Knee pain is a very common condition and can occur at different times throughout your life. It is common during growth spurts in children, or with trauma from sport or falls, or it may come on as we age with everyday wear and tear. Various structures can be responsible for pain in the knee, eg. muscles, ligaments, tendons, cartilage and the meniscus (the rubbery cushion inside the knee). Sometimes knee pain can even be referred from the hip joint or the lower back.
Causes of knee pain
Acute knee injuries most often occur with sports which involves rapid acceleration, deceleration, twisting, kicking, or a sudden change of direction. These activities are common in sports like football, soccer, netball, basketball and skiing. These types of injuries can damage the ligaments or even the meniscus or the cartilage which protects the bones and joints. Physiotherapy is important to identify which structure has been damaged or to refer you to your doctor if necessary to have further investigations. Physiotherapy treatment following a sports injury is aimed at reducing the swelling, restoring the knee movement and easing the pain with massage, ultrasound, ice and TENS. A tailored exercise program is important to help speed up your recovery and return you back to your sport or favourite activity as soon as possible. The exercises prescribed will be a combination of stretches, strengthening, balance work and endurance to restore the biomechanics around the whole leg to get you back to your optimal level of function in the shortest amount of time.
A more gradual onset of knee pain can occur during growth spurts in children or activities which involve a lot of repetition, eg. high volumes of running, jumping, kicking or squatting. The most common site for this type of pain is the front of the knee around the knee cap (patella). This type of injury responds well to Physiotherapy which identifies the cause of the knee pain and provides treatment to alleviate the pain. This would involve things like massage, ultrasound, ice and TENS. Taping or bracing of the knee may also be a necessary part of the pain relief management and the physiotherapist will advise you as to what would be appropriate for your knee. An individualised home program of exercises is extremely important to address the muscle imbalances to correct the problem and to prevent recurrence of your pain or injury. The physiotherapist will advise you on managing your sport and training work load, and whether time off sport to rest is appropriate or not.
ACL injury
The ACL (anterior cruciate ligament) is a ligament which sits deep inside the knee. It’s job is to prevent the femur (thigh bone) from sliding forwards on the tibia (shin bone). It is most commonly torn with a twisting-type of injury in sport like football, soccer, netball or skiing. Sometimes it can be injured when the knee is forced into hyperextension which is beyond it’s straightest position. Many people hear or feel a ‘pop’ in the knee when an ACL injury occurs. The knee may swell and feel unstable and usually becomes too painful to walk on.
The severity of the ACL injury will determine the treatment. It may include rest and Physiotherapy rehabilitation exercises to help you regain your knee movement, strength and stability, or it may require surgery to replace the torn ligament with Physiotherapy recommended before as well as after surgery.
Physiotherapy prior to a surgery aims to reduce the swelling in the knee and restore the knee movement. The exercises prior to surgery are to ensure the muscles around the knee are a good length and as strong as possible. This helps to speed up the recovery after surgery.
Physiotherapy after surgery will work on reducing the swelling, pain and inflammation with massage, ultrasound, ice and TENS. Exercises in the initial stages will help to restore the knee movement and muscle length. Strengthening work begins immediately postoperatively to help to switch the muscles back on and get them strong again. Once the pain and inflammation reduce the exercises concentrate on strength, power and endurance with a focus on balance and coordination. We tailor the exercises to your individual sport or favourite activity which is very important. Different sports and activities place different demands on the knee and so it is important to make sure the knee rehabilitation includes the specific demands of your sport to prepare your knee for returning to sport. This helps prevent ongoing issues in the knee or any other part of the leg which could compensate for weaknesses if they are not rehabilitated fully.
A comprehensive Physiotherapy program may also help to prevent an ACL tear. This is done by assessing and treating specific weaknesses, muscle imbalances and balance/coordination issues which could predispose you to an ACL injury. It is helpful to have an assessment in the preseason to see if there are any exercises you can do throughout your sport season to help reduce your risk of injuring your ACL. This is especially important in sports where an ACL injury is common like soccer, netball or football.
Patellofemoral (knee cap) knee pain
Patellofemoral knee pain is a general term used to describe pain in and around the patella (knee cap) at the front of the knee (femur). It is a very common problem that we see in young active sports people as well as older clients. It is often caused by poor patella alignment which over time starts to damage the surface at the back of the patella. The patella has a groove in the femur in which it normally glides up and down, but if the patella doesn’t glide in the centre of this groove, then it can rub the back of the patella on the edge of the femur, causing pain, mild swelling and damage to the cartilage which lines the back of the patella. If it continues it can be felt as clicking and grinding when the knee is bent and straightened.
The most common causes of the patella maltracking are poor biomechanics created by muscle tightness and/or weakness. Patellofemoral knee pain is common in sports which involve running, jumping, changes of direction and squatting, eg. running, tennis, netball, soccer, football, skiing, basketball and cricket. It is also common in children going through a growth spurt where their bones lengthen first, and their muscles are tight until they stretch out fully.
