Knee Pain

The Knee Joint

The knee is a complex joint involving the femur, tibia, fibula and patella. The main joints involved are the tibiofemoral and patellofemoral joints. The knee is a common area for injury and/or pain in those that participate in sport that involves quick changes in direction, heavy loading or repetitive use.

The knee has strong ligaments and cartilage to cope with the diverse movement and loading it goes through. Unfortunately, in severe cases these structures can fail, but for the most part, repetitive overuse can overstress these areas and cause pain.

The following list is by no means exhaustive but aims to cover and explain the most common disorders and problems we see in clinic.

Meniscal Tears

A meniscus is a curved, horse-shoe shaped piece of cartilage which provides improved shock absorption and congruency of the joint. In the knee there are a pair of meniscuses, one on the inside (medial) and the other on the outside (lateral). The medial meniscus is bigger and thicker and most prone to damage as the majority of the weight bearing force transmits through this area. There are a variety of presentations and severities of meniscal tears and will depend on the cause and duration of the problem.

Typical Symptoms may include:

Clicking or popping
Giving way, buckling or Instability
Locking or reduced range of motion
Pain on bending or straightening the affected knee fully
Pain on the inside of the knee
Pain on weight bearing
Difficulty walking or going upstairs
Joint line tenderness

Treatment plan: Every patient is unique and the approach will reflect this. Together, you and your osteopath will discuss a course of action and treatment which best suits you. Common key areas to be addressed may include:

Create a ‘return to activity’ plan with progressive strengthening and mobility exercises for the lower limbs working with pain threshold
Address compensations – the knee is described as a ‘slave’ to the ankle and hip. Any maladaptive function at the ankle and/or hip would directly affect the knee
Gait mechanics – our knees have to cope with a variety of vectors (forces in a direction) when walking and running, thus optimising your gait can help to alleviate forces through the meniscus.
This includes assessing the foot, ankle, knee, hip, pelvis and spine.
Reduce/ manage aggravating factors – as part of the ‘return to activity’ plan, we will manage areas of your life that may attribute to the problem and give you strategies to combat them: ergonomics, running, occupational activities, social activities, etc
Surgery – when conservative management (everything not surgery) fails, surgery may be implicated and we can communicate with your GP to arrange further investigations

Ligament Sprains/Tears – The Unhappy Triad

There are four main ligaments in the knee: the lateral collateral ligament (LCL), medial collateral ligament (MCL), anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). Combined with the meniscus, joint capsule and surrounding musculature, these ligaments create a robust yet highly mobile joint.

The most common ligaments in the knee that have problems are the ACL and MCL typically from acute injury with excessive shearing and rotational forces whilst weight bearing e.g. skiing, football, netball or trauma e.g. direct impact from the side. Accompanied by the medial meniscus (discussed above) this is called the ‘Unhappy Triad’ when all three structures undergo injury.

Typical Symptoms may include:

Apprehension
Difficulty weight bearing
Swelling and redness (acute)
Knee pain (diffuse)

Treatment plan¹: The degree of ligamentous injury is graded 1-3 and will dictate the type of treatment required. Together, you and your osteopath will discuss a course of action and treatment which best suits you. Common key areas to be addressed may include:

Muscle strength – the surrounding muscles need to provide extra support to accommodate for the loss of stability from the affected ligaments including: quadriceps, hamstrings, adductors and gastrocnemius
Surgical intervention – with full tears, ACL reconstruction may be indicated. By liaising with your orthopaedic surgeon, you can decide on what is realistically achievable and agree on an approach
Post-surgery rehabilitation – a progressive exercise routine to improve range of motion, minimise swelling and engage stabilising muscles with the aim of returning to your activity, sport or whatever your goal maybe
Taping, bracing, open-chain exercises are used sparingly as it is important to start ‘normal’ activities as soon as you are capable. This improves healing and recovery time

1. 2016. Anterior Cruciate Ligament Injury Treatment & Management. Available at: http://emedicine.medscape.com/article/89442-treatment#showall [Accessed on 7/07/2017]

Bursitis

Bursitis is a term to describe an inflamed bursa. Bursas are fluid-filled sacs that are found throughout the body to reduce friction as muscles/tendons move against bony prominences. There are more than 150 bursae in the human body1 but only a small portion become symptomatic. The main ones affected in the knee include the prepatellar, medial collateral ligament, popliteal and pes anersine bursa.

