To understand why you are experiencing knee pain, it is important to understand how the knee works. The knee joint is where the end of the thigh bone (femur) meets the beginning of the shin bone (tibia). At the joint meeting points between the femur and tibia, there are two smooth, rounded bone surfaces coated with tough, smooth articular cartilage. The two rounded surfaces of the bones are attached to the knee joint bones by three main things: the joint capsule, the joint synovium, and ligaments. Any damage to these structures or the bones themselves can result in pain within the knee joint.
Knee pain is a common complaint and is often caused by an injury to the knee. In a very active population, such as in knee pain Singapore, the most likely group of people to experience knee pain are the young and the middle-aged. This is a reflection of the amount of strain that is being placed on the knee. For the slightly older crowd (mostly above 40), the wear and tear on the knee over the years begins to take its toll, and it is at this point that they might start to experience knee pain. This guide will help you understand more about knee pain and what you can do to help resolve this problem.
Understanding Knee Pain
One of the most complex joints in our body, the knee is used with essentially every movement, and it takes the full impact of our weight. It is no surprise that knee pain is a common health complaint, accounting for 1/3 of all knee pain doctor‘s visits for muscle and bone pain. With today’s increasingly active society, the number of knee problems is increasing. Knee pain has a wide variety of specific causes and treatments. The knee joint is often simply called a ‘hinge joint’. This doesn’t do it justice since it actually does more than simply bend and straighten. The knee is a complex joint which flexes, extends and rotates. Plus it is made up of more than one joint. All this movement is controlled by a combination of muscles and ligaments, with bones guided by the meniscus. Since the knee is so vulnerable to strain and injury, it is important to understand injury in the context of the mechanics. Any irregular movement or distorted shape of the joint can lead to increased load in one area, leading to premature wear and tear. Also, the more serious the injury (for example a torn ligament), the more likely the onset of osteoarthritis in later life. This is because damage to the surface of the joint prevents it from moving smoothly, causing further irregular joint wear. There are several things which can lead to pain such as inflammation to the tendons, arthritis and chondromalacia (softening of the cartilage). Although it is beyond the scope of this discussion to describe all injuries in detail, the underlying theme therapy for knee pain is to try and correct irregular joint mechanics at the site of pain.
Common Causes of Knee Pain
One of the most common acute injuries is a tear of a meniscal cartilage. The meniscus is a C-shaped wedge of fibrocartilage with the consistency of rubber. Each person has 2 menisci; one on the inner side of the knee and one on the outer. Their functions are to act as ‘shock absorbers’ in the knee, and as a result, the majority of meniscal tears occur when attempting to lift a heavy load and twist at the same time. Athletes in sports like football, netball, and soccer are particularly susceptible to meniscal tears, often in a minor injury when the person realizes their knee is ‘never quite right’ after a trivial twisting incident. A small tear in a younger patient may cause locking or sharp pain, but in an older patient, the ‘degenerative’ meniscal tear can result in swelling and pain without any specific aggravating incident. An assessment is very easy to make with a combination of physical tests and an MRI scan where the patient has persistent symptoms.
In talking about the ‘common causes’ of knee pain, it is probably more meaningful to talk about the common conditions that can cause knee pain. There are many, but in this context, it is useful to briefly discuss those that are most likely to present to a ‘sports knee’ practice. These patients will have knee pain that is impacting their ability to perform some or many of their recreational activities, often related to a specific sports-related incident or sometimes insidiously where the patient has realized that a particular activity is becoming increasingly uncomfortable.
Seeking Professional Help
Therapists work to improve your mobility, strength, and function. This is done through exercise, manual therapy, and education. Physiotherapists often have a good understanding of the diagnosis but do not make medical diagnoses. At times, you may be referred to a physiotherapist for rehabilitation following surgery from a different healthcare provider. This may include education in the pre-operative period. Occupational therapists help you achieve independence in your daily life and work by developing strategies and adapting tasks and the environment to your needs. This may also involve education in the pre-operative period to prepare for changes after surgery.
