Knee Pain

Patellofemoral Pain Syndrome (PFPS) is a broad term or “umbrella diagnosis” that is used to describe any pain at the front (anterior) of the knee, on or around the patella. It is by far the most common knee complaint that presents to physiotherapists. There are many factors that contribute to the development of PFPS and symptoms can vary greatly between individuals, but always involve pain somewhere on the front of the knee.

Potential contributing factors may include:

• Individual anatomical variants of the patella and/or femur

• Types of activity and changes to activity levels

• Muscle imbalance

• Biomechanical faults

Risk factors include:

• Age - PFPS is more common in adolescents and young adults

• Gender - Women are twice as likely to develop PFPS than men

• Activity - running and jumping sports carry a higher risk

Many people often put up with their symptoms for weeks or months before seeking help. Physiotherapy should commence sooner rather than later, with the goal of:

• Assessing you as an individual to determine what factors may have contributed to the development of your pain

• Educating you about your condition

• Commencing treatment specific to you, based on your assessment

• Planning out your return to activity and sport

Osteoarthritis (OA) of the knee is a degenerative joint disease that is characterized by a loss of joint space and articular cartilage, the formation of bony spurs, and subchondral cysts. Clinically it presents with pain, swelling, a loss of range of motion, morning stiffness, crepitus or “creaking”, and stiffness after prolonged rest. It is more prevalent in older age groups and in obese individuals, usually only affecting people over the age of 40, and is the result of wear and tear over many years. Treatment for knee OA is always conservative to start with. We cannot replace cartilage or reduce the loss of joint space, however we can slow the progression of disease, and improve symptoms and function, by improving range of motion and strength and leading active low-impact lifestyles. Plain film X-rays are used to diagnose and monitor the progression of the disease. The goal of physiotherapy is to

• Educate you about your condition

• Reduce pain and improve range of motion

• Build Strength

• Improve function and quality of life

• Avoid surgical intervention if at all possible

The Patella is a large sesamoid bone that sits at the front of the knee, inside the quadriceps muscle between the quad tendon and patella tendon. It articulates with the femur (thigh bone) creating the patellofemoral joint. The patella most commonly dislocates laterally (towards the outside of the knee) and is usually the result of contact e.g. a player hitting the inside of the knee. The patella may dislocate without contact or force too, either because the individual displays certain anatomical variants that predisposes the patella to dislocating, or because the patella has dislocated before in which case it is much easier to do so again. There may or may not be associated fractures, and it may relocate immediately by itself, or require assistance. The severity of these injuries varies greatly. Some individuals who experience recurrent dislocations may be able to weight bear immediately without much pain and swelling, whereas others experiencing their first traumatic dislocation may have extreme pain, swelling, a loss of range and strength, and an inability to weight bear. Many factors impact the type of treatment and recovery timeline, which may span weeks to months. Some dislocations with associated fractures require surgical stabilization and/or bracing. Plain film X-rays are usually recommended following an acute dislocation to rule out a fracture. Conservative management should begin immediately if surgery is not required, or after surgery as directed by your specialist.

The goals of physiotherapy are to:

• Educate you about your injury

• Assist you in acute injury management, and to minimize pain and swelling

• Protect the injured structure

• Commence early rehabilitation

• Plan out your return to sport and activity

A meniscus is a piece of thick fibrocartilage that is located inside the knee joint, and sits on top of the tibia (leg bone). Each knee has 2 menisci; the medial meniscus which is more of a C-Shape and less mobile due to its attachments to the MCL and joint capsule, and the lateral meniscus which is more round and mobile. Blood supply to the meniscus varies, with the inner third being almost avascular, and the outer third being highly vascular. The menisci are often injured acutely during weight-bearing and twisting motions of the knee, and may be injured in isolation or in conjunction with other structures e.g. the ACL. The menisci can also degenerate over time and sustain small degenerative tears which may flare up later down the track. The severity of the injury depends on which meniscus is involved, in which zone the tear is located (more vascular zones have more ability to heal), the type of tear, and whether it is an acute or chronic injury. Symptoms may include knee swelling, tenderness along the joint line/s, pain or restriction to bend the knee, pain and difficulty weight bearing, an inability to bend, squat and kneel, and a catching or locking sensation that may or may not be painful. Recovery can take anywhere from several weeks to several months. Generally imaging is not required right away (if at all), nor is a referral to a specialist. Following injury, physiotherapy should commence right away, with the goal of:

