Knee injuries can occur across all ages and can be either acute or gradual in onset. The knee is heavily influenced by the biomechanics of the hip and ankle, so consideration of the whole lower limb chain is essential to long-term treatment and injury prevention.
Common knee injuries include:
Ligament Injury (ACL, PCL, MCL, LCL)
Ligament injuries most commonly involve the anterior or posterior cruciate ligaments and the medial or lateral collateral ligaments. In more severe injuries, more than one ligament may be affected. The most common mechanisms of injury for each ligament are outlined as follows:
- Anterior Cruciate Ligament (ACL)Sports involving rapid changes in direction, jumping or sudden deceleration, e.g. landing from a jump then turning on a planted foot
- Posterior Cruciate Ligament (PCL)Direct blow to the front of the tibia while the knee is bent, e.g. dashboard injury during a motor vehicle accident
- Medial Collateral Ligament (MCL)Impact to the outside of the knee when the foot is fixed on the ground
- Lateral Collateral Ligament (LCL)Impact to the inside of the knee, or lateral rotation during weight-bearing, e.g. during sports with rapid changes in direction
On assessment, ligament injuries are graded according to their severity;
- Grade I injury: Indicates the ligament has limited damage (sprain) but is still able to stabilise the knee
- Grade II injury: Indicates the ligament has been partially torn, with a resulting decrease in joint stability
- Grade III injury: Indicates a complete tear or rupture of the ligament
Following a ligament injury, patients will often report immediate pain, swelling and bruising. A popping sound may also be reported at the time of the injury.
Treatment can vary, depending on which ligament was injured and the severity of the injury. Initial management generally involves managing swelling and inflammation and reducing pain. Crutches may also be recommended depending on the level of pain and the patient’s ability to weight bear. For MCL injuries, patients will often be required to wear a limited range of motion brace for several weeks to protect the ligament from further damage. Treatment of ligament injuries generally involves extensive rehabilitation for a safe return to sport and prevention of future injury. In some instances, surgery may also be required.
Meniscus Injury
Acute meniscal injuries often occur as a result of a combined compression and rotation force. For example, twisting while the foot is anchored on the ground. Symptoms can vary depending on the severity of the injury but typically swelling and pain may not develop until 24-48 hours after the injury. In more severe cases, restricted knee movement and locking of the knee may be experienced.
Treatment of meniscal injuries varies depending on the severity and in some cases, surgery may be indicated. Initially, treatment involves the management of pain and swelling. Following this, specific strengthening, stabilisation and range of motion exercises will be included. Physiotherapy management should always be considered for meniscal injuries, even when surgery is indicated, because patients will often have better postoperative results if they have performed preoperative rehabilitation (or “prehab”).
Degenerative meniscal injuries commonly occur in older adults often without any trauma or any resulting symptoms. Conservative physiotherapy treatment, again involving strengthening, stabilisation and range of motion exercises, is often successful for degenerative meniscal injuries.
Patellar Dislocation
Patellar dislocation is often associated with a traumatic force to the knee and may occur in sports involving twisting or jumping. Although the patella may relocate spontaneously soon after the dislocation, severe pain and swelling will often be experienced immediately. Locking of the knee and instability may also be experienced. Following a patellar dislocation, imaging is often recommended to exclude an osteochondral or avulsion fracture.
For a first-time patellar dislocation, treatment often involves immobilisation in a brace for six weeks, followed by physiotherapy treatment to improve stability, range of motion and strength. In some cases, surgery may be indicated.
Patellar Tendinopathy (Jumper’s Knee)
The patellar tendon is located below the patella (knee cap) and works with the quadriceps muscles and quadriceps tendon to straighten the knee. Patellar tendinopathy can occur following a sudden increase in load or as a result of overuse and is often associated with biomechanical abnormalities, muscle weakness or poor motor control. Patellar tendinopathy is a common cause of knee pain in jumping sports. It may also occur in sports involving rapid and frequent directional changes. Patients may report knee pain aggravated by jumping or walking downstairs.
Treatment of patellar tendinopathy is individualised to the patient but often includes initial load reduction, soft tissue therapy, targeted strengthening exercises, correction of biomechanical abnormalities and specific motor control exercises. An important part of patellar tendinopathy rehabilitation is a graduated and structured return to sport, as increasing load too quickly can delay rehabilitation and cause the tendon to become symptomatic again.
