By Don Williams
B.Sc., M.Chiro., ICSSD., PG Dip. NMS Rehabilitation Cert DNS. Memb: FICS, CEA
Knee pain and dysfunction is a common presenting complaint to our team here at the clinic.
On a daily basis we see a wide range of knee injuries ranging from overload injuries to developmental disorders and from trauma to serious pathology. Generally, knee conditions can be grouped into a these categories. This article aims to clarify and describe some of these issues and strategies to deal with them.
The Knee is an important link in our biomechanical chain for all of our standing activities. Injuries to the knee will affect our ability to stand, walk, run, ride and even sit and work. When you have suffered a severe knee injury you start to realise just how vital they are for our sport, recreation and normal daily activities.
Any time there has been an impact, fall, major twist or other traumatic event. Pathology including ruptures, tears and fractures should be eliminated.
Ligament Ruptures (ACL, PCL, Collaterals)
ACL or Anterior cruciate ligament ruptures are probably the most well-known and are particularly prevalent in ball sports, although they can occur in a range of circumstances. The ACL prevents the lower leg (tibia) from sliding forward in regards to the upper leg (femur). Complete ruptures require graft stabilisation, partial tears can be conservatively managed with rest and rehabilitation exercises. Some theories suggest that if the person is not young, then a complete rupture does not need to be repaired, however, it appears to us that there is a higher prevalence of knee replacements and marked degenerative changes in the ruptured side compared to the normal side. We are fans of having a graft and effective rehab.
The PCL (posterior cruciate) prevents backwards movement of tibia and is less frequently injured, and usually in combination with the ACL and/or Collaterals.
Collateral ligaments prevent side to side movement of the knee. They will sometimes be repaired and once again, full ruptures are more often in combination with ACL and or PCL ruptures.
Often called cartilage injuries. The meniscii are little “C” and “J” shaped rings of cartilage, wedge shaped that help locate the knee for effective movement. The inner 1/3 is poorly vascularised and tears can cause a “flap”, which gets caught. These may require debridement (arthroscopic clean up) to remove the flap and stop the catching and jamming. The outer 1-3 to 2/3 does have blood supply and sometimes tears in this area will heal. Conservative management is certainly worth trialling and if not successful progression on to surgery to “stitch up” the tear can be indicated.
Articular Cartilage injuries
The articular cartilage is the smooth hyaline cartilage that covers the ends of the bones and allows the knee to glide smoothly through its movements. Injuries to the articular cartilage are less common and are usually traumatic. They are very difficult problems to manage and often don’t recover well. Optimising joint mechanics can be helpful. Different surgical interventions are aimed at trying to grow new cartilage, transplant cartilage and remove jagged edges with varying success.
Frequent presenting complaints. In severe cases knee replacement surgery will have a profound impact on the mobility and ability to enjoy life. In less severe cases, addressing footwear, improving mechanics around the knee and hip can be very helpful.
Research does not support the theory that running specifically speeds up degeneration of the knee. We are big fans of optimising gait mechanics in runners and wearing appropriate footwear. Really, the more active we keep people, generally the better they do.
Knee fractures, whilst not being very common, do occur and there are a range of different types of fractures. Mostly they require a period of immobilisation and the use of crutches. Some cases will require surgery. We do see these at times but regularly refer on for orthopaedic assessment and management in the early stages, then reconnect again after the fracture has healed for rehabilitation.
There are a range of overload injuries which occur around the knee. These can be simple injuries of the calf, hamstring and quad muscles which in turn effect the mechanics of the knee, causing pain and dysfunction. Additionally, we will see issues develop as a result of dysfunction in the ankles or hips. Poor footwear choices and foot mechanical issues will overload the knee leading to problems. Weakness in the gluteal muscles and poor hip mechanics will also cause problems. Differentiating what the deficiency is and how to address this is the important point.
Patellofemoral/patella tracking syndromes
These issues present usually with pain behind the knee cap or near the new cap. Usually the issues are with the patella tracking laterally or too far to the outside of the knee. This causes increase pressure on the “groove” that the knee cap runs in causing pain in the back of the knee cap or in the groove itself. More often worse with flat footed people or people who drive their knees together in squat and lunge exercises. These are usually simply managed and if addressed relatively early will normally settle relatively quickly with homework.
There are little fat pad with sit on top of the patella, above and below the patella and on the medial (inside of the knee) a couple of centimetres down from the joint. Direct impact or trauma can cause these to become inflamed or irritated, although they more frequently become sore from overload from poor mechanics or movement patterns of the lower limbs. Early management may include ice and anti-inflammatory regimes, although a long term outcome is usually best achieved by addressing the weaknesses and dysfunction which cause the problem.
These conditions may be regards as histological disorders. The usual onset for these conditions is in the early teenage years and often coincide with growth spurts. Essentially the insertion point of the tendon on the bone starts to pull away and becomes inflamed and painful. In rare cases they can completely snap off. They are more commonly associated with explosive sports (sprinting, jumping, and kicking) and are usually conservatively managed. They can recur over a number of years, although good compliance with homework makes them quite manageable.
Osgood Schlatters occurs where the patella tendon inserts on the tibial tuberosity (on the upper shin bone) whereas Sinding Larsen Johansson disease occurs at the bottom of the patella (knee cap).
We usually incorporate activity modification in a flare up with management of the inflammatory process. Then incorporating stretching and strengthening exercises to improve the mechanics and flexibility to manage the presentation and prevent future flare ups.
There are a number of pathologies of the knee ranging from low force fractures through to malignancies (tumours) and other weird and wacky complaints. Developing complaints for no apparent reason may be a serious problem but it may be an overload issue, so certainly don’t panic until it has been assessed and identified.
When we assess new knee injuries are first point is to eliminate major pathology then address the issue if it falls within our scope of practice
Management of Knee Injuries
The management of all of these injuries can vary but the principles remain the same; effectively assess the injury and the causative factors, identify the problem, protect the knee from further injury, treat the problem, progress the knee back to normal function.
Inappropriate footwear is certainly a common contributing factor. Generally speaking, flat/ low arch feet need stability and control in footwear, high arch/rigid feet need cushioning. Less commonly we see feet that require complex combinations of cushioning and support. These unusual foot types are not normally well managed by the shoe chain stores.
Poor mechanics in running gait and exercises (squats, deadlifts, leg press etc) can also be a big factor. It is not easy to simply describe how to do these activities appropriately. However, if you have issues and want them assessed, book an appointment with Don Williams or Martin Cooper and they will be happy to assess your movement patterns and show you how to improve any deficits.
At Institute of Sports and Spines we pride ourselves on doing comprehensive assessment of presenting complaints, using advanced imaging, such as MRI to confirm and identify the problem and then develop effective strategies to address the issue. At times this requires referral to orthopaedic surgeons for complex cases. If surgery is required we are well equipped you help you work through the problem and progress back to normal.
With almost all knee injuries Rehabilitation exercises are usually an important factor in achieving a good outcome, whether an overload or mechanical issue caused the issue or whether a traumatic injury caused weakness in the controlling muscles, addressing these deficiencies will improve your long term result.
We also offer a range of treatment modalities from Acupuncture and Massage to Chiropractic to help you through the symptomatic phase.