Knee Pain

Knee pain may arise due to injury of several structures both inside & surrounding the knee joint. The knee is stabilized externally by a joint capsule and the collateral ligaments that run down either side of the joint line.

Internally, knee joint stability & control of rotation is provided by the anterior & posterior cruciate ligaments & the meniscus (cartilage). The anterior cruciate ligament is smaller & more vulnerable than the posterior cruciate ligament. The anterior cruciate is roughly the size of your little finger.

 

Causes of Knee Pain

Because the knee is a weight-bearing joint it undergoes significant load during walking & running; therefore, it is particularly prone to injury.

There are several causes of knee pain & expert physiotherapy assessment is necessary to differentiate between the many causes of this condition.

  • Muscular
  • Tendon
  • Cruciate ligament tear 
  • Meniscus/Cartilage injury
  • Medial or Lateral ligament injury
  • Osgood Schlatter disease: this is an irritation of the patella ligament where it inserts into bone & is most common from 9-16 years of age.
  • Referral from: lumbar spine, pelvis or hip
  • Vascular (blood flow related) conditions may also give rise to knee pain

 

Knee Joint Assessment

If knee pain occurred due to trauma then evaluation will focus on the knee joint itself. Potential structures involved include the muscles, anterior cruciate ligament and meniscus.

If, as in most cases, the knee joint pain arose due to overuse, then a movement quality evaluation of the whole lower limb & trunk region is warranted.

Abnormal alignment of the hip or knees such as present with knocked knee posture may predispose some individuals to knee pain.

Swelling, clicking, or giving way are all strong indicators of knee joint pathology and should be investigated immediately. Causes of such complaints include ACL & meniscus injuries or a loose body (cartilage or bone) within the joint.

Pain in the front of the knee which is made worse with running & jumping may indicate injury to the knee ligament just below the kneecap (the patellar ligament) or Osgood-Schlatters disease (irritation of the patellar ligament where it inserts into bone).

 

Knee pain treatment at the Physio Clinic - Naas & Newbridge

Ross Allen is a former Ireland rugby International & County Football Player. Ireland’s only dual qualified Chartered Physiotherapist & Chiropractor.

 

Why does my knee click?

Clicking or cracking of the knee is commonly reported in those suffering from patellofemoral pain syndrome.
Patellofemoral pain syndrome is a pain to the front of the knee that occurs around the kneecap due to activation of pain-sensitive nerve endings in the area.
The pain is frequently caused by vigorous, repeated physical activity such as jogging or squatting. Any sudden changes in exercise frequency or intensity will also increase the likelihood of this condition developing.
Cracking below the kneecap may also occur due to a condition called chondromalacia patella. This involves small cracks (fissuring) of the cartilage underneath the kneecap.
Abnormal tracking of the kneecap in the groove into which it sits (the trochlear groove) can also be a predisposing factor. When the knee is bent the patella can tilt to one side and increase the pressure between the kneecap and underlying bone.
Although knee pain can be quite concerning, it is important to maintain activity levels as best you can to avoid muscle wasting and decreased joint capacity. However, it is best to decrease the frequency or intensity of activities that induce knee pain. 
This may mean switching part of your exercise routine to less stressful activities such as cycling. If you have a high body-fat percentage then changing your diet and lifestyle to help decrease this will help to decrease the amount of inflammation present in your body. Body fat acts as a storage site for inflammatory markers which can circulate in the joint & increase pain and degeneration.

Causes of knee clicking

1) Gas bubbles inside the joint will expand as the joint is distracted and pop as a result
2) A fine grating noise is commonly an indicator of patellofemoral joint involvement (kneecap). This can be normal or due to degeneration of the cartilage underneath the kneecap.
3) If the noise is more like a creak (a closing door sound) then this may indicate arthritis of the knee.

Physiotherapy for Knee Pain

Knee pain or clicking should never be ignored and the earlier in the process the problem is dealt with, the better the long-term outcome from care. It is my experience that knee pain can be particularly responsive to appropriate physiotherapy management. Thankfully, the majority of knee complaints can be resolved without requiring surgical intervention.