Quadriceps Tendinopathy
The quadriceps tendon is a single tendon for all four quadriceps muscles, located above the patella (kneecap). Quadriceps tendinopathy is an overuse injury, associated with overloading of the quadriceps tendon. Weightlifters may be more prone to developing a quadriceps tendinopathy, due to the increased loading of the tendon in deep squats. Symptoms will often include pain above the patella and pain with resisted contraction of the quadriceps. Treatment of quadriceps tendinopathy is often similar to the treatment of patellar tendinopathy, including load reduction, targeted strengthening and motor control exercises and correction of biomechanical abnormalities.
Patellofemoral Pain Syndrome (PFPS)
Patellofemoral pain syndrome (PFPS) refers to pain around the patellofemoral joint and surrounding soft tissues, which is commonly related to increased or unaccustomed loading of the joint. PFPS may be caused by either intrinsic or extrinsic factors, however, a combination of both will often be present. Intrinsic factors contributing to PFPS may include rotation of the femur or tibia, the angle of the knee or ankle joint, muscle flexibility, muscle strength and movement of the patella. Extrinsic factors may include training load, volume or intensity; the type of training (e.g. hill running, long-distance running, cycling); training surfaces (e.g. concrete, grass, trails) and training technique.
Consideration of both intrinsic and extrinsic factors contributing to PFPS is essential for treatment and long-term recovery. Initially, taping or stabilisation braces may be recommended, combined with a decrease in training load or intensity. Following this, rehabilitation often involves targeted strengthening exercises, soft tissue release, correction of technique and biomechanical abnormalities and a graduated return to the patient’s former training load.
Iliotibial Band Friction Syndrome (ITBFS)
The iliotibial band (ITB) is a band of fascia running from the hip to the knee along the lateral aspect of the thigh. Iliotibial band friction syndrome (ITBFS) is an overuse injury caused by friction between the ITB and structures around the lateral knee, commonly occurring in runners, cyclists and endurance athletes. The main symptom of ITBFS is aching in the lateral knee aggravated by running, cycling or walking downhill. There may also be tightness of the ITB and weakness of the hip muscles.
Treatment of ITBFS often focuses on initially reducing the patient’s training load, correcting biomechanical abnormalities and strengthening muscles around the hip, before gradually returning to a high training load.
Osteoarthritis
Knee osteoarthritis is a common degenerative condition. It mostly affects the articular cartilage which allows the bones to glide smoothly and painlessly over each other, while also helping to absorb shock. Knee OA is characterised by the degeneration of this articular cartilage, causing the cortical bone below to become exposed. OA is diagnosed with x-ray, which will show a loss of joint space and changes to the bony surfaces of the joint.
In July 2018, the Royal Australian College of General Practitioners published new guidelines for the management of hip and knee OA. These guidelines confirm that exercise and weight management are the best treatments for OA. Specifically, land-based exercises such as walking, strength training and tai chi, are recommended. Treatments such as heat, massage, hydrotherapy and medication can also be used for OA but should only be used as adjunct treatments to exercise and weight management. Before commencing an exercise program for OA it is important to consult a physiotherapist. A thorough physiotherapy assessment will allow for the development of an appropriate exercise program, based on symptoms, functional limitations, personal preference and goals.
Total Knee Replacement
A total knee replacement (TKR) is a common surgery for end-stage osteoarthritis (OA). Following TKR surgery, patients will be treated by a hospital-based physiotherapist until discharge. Initially, physiotherapy is focused on mobilisation out of bed within the first 12-24 hours of surgery. This may begin with just sitting on the edge of the bed, standing at the bedside or taking a few steps with a forearm support frame. Over the next few days, physiotherapy involves regular walking with a walking aid, range of motion exercises and gentle strengthening exercises. Often patients will need to demonstrate at least 90 degrees of knee flexion on the operated knee and be able to walk independently with crutches or a walking frame before being discharged from hospital.
Following discharge, a strict exercise program of range of motion and strengthening exercises should be followed, both at home and under the guidance of a physiotherapist. These exercises are often required to be performed multiple times daily to avoid post-surgical stiffness and allow a full return to normal daily activities and hobbies. At Hawker Place Physiotherapy and Pilates, we provide individualised exercise programs for patients who have had a TKR, regardless of the length of time since surgery. Prior to TKR surgery, undergoing a pre-operative rehabilitation (“prehab”) program of strengthening and mobility exercises may also improve early post-operative pain and function.
Post-surgical Pain & Stiffness
Following knee surgery, patients will often experience pain and stiffness, particularly if the joint has been immobilised. Treatment for post-surgical pain and stiffness may include passive joint mobilisation, range of motion exercises, strengthening exercises and stabilisation or proprioception training. Treatment can also include gait re-training and specific rehabilitation for return to sport or pre-injury activities.