Some medical professionals specialize in the diagnosis of the problem. Others treat problems associated with the knee, while some do both. It is important to know what type of healthcare provider you are visiting and what their expertise is. All medical professionals listed can help you. Your choice should be based on the severity of your problem. This may change over time, so you may see more than one type of provider. If your problem is not resolved, you may need to try a different provider.
When you are in pain, finding help may seem overwhelming. Being familiar with the various types of healthcare providers can help you make the best decisions. The following is an overview of the different types of healthcare providers and how they can help you.
Diagnosis and Treatment Options
Even with little or no findings on their X-rays, patients with significant pain and/or other symptoms may still have substantial soft tissue injury. Therefore, if the treating physician still strongly suspects a significant soft tissue problem despite a normal or near-normal X-ray, he or she may then order an MRI. An MRI is the best imaging study for soft tissues, and the MRI findings often strongly correlate with the patient’s symptoms and findings on clinical examination. In some cases where the MRI findings are still inconclusive, a diagnostic arthroscopy may be performed to identify and treat the problem.
Once a thorough history and physical examination have been performed, X-rays are typically the first imaging study that will be ordered. While X-rays cannot show injuries to soft tissue, such as the ACL, PCL, meniscus, or muscles, they are still useful because they can show the alignment of the bones, any abnormal bone shapes (which may indicate a fracture or other problem), and they can also show signs of osteoarthritis.
Diagnostic Procedures for Knee Pain
There are many available diagnostic procedures before deciding to undergo knee surgery, including, but not limited to: 1. Thorough and accurate medical history-taking so that the accurate diagnosis can be reached. 2. Physical examination for the knee to reveal any abnormal knee movement and to assess the knee instability and knee pain location. 3. X-ray examination to visualize the knee joint space, knee alignment, and presence of calcium deposit. This is useful to confirm the diagnosis of knee arthritis, gout, or meniscus calcification. However, many knee problems will not be visible on x-ray, especially ligament, meniscus, articular cartilage, and synovium problems. 4. MRI (Magnetic Resonance Imaging) to provide a big improvement over x-rays and CT scans. It does not have ionizing radiation, it provides excellent and clear results of the knee soft tissue (ligament, meniscus, articular cartilage, and synovium). However, MRI is costly compared to X-ray and it will not show the cause of arthritis and bone problems. Therefore, to date, MRI is a choice examination for any soft tissue knee problems and before considering knee arthroscopic surgery.
Non-Surgical Treatment Approaches
Weight Loss Excess body weight has a significant impact on knee pain, and increasing body mass is a modifiable risk factor for developing osteoarthritis. Weight loss will reduce the load through the knee joint and is a key strategy for reducing symptoms and slowing disease progression. A diet high in fruit and vegetables and low in refined carbohydrates has been shown to slow the progression of knee osteoarthritis. See the Australian Dietary Guidelines for more information on healthy eating.
Exercise Therapy Exercise programs aim to improve the strength of the quadriceps and hamstrings, correct muscle imbalance, improve flexibility, and subsequently improve patellofemoral (kneecap) alignment and tracking. Exercises also aim to improve the strength and fitness of the muscles that support the knee. This includes muscles around the hip and pelvis, as well as the calf and plantar flexor muscles. Exercises need to be individualized and progressed gradually, and in general should not exacerbate pain or swelling.
Management of knee pain is invariably conservative and is based on decreasing symptoms and improving function. This can be achieved through an exercise program, weight loss, activity modification, and analgesia/anti-inflammatory medications. Often, a combination of these measures is required for adequate symptom relief.
Surgical Treatment Options
Arthroscopy is a surgical procedure that allows the physician to look at the inside of the knee joint. This is done using a ‘scope’ (a long tube) that has a small camera on the tip. The camera sends images to a TV monitor which the physician can review. Small incisions (cuts) are made to allow the ‘scope’ and surgical tools to be inserted into the joint. Arthroscopy is used to investigate the cause of knee pain that is not responding to nonsurgical treatment (i.e. activity or injury). This procedure is very versatile and can be used to remove loose bodies, clean and wash out the knee joint, trim damaged meniscus or cartilage, and smooth off damaged articular surfaces.