If swelling is present then the first goal should be to bring this under control with use of a R.I.C.E. protocol (Rest, Ice, Compression, Elevation). An active physiotherapy & exercise intervention can then be commenced which will prioritise progressive strengthening of the involved area as well as addressing biomechanical deficiencies that may have given rise to the injury.

Is Swimming Good for Knee Pain or Arthritis?

Patients frequently ask about the benefits of swimming for knee pain. While swimming is a low impact activity & therefore is unlikely to aggravate the knee it also is unlikely to improve strength & muscle control around the joint.

Therefore, I prefer weight-bearing exercises, where possible, to improve the capacity of the knee joint to withstand normal daily activities and to prevent a further diminishing of overall muscle strength. If knee strength or control diminishes then so does overall capacity.

Many people are often fearful of loading a degenerative or painful knee but you can rest assured that the research does not support a link between exercise or knee joint loading & knee arthritis (Chakravartv et al. 2008).

One study by Roos & Dahlberg (2005) demonstrated that exercise improved knee cartilage quality in a group of individuals at risk of knee joint arthritis. This suggests that exercise is protective as opposed to being harmful in this population.

There are also animal studies demonstrating that cyclic loading (where load is applied to the joint & then released) applied to cartilage encourages healthy cell division & cartilage quality. This cyclic loading mimics running & walking activities.

Prolonged loading of the knee without rest, on the other hand, can give rise to cartilage degeneration in animal studies. This may partially explain the higher incidence of knee arthritis in overweight individuals.

Interestingly, long-term studies in runners do not demonstrate an increased rate of knee arthritis in this group. Most people are surprised to hear this as they assume that more exercise will lead to a higher incidence of degeneration.

Research from the University of Maryland has demonstrated that, although the forces applied to the knee are high during running, the overall load on the knee is comparable to walking over the equivalent distance. This is because the longer stride used for running leads to less contact time with the ground compared to walking.

Does Obesity Increase the Risk of Knee Arthritis?

Obesity is a predictor of inflammation within the body. As fat acts as a store of inflammatory markers, your body fat is a predictor of your overall inflammation. Inflammatory chemicals can increase in the blood in such individual and over time can lead to degeneration within the joints. 

Research suggests that individuals who are overweight or obese have three times the risk of developing knee arthritis. Therefore a weight management component should form an important element in managing knee pain in those suffering from arthritis.

Do I need Knee Surgery?

According to Professor Andrew Carr who is a leading surgeon, many keyhole surgeries are no more effective than painkillers. He states that the success of many such procedures is down to the placebo effect. The placebo effect is where patients feel better as a result of their belief in the treatment. He also warned that keyhole surgeries carry serious complications such as infections or pulmonary embolisms. One in 1,000 people died as a result of the procedure.

The research from Lund University in Sweden involved a systematic review of the research to date on arthroscopic procedures carried out on individuals with cartilage tears or arthritis. The authors found that rehabilitation exercise for such conditions was almost as effective but without the serious side-effects involved in surgery.

Bart Ferket of Mount Sinai Health System, New York, says it’s best to treat the person, not the X-ray. X-ray and MRI findings don’t correlate well with symptoms; you can have an awful-looking X-ray but not suffer much pain or stiffness, and vice versa.

Bart has carried out a study in the US to look at the cost-effectiveness of knee replacements. Most people with knee symptoms do report an improvement in symptoms after this major operation but, unsurprisingly, the worse you are before the op, the bigger the improvement.

It is recommended that knee replacement surgery should only be attempted after other interventions, such as physiotherapy guided exercise regimes, weight-loss, and painkillers have been attempted.

 

Thorlund et al. (2015). Systematic Review of the Knee Pain Literature

The authors performed a randomised controlled trial assessing the benefit of arthroscopic knee surgery in middle aged and older patients with knee pain and degenerative knee disease. When analysed over time of follow-up, interventions including arthroscopy showed a small benefit of 3-5 mm for pain at three and six months but not later up to 24 months. No significant benefit on physical function was found.

