better understanding of anatomy/physiology and pain management. Always seek professional help before taking any drastic measures. Do not hesitate to call or email or use the contact us part of the website as well if needed.
LIGAMENT INJURY GRADING:
Ligamentous injury grading (Physiopedia, 2023):
· Grade I: only structural damage is present on a microscopic level, local tenderness and no instability is noted. You may see mild swelling.
· Grade II: Partial tearing (rupture) of the ligament, swelling and noticeable tenderness, and can be present with or without mild joint instability
· Complete tear of the ligament, significant swelling and instability of the joint
Mild to moderate strain grade I and II are often treated conservatively and normally heal within 6 to 8 weeks (often sooner with grade I).
Valerian Osteopathy - Knee Pain
COMMON KNEE PAIN CONDITIONS:
· Anterior Cruciate Ligament (ACL) strain/Tear
The anterior cruciate ligament controls the tibia (shinbone) from moving forwards on its above counterpart, the femur or thigh bone. It also prevents the tibia from turning in and out, increasing stability.
Injury to the ligament can happen from repetitive micro injuries over time and one significant traumatic injury, often from sporting injuries or accidents.
The ACL is anatomically quite significant and is linked to the medial (inside) meniscus and the medial collateral ligament (MCL). In fact, the MCL and ACL have fibres that blend with the medial meniscus. For this reason, they often get injured together which awarded them the name of the “unhappy triad’.
Mechanism of injury:
- Often sharp deceleration with a sudden change of direction (twisting)
- Straight-legged landing from a horse from an angle also can be a reason for
ACL injury
Presentation:
- Deep knee pain, a popping sound might be heard at the time of injury
- The pain might have started on running and then quickly changing the direction of the run, landing with the leg straight from a jump or having the knee forcefully going backwards behind what is normally the end range of that motion (hyperextension).
- If there is to be knee swelling, it is usually noticed within 2 hours post-injury.
- A history of previous injuries or knee stability issues (like being hyper-mobile or “double jointed” as is commonly known).
- As we said earlier, the ACL is part of the “unhappy triad”. For this reason, the medial collateral ligament and the medial meniscus might get injured as well, and symptoms like clicking and pain on the inside of the knee may also be present.
Prognosis/Rehabilitation:
- Mild tears respond well to conservative treatment.
- In the case of surgery <75% of patients return to normal daily activities without issues.
- Starting with core stability exercises and then starting with knee exercises that focus on a pain-free range of motion will help with recovery quickly.
- Maintaining knee extension should be a priority in rehabilitation
- Good prevention and rehabilitation regimes that focus on strengthening the hamstrings and quadriceps of the legs will provide better results.
- Aquatic exercises can be particularly useful.
Medial Collateral Ligament (MCL) Strain/Tear
The MCL gives stability against valgus force (forces coming from the outside of the knee, pushing the knee inward). It is the commonest ligament to be injured in the knee.
Mechanism of injury:
- Contact sports are a very common place for this to happen.
- Can be an overuse injury in the swimming population, especially the frog kick movement of the breaststroke.
- Prior injuries can be a predisposing factor as well as instability.
Presentation:
- May hear a pop or feel a tearing sensation on the inside of the knee
- The pain will be following a blow from the outside of the knee, like a tackle for example in football or other sports.
- The pain will be located on the inside of the knee
- Because it is part of the “unhappy triad”, the ACL can be injured in 20% of grade 1 injuries (see grading above in this article).
- The medial meniscus is injured 5-25% of the time and can evolve with the severity of the MCL injury.
Prognosis and rehabilitation:
- Most patients with mild to moderate presentations return to full function within three months.
- Severe injuries may take 6-9 months to heal.
- Rehabilitation follows the same principle that we discussed before.
Knee Pain
· Meniscal tears
The meniscus is the C-shaped fibrocartilage inside the knee joint, there are positioned on top of the tibia in an area called the tibial plateau. There is a medial and a lateral meniscus.
50% of the load is transmitted to the knee when it is unlocked in extension and 85% when the knee is bent at 90 degrees.
Mechanism of injury:
Often twisting and repetitive activity in younger patients and accompanied by osteoarthritis in the older population.
Most injuries (around 75%) of injuries involve the medial meniscus.
Types of Meniscal Tears
Image Physiopedia (2023)
Above are the different types of meniscal tears. Certain more complicated tears, like the bucket-handle tear, can trigger symptoms like locking and signification clicking of the knee.
As previously mentioned, the medial meniscus is part of the unhappy triad, for this reason, 33% of tears in adults are associated with ACL tears. In younger patients, this number rises to 98%.
Presentation:
- Joint line tenderness is a tell-tale sign of a meniscal issue and will be present in 77-86% of cases.
- Can be immediate swelling or none at all.
- Can happen through repetitive squatting and/or twisting or a single traumatic event.
Prognosis and rehabilitation:
- Surgery might be advised in more complex and traumatic onset tears. Surgery has a mixed outcome. The factors in proper healing inappropriate rehabilitation. Strengthening is key alongside regular physical therapy, like osteopathy.
- Rehabilitation should be focusing on the quadriceps and hamstrings. The workouts should be low or nonimpact (indoor cycling or straight leg raises for example).
- As usual, for balance and proprioception, progressed to wobble boarding and one-legged exercises.
· Knee Bursitis
Inflammation of the pockets of fluids around the knee (bursa, plural bursae). Bursae are designed to protect the knee and help tendons and ligaments glide without issues. Any repeated trauma to the muscles, tendon or ligament could irritate the bursa and cause them to swell up. Bursae are normally non-palpable when they are not inflamed.
There are several bursae in the knee:
Bursae
Image, Rehab My Patient, 2023.
Presentation and history:
- Pressure, and tenderness in the knee. Swelling will be at the specific site of the inflamed bursa.
History of repetitive activities. For example, the prepatellar bursae is quite commonly inflamed in people who kneel a lot.
- The pain would be worse for knee movements as the swelling will make certain movements quite difficult.
Prognosis and rehabilitation:
- The prognosis is excellent with conservative treatment. The use of ice is advised in the acute phase.
- Surgery is rarely required.
- Gentle stretching of the leg followed by the strengthening of the thigh muscles (flexors, extensors, abductors, and adductors) are the best way to rehabilitate and prevent reoccurrence.
This article only covered some of the issues that might arise in the knee. If you are struggling with knee pain and want more information, are seeking to get treatment or just want to rehabilitate or make your knees stronger, do not hesitate, to call/email us or book an appointment with us online.
Here at Valerian Osteopathy, we have a great system for rehabilitating knee pain conditions. So if you would like to book with us you can do so through our easy-to-use link button below.
Knee Pain