• Educating you about your injury

• Assisting you in acute injury management, and to minimise pain and swelling

• Protect the injured structure

• Commence early rehabilitation

• Plan out your return to sport and activity

PCL

The Posterior Cruciate Ligament (PCL) is one of the four major stabilizing ligaments of the knee. It is located inside the knee joint itself, and is responsible for limiting backwards movement of the tibia (leg bone) in relation to the femur (thigh bone) as well as providing rotational stability. The PCL is often torn due to the impact of external forces e.g. car accidents, on the sporting field. Injuries are graded I-III based on severity. Symptoms will vary depending on severity, but may include pain, swelling in the calf (and usually not in the knee), a loss of knee range of motion, a feeling of instability or episodes of giving way, difficulty walking, and a loss of strength. Unlike the ACL, the PCL does not require surgical reconstruction and treatment is almost always conservative. Recovery can be as quick as several weeks, or take several months. Following injury, physiotherapy should commence right away. The goals of treatment are to:

• Educate you about your injury

• Assist you in acute injury management, and to minimise pain and swelling

• Protect the injured structure

• Commence early rehabilitation

• Plan out your return to sport and activity

ACL

The Anterior Cruciate Ligament (ACL) is one of the four major stabilizing ligaments of the knee. It is located inside the knee joint itself, and is responsible for limiting forward movement of the tibia (leg bone) in relation to the femur (thigh bone) as well as playing a pivotal role in providing rotational stability to the knee. It is often a non-contact injury sustained during cutting or side stepping movements, where the foot is planted and the knee rotates. These injuries are characteristically accompanied by a loud “pop” or “crack”, pain, and swelling within the hour. Young females with a history or family history of ACL tears are most at risk, as well as anyone playing cutting sports. Complete tears are most common, however partial tears can occur. Symptoms vary between individuals but may include pain, swelling, a loss of range of motion, instability of the knee and episodes of giving way, inability to weight-bear initially, loss of strength and difficulty walking. Recovery takes months to years, and depends on whether treatment is conservative (physiotherapy and exercise) or surgical (ACL reconstruction). The ACL is unable to heal by itself, so the ligament must be reconstructed surgically. However, there is emerging evidence that shows that reconstruction is not absolutely required to make a full recovery, and that many individuals are able to recover their strength and stability by conservative means (and without an ACL). Which treatment option is right for you depends on many factors and is a decision that you should make after consulting your treating health professionals. Whichever treatment path is chosen, it is recommended that you do not return to high risk sports for 12 months as the risk of re-injury is highest in this timeframe. Following injury, physiotherapy should commence immediately. The goals of treatment are to:

• Educate you about your injury

• Assist you in acute injury management, and to minimise pain and swelling

• Commence early rehabilitation

• Assist in decision making on conservative vs non-surgical treatment options

• Commence treatment and plan out your return to sport and activity (regardless of which path you choose)

The Medial Collateral Ligament (MCL) is one of four major stabilising ligaments of the knee. It is located on the inner side of the knee and is responsible for limiting how much the joint collapses “inwards” or “opens up”. The MCL is often injured during cutting movements where the knee collapses in, or during contact sports where another player may impact the outside of the knee, forcing it inwards. It can be injured in isolation, or in conjunction with other structures such as the ACL or meniscus.

The Lateral Collateral Ligament (LCL) is another of the four major stabilising ligaments of the knee. It is located on the outer aspect of the knee and is responsible for limiting how much the joint collapses outwards or opens up in that direction. The LCL can be injured in isolation, but is much more commonly injured in conjunction with other structures such as the ACL, meniscus and posterolateral corner structures. The LCL is normally injured during contact sports, skiing or water skiing where the feet are locked/immobile, or during non-contact injuries where the ACL and meniscus are also torn.

Collateral ligament injuries are graded I-III based on severity. Symptoms will vary depending on severity and which other structures are involved, but may include pain, localized swelling or a knee joint effusion (large global swelling of the knee), a loss of knee range of motion, tenderness along the inside of the joint, a feeling of instability or episodes of instability where the knee gives way, difficulty walking, and a loss of strength. These injuries are almost always managed conservatively, without surgical intervention. Recovery can take anywhere from several weeks to several months. Following injury, physiotherapy should commence right away. The goals of treatment are to:

• Educate you about your injury

• Assist you in acute injury management, and to minimize pain and swelling

• Protect the injured structure

• Commence early rehabilitation

• Plan out your return to sport and activity