The authors concluded that ‘the small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery’. Knee arthroscopy is also associated with harmful side effects including deep venous thrombosis, pulmonary embolism, infection, and death.

‘These incidents occur at a rate of 4.13 per 1000 procedures. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis’.

Knee operations for UAE’s elderly ‘expensive and unnecessary’. The National, UAE. July 31, 2016. 

The BMJ reviewed 18 studies on knee surgery compared with exercise and a placebo operation, for patients in Denmark and Sweden between 48 and 63 years old. No significant benefit to the knee’s function was found after surgery.

Nine more studies were evaluated to assess the degree of harm that patients were at risk from. Deep vein thrombosis was the most frequently reported adverse effect.

‘Knee surgery is often only necessary when arthritic changes are so advanced that the patient cannot walk, but rarely in anyone under 55’.

Orthopaedic surgeon Dr Anurag Sapolia performs up to 20 knee procedures every month at Medeor Hospital in Dubai. “It has been a proven fact that arthroscopic surgery for pain management in older patients is often not necessary,” he said. “Physical therapies are a better option. Surgery is always a last resort.”

“I don’t recommend surgery in older people unless there is structural damage, maybe only one patient every three months or so,” Dr Sapolia said. “Other clinics are definitely pushing these kind of surgeries when they are unsuitable.”

What Physiotherapy Treatment Is Best for Knee Arthritis

Pain is experienced through the nervous system. Overactivation of the nervous system is the defining characteristic of pain. Some of the proposed treatment benefits of joint mobilisation occur through decreasing the activation of the central nervous system pain pathways (nociceptive pathways)

Impaired of these pathways has been found experimentally in persons with knee and hip arthritis. One way of measuring the effectiveness of treatment interventions on the nervous system is to measure a person’s sensitivity to painful touch before and after applying a treatment. 

Courtney et al. (2016) found that joint mobilisation resulted in a global increase in pressure pain threshold. In other words the person could withstand more skin pressure prior to experiencing pain after having the joint mobilisation. Resting pain was also significantly lower following the joint intervention.

 

References

  1. Blagojevic, M., Jinks, C., Jeffery, A., Jordan, K.P. (2010). Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthritis Cartilage; 18(1): 24-33. http://www.oarsijournal.com/article/S1063-4584(09)00225-8/abstract
  2. Roos EM, Dahlberg L. (2005). Positive effects of moderate exercise on glycosaminoglycan content in knee cartilage: a four-month, randomized, controlled trial in patients at risk of osteoarthritis. Arthritis Rheum; 52(11): 3507-3514.
    https://onlinelibrary.wiley.com/doi/full/
  3. Chakravartv, E., Hubert, H., Lingala, V., Zatarain, E., Fries, J. (2008). Long Distance Running & Knee Osteoarthritis. A prospective Study. American Journal of Preventative Medicine; 35(2): 133-138.
    http://www.ncbi.nlm.nih.gov/pmc/articles/
  4. Knee operations are no better than painkillers, says leading surgeon – so is keyhole surgery all in the mind?
    http://www.dailymail.co.uk/sciencetech/article-3634434/Knee-operations-no-better-painkillers-says-leading-surgeon-keyhole-surgery-mind.html#ixzz4C2bEMwPh
  5. Thorlund, B. (2015). Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ; 350:h2747.
    http://www.bmj.com/content/350/bmj.h2747
  6. Knee operations for UAE’s elderly ‘expensive and unnecessary’. The National, UAE. July 31, 2016. Author: Nick Webster. http://www.thenational.ae/uae/knee-operations-for-uaes-elderly-expensive-and-unnecessary
  7. Courtney et al. (2016). Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee. The Journal of Orthopaedic and Sports Physical Therapy;46(3):168-76. http://www.ncbi.nlm.nih.gov/pubmed/26721229

 

To find out more regarding Knee pain, contact Naas Physio Clinic on:
(045) 874 682

or email us at info@physioclinic.ie

For further information on conditions treated go to:
www.physioclinic.ie/conditions