Surgery is considered to be the last level of treatment where conservative treatment has failed. Deciding on the type of surgical treatment is dependent on the source of the knee pain and the inciting activity that caused the pain. The four most common types of surgery are arthroscopy, partial knee replacement, total knee replacement, and high tibial osteotomy.
Rehabilitation and Pain Management
First off, exercise is key. People with osteoarthritis of the knee can lessen joint pain and improve joint function by doing flexibility and strengthening exercises. Often, exercising a painful joint seems contradictory. “And a lot of people when they feel that pain they feel they are doing damage to the joint,” says Dr. Lau. However, in the absence of a major injury or systemic arthritic condition, regular moderate exercise is beneficial for people with osteoarthritis. It can help to decrease fatigue, strengthen the muscles that support the joint, improving flexibility and cardiovascular fitness, and help to achieve or maintain a healthy weight; which in turn reduces the stress on the joint. At first you might feel some pain, but the many long-term benefits should keep you motivated. Swimming, or the use of aquatic exercises is an excellent place to start as the water supports body weight, therefore reducing pressure on the knee joint. Other good activities include stationary or recumbent cycling and Tai Chi, a slow and gentle form of martial arts. These exercises can be easily incorporated into Dr. Lau’s lightbulb analogy. The more you do, the stronger the muscles around the knee joint become, providing more stability and protection for the bones. This will then lead to less wear and tear of the cartilage, and decrease the rate of progression of arthritis in the long run. Always remember to consult a physician before starting an exercise program, and if an exercise causes prolonged increased joint pain, please discontinue and seek advice from a healthcare provider.
Rehabilitation Exercises for Knee Pain
Range of motion (ROM) exercises should be performed 5-7 days post-injury or surgery in order to regain full knee flexion and extension. Continuous passive motion (CPM) has been suggested for use immediately following surgery. It has been proposed that CPM will reduce pain and swelling and improve knee flexion. Recent studies have shown little to no effect on swelling and no difference in pain compared to elevation. Step-down knee bending produced similar results in knee flexion compared to CPM; however, step-down bending was better tolerated and less time-consuming. Static stretching exercises may also be used to increase ROM; however, it has been suggested that stretching exercises performed immediately post-injury may pose some deleterious effects on the healing of the ligament.
Rehabilitation following knee injury or surgery is crucial to restoring functional performance and ensuring a safe return to sports participation. The primary goals of rehabilitation are to enhance the healing process, regain flexibility, strength, muscular endurance, power, and proprioception. Exercise selection and program design are dependent on the type of injury, surgery, and the demands of the patient. An individual that partakes in recreational activity may require a less intense program compared to a competitive or elite athlete. Adherence to the suggested rehabilitation program is necessary. Compliance to the program will result in a more favorable outcome.
Pain Management Techniques
There are 2 broad categorizations of knee pain that can be subdivided into 3 smaller groups. The first is acute knee pain, a recent injury that resulted in pain. This can have many simple causes such as a broken bone, torn ligament, or a meniscus tear. These can usually be diagnosed through an x-ray and physical examination. If the injury is not too severe, it can often be immobilized and protected by a knee brace. Rest is essentially the most important thing in the healing process. At this stage, RICE is the best known method for relieving knee pain and preventing further injury. This stands for Rest, Ice, Compression, and Elevation. Rest is necessary to protect the injury and give it time to heal. Cool packs and ice decrease pain and swelling, with the most effective method being ice massage. Compression with a bandage also minimizes swelling, and elevation lessens swelling and pain. The overall outcome is to quicken the healing process and therefore, reduce pain. The second broad category is chronic knee pain which is long-term pain, often caused by chronic disease (the most common being osteoarthritis). The three types of pain experienced by people with chronic knee pain are constant, frequent, and chronic acute. Overall, chronic knee pain is hard to manage and can get in the way of patients’ everyday living. They usually try various pain management techniques to alleviate their pain.