There are multiple causes of bursitis including the following:

Repetitive Injury or Acute Trauma – overuse in a repetitive fashion can cause irritation and eventual inflammation of the associated bursa
Gout/Pseudogout – crystal deposition within the bursa as a sequelae of crystal arthropathy
Systemic disease – autoimmune disease or infection

Typical Symptoms may include:

Pain/tenderness over bursa site
Reduced range of motion
Aggravated with kneeling
Swelling/redness/warmth around the area of the bursa

Any non-mechanical systemic causes must be ruled out, referred and treated as appropriate (infection, autoimmune disease, gout etc)
Identifying aggravating factors (occupational, activities etc) and providing strategies to manage these
Symptom relief – oral/topical analgesics and cold hydrotherapy may be recommended to reduce pain and allow for improved function
Gait assessment – spine, pelvis and lower limb biomechanics will need to be assessed to identify areas that could be attributing to the problem – proprioceptive exercises, K-tape and strengthening could be used to facilitate improvement
Onward referral if necessary

1. BMJ Best Practice. 2016. Bursitis. Available at: http://bestpractice.bmj.com/best-practice/monograph/523.html [Accessed on 10/07/2017]

Knee Osteoarthritis (OA)

Knee (and hip OA) is considered to be an ‘age-related’ or ‘wear and tear’ type disease where the cartilage, bone and joint tissues slowly degrade. However, it is not as simple as: older people get OA. Multiple factors may be attributed to the risk of developing OA including history of trauma, obesity, genetics, occupation and abnormal joint mechanics.

Knee OA commonly affects the inside of the knee, the most weight bearing area, but can also effect the patella (knee cap).

Typical Symptoms may include:

Pain on the inside of the knee
Pain worse with weight bearing
Improves with movement (depending on area affected)
Knee locking or giving way
Reduced range of motion
‘Knocked-knees’ or ‘Bow-legs’ deformity
Clicking/creaking, morning stiffness, tenderness and/or swelling of the knee

Addressing lifestyle factors that may be attributing to the problem
Nutritional and lifestyle advise to help reduce your weight, and thus, the weight through your joints
Biomechanics – does your back, hips, knees, ankles and feet work synergistically and smoothly or not?
Exercise – improve muscle strength around the knee (quadriceps, hamstrings, gastrocnemius) to provide support and self-confidence in your knees. Exercises will also improve proprioception, balance and stamina
Progressive ‘return to activity’– with an exercise routine and manual treatment, we will aim to get you back to do doing normal day-to-day activity whether that is gardening or playing competitive sport

Iliotibial Band (ITB) Syndrome

The Iliotibial Band (ITB) is a taut length of connective tissue, like a tendon, which originates from the gluteus maximus and tensor fascia lata (TFL) muscles on the outside of the hip and attaches to the outside of the knee. Common in runners, the ITB can become irritated with repetitive motion as it ‘rubs’ over a bony prominence around the knee.

Typical Symptoms may include:

Localised outside (lateral) sharp knee pain
Pain may radiate up the thigh or down the calf
Pain aggravated with weight bearing activity e.g. running, squats
Relieved with rest, in early stages
Trying to ‘train through the pain’ can make it worse
Recent increase in intensity or frequency of activity

Pain relief with active/dynamic stretching, hydrotherapy and analgesics
Assessing walking/running or cycling style/setup – modify any factors that could attribute to problem and provide alternatives
Muscle SSS – Exercise routines and manual treatment to provide appropriate strength, stamina and suppleness of the hip muscles to support the pelvis and hip during gait
Progressive ‘return to activity’ routine – provide specific, measurable, attainable, relevant and time bound (SMART) goals to create self-feedback strategies to monitor progression
Biomechanics – does your back, hips, knees, ankles and feet work synergistically and smoothly or not?
Shoes and Foot-mechanics – are your shoes attributing to the problem?