Lifestyle Changes for Long-Term Relief
Previous sections have discussed treatment and surgery for knee pain, but sometimes it is the same for them. Here are some alternative activities countless individuals have tried in promoting knee health. The efficacy of each activity is highly individual, thus it is recommended to try each one for a period of time and note the effects on your knee pain. Often times, the simple awareness and behavior modification which these activities entail can have lasting benefits.
Long-term relief from knee pain would mean reducing the symptoms of pain and inflammation, and prevention of further joint damage. It involves making an ongoing effort to improve your health and well-being, and find a balance between limiting activities that aggravate your knee pain and adopting alternative ones that are beneficial to your overall health.
There have been many times where we have come across an individual whose knee pain has hindered their ability to engage in activities or simply walk for long. With knee pain being so prevalent, the concept of a permanent solution via lifestyle changes is a topic worth exploring.
Preventing Knee Pain
When it comes to prevention, it is always better than cure. This applies to knee pain as well. Preventing the occurrence of knee pain is far easier than treating it thereafter. After an episode of knee joint unduly stressed by force or movement producing structural damage or tissue injury, there is little that treatment can do to reverse the damage. Most often, treatment is designed to reduce pain and swelling, ensure the mobility and strength of the other joints, and return the individual to his/her activities. But if the damage to the knee has predisposed it to further structural change, the treatment has little chance of preventing the progression to osteoarthritis. Here we are going to talk about how to prevent knee pain by maintaining a healthy knee joint and preventing injuries to the knee.
Maintaining Healthy Knee Joints
Healthy Eating and Hydration. It is important to follow a diet which is healthy for your joints. This includes ensuring you are drinking plenty of water as hydrated cartilage is healthier than dehydrated cartilage. When cartilage is dehydrated, it is more brittle and prone to damage. Softer drinks like fruit teas have been shown to be less healthy for joints with an increased risk of developing arthritis in people consuming higher quantities of these drinks. Weight management is also important. With every step we take, the load on our knees is the same as 3-6 times our body weight. So, as an example, every 1kg of weight lost results in 4kg less load on the knee during daily activities. Prolonged increased loading on the joint will cause faster wear and tear of the knee leading to knee pain and even arthritis.
Cartilage – the “shock absorber” of our knees. In order to maintain healthy knee joints for as long as possible, it is crucial to look after our knee cartilage. Cartilage and the underlying bone are the two structures which determine how our knee feels and functions. Damage to the articular cartilage has very limited capacity to heal. Sometimes the body tries to help out by growing new bone around the damaged area, unfortunately this can cause pain and restricted joint movement as well as further limiting the potential for successful cartilage repair.
Preventive Measures for Knee Injuries
- B) Conditions due to Overuse. For prevention of Patellar tendinopathy, quadriceps tendinopathy and retropatellar OA, it is best to avoid activities that involve a lot of jumping (e.g. basketball, volleyball), frequent squatting and forward running. As pain or stiffness is a common complaint before these conditions, it is important to modify activity level to allow adequate rest of the knee and prevent accumulation of too much damage to the patellar tendon or cartilage. Any quadriceps imbalance should be corrected with the vastus medialis (inner quadriceps muscle) being the main target due to its important role in shock absorption and maintaining patellar tracking. Lastly, maintaining good thigh muscle strength and flexibility and good bodyweight are protective against knee OA.
An ACL tear or other serious knee injury usually responds best to a start-stop activity with ample rest. Wearing the right shoes can help in preventing knee injuries. The wrong shoes can impair your gait or change the biomechanics of how you walk. This may lead to other injuries to the leg or hip. When you participate in high-impact activities such as basketball, badminton, while you are jumping, landing and quick direction changing, it is best to use a knee brace for additional support.