Patella (Knee Cap) Related Pain

The knee cap, or patella, functions as a ‘pulley-type’ mechanism to create more efficient movement and power of the quadriceps. The patella glides against the femur (thigh bone) making up the patellofemoral joint. If there is overload or over-pressure going through the patella into the femur due to poor biomechanics, muscle imbalance or poor gait, it causes dysfunction and pain. This has described as ‘Patellofemoral Pain Syndrome’ however the fundamental causality and treatment approaches are still debated^1,2,3. Because of the nature of the knee, other causes that may explain these symptoms include: chondromalacia patella, patellofemoral osteoarthritis (OA), quadriceps tendonitis/opathy or any or a combination of the above. A thorough case history and examination helps to differentiate these diagnoses.

For Patellofemoral Pain Syndrome, typical symptoms may include:

Ache/ pain around the front of the knee
Gradually gets worse, not usually traumatic
Aggravated with bending the knee whilst weight bearing i.e. squats, going upstairs, prolonged sitting, running
Muscle tightness/tenderness around the knee and into the quadriceps

Addressing biomechanical changes between the pelvis, hip, knee and ankle
Addressing muscle tension or weakness
Support – bracing or taping may be a useful way to allow normal activities
Progressive ‘return to activity’ – with an exercise routine and manual treatment, we will aim to get you back to do doing normal day-to-day activity whether that is gardening or playing competitive sport
Self-management techniques – rest, hydrotherapy, analgesics, exercise, stretching, strengthening
Education – remove fear of pain through demonstration and promote self-help

1. Medscape 2017. Patellofemoral Syndrome. Available at: http://emedicine.medscape.com/article/308471-overview?pa=mLAHaEAFtyc1YJf9RTzipEHft17IxMAJi193p%2BQDjUCYZB9sL%2FRopNsQ3WANEMwG43mU9jD%2B1DtnxY47OmyybA%3D%3D [Accessed on 12/07/2017]

2. Pain Science. 2017. Patellofemoral Pain Syndrome. Available at: https://www.painscience.com/tutorials/patellofemoral-pain-syndrome.php [Accessed on 12/07/2017]

3. Crossley et al. 2016. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions) Br J Sports Med 50: 844-852.

Muscle Strains & Injuries

Muscle strains or ‘pulling a muscle’ is a common injury in sport and is usually caused by excessive, over-stretching, explosive movement after an ineffective or absent warm up. Effectively, the muscle was not ready for the exercise put upon it. This can cause microscopic to significant tears in the muscle or tendon or anywhere in between. The most common areas to ‘pull a muscle’ are the hamstrings, quadriceps, groin, calf and back.

Muscle pain is called myalgia and can be consequence of a muscle strain or tear where there is physical or structural change to the muscle. Myalgia can also occur from a functional problem i.e. delayed-onset muscle soreness (DOMS), fatigue-induced (getting tired from being in one posture for too long) or a neuromuscular problem such as nerve impingement in the spine or dysfunction nervous control¹.

Typical Symptoms may include (will depend on the specific type of muscle injury):

Aching muscle firmness
Can provoke pain at rest
Worsening with activity
Sudden pain, pain at rest hours after activity
Reduced mobility of adjacent joints
Muscle swelling
Sensitive to touch
Cramping
Sharp/stabbing pain

Assessment and diagnosis of the specific type of muscle strain to help direct treatment
Direct muscle treatment – may be necessary, however may be detrimental if severely damaged
Address nerve/ circulation dysfunctions – appropriate innervation via the nerves from the spine and local blood supply are crucial to recovery and healing
Movement – progressive exercises to allow healing whilst maintaining strength, stamina and suppleness. An inactive injured muscle can waste and become fibrotic causing further problems

1. Mueller-Wohlfahrt et al. 2012. Terminology and classification of muscle injuries in sport: The Munich consensus statement. Br J Sports Med.