Physiotherapy is very effective in treating patellofemoral knee pain. Treatment initially is aimed at easing the pain and swelling associated with the condition by using ultrasound, ice and TENS. People with patellofemoral knee pain respond very well to a specific exercise program to correct the underlying muscle imbalances and strength issues. We can use taping or braces to ease the pain temporarily until the muscles are working more efficiently. The exercises are progressed as the pain allows to include balance and endurance work and sport specific exercises to prepare you for your individual sport or activity. We give advice on how long to rest and when it is safe to return to training or sport. We can also give advice on correct footwear and supply orthotics if required to help with correcting the foot, knee and hip alignment if you have flat feet which can contribute to your poor biomechanics.
Meniscal or cartilage injuries
A torn meniscus is another common knee injury. It is caused by a forceful twist, especially if you have your full weight on your knee. The knee has two menisci. They are C-shaped pieces of cartilage which act like a cushion between the femur (thigh bone) and tibia (shin bone). A torn meniscus is a very painful injury which causes pain, swelling and stiffness. You can also experience difficulty straightening or bending your knee if it is torn.
In younger people a tear is usually caused in sports when the knee is twisted in a slightly bent position. It is common in sports with lots of changes of direction, eg. netball, soccer, football and basketball. In older people a degenerative tear is more commonly caused by normal age-related wear and tear of the joint surfaces and the cartilage. The bones can roughen with age and arthritis, and start to rub and wear the softer meniscus inside the knee.
Physiotherapy works to reduce the pain, swelling and inflammation associated with a meniscal tear. We help to restore the knee joint range of motion. We also work on correcting any poor biomechanics which may have contributed to the problem occurring in the first place. Things like muscle tightness, weakness, or poor foot, knee and hip alignment. We help to restore strength in all the muscles of the lower limb, the calf, quadriceps, hamstrings and pelvic muscles. We work on balance, coordination and correct techniques for running, changing direction, squatting, jumping, hopping and landing to help prevent future injury.
Some meniscal tears will require surgery and your Physiotherapist will advise you when it is appropriate to see your doctor or specialist to organise further investigations. Most specialists will recommend a few weeks of Physiotherapy to either successfully rehabilitate your knee without requiring surgery, or to strengthen your knee in preparation for your postoperative rehabilitation. It is important if undergoing surgery that the muscles are not too tight and that they are as strong as possible to help speed up your recovery after the surgery.
Iliotibial band (ITB) friction syndrome
This is one of the most common causes of pain in runners. It is a repetitive strain or overuse injury as opposed to a single traumatic event. The ITB is a long thin band of fibrous tissue that runs down the outside of the thigh from the hip to the knee. It attaches from the outside of the pelvis at the top of the hip to just below the outside of the knee on the tibia (shin bone).
There are varying degrees of severity of ITB friction syndrome. The most common symptoms are burning or sharp pain just above the outside of the knee. It worsens with running or repetitive activities. There can be swelling on the outside of the knee, pain with bending the knee and if left untreated the pain will tend to get worse and worse, and start to interfere with your running or even everyday activities like walking, sitting, standing up from a chair or walking up/down stairs.
It is caused by the ITB sliding forwards and backwards across the outside of the femur at the knee creating friction. The repetitive sliding is most common when the knee is bent slightly, eg. when the knee bends just before hitting the ground when running. ITB friction syndrome is mostly caused by poor running biomechanics due to muscular tightness and weaknesses. These include things like poor running technique where the knees roll inwards or the muscles around the hip and knee aren’t strong enough to maintain good alignment. Also a sudden increase in running distance and speed or frequency of training can also contribute by causing fatigue and poor alignment. Poor footwear or lack of arch control can alter the leg alignment and contribute to injury.
Physiotherapy identifies the underlying cause of the ITB friction syndrome and helps to correct the underlying issues. We treat the pain, swelling and inflammation, restore the knee range of motion, and correct any muscle tightness or weakness issues. It is important to have a personalised exercise program tailored to your specific running and exercise needs. We give running gait and footwear advice as required. We also work on balance and control of the hip, knee and foot to make sure the problem does not reoccur. If necessary we will fit you with orthotics to help you with the arch support necessary to improve the alignment of your knee. In severe cases there is a surgical procedure to lengthen the ITB but most respond well to physiotherapy and treating the underlying causes.
Patella Tendinopathy or Jumper’s Knee
This is a common injury which affects the tendon that straightens the knee and is caused by overuse or overtraining. It is characterised by pain at the front of the knee and usually mild swelling. Generally there is no pain at rest, the pain comes on with activity.
The patella tendon is located just below the patella (knee cap) and attaches the patella to the tibia (shin bone). It’s job is to transfer the force of the quadriceps muscle to the lower leg to straighten the knee or to absorb shock when jumping or landing. The quadriceps muscle is very important in running, jumping and kicking which occurs in most sports. It is often referred to as jumper’s knee as the patella tendon has the greatest amount of stress put through it during jumping and landing activities and therefore is most commonly injured with repetitive jumping and landing.
Patella tendinopathy (tendinitis) affects athletes playing sports like netball, volleyball, football, gymnastics, and athletics like running, high jump and long jump. In older people the mechanism is a bit different. The patella tendon can weaken with age and degenerate slowly over time.
Physiotherapy helps to alleviate the pain, swelling and inflammation associated with the tendinopathy. We can supply you with a brace if appropriate or use tape for pain relief in the initial stages. We can advise appropriate rest periods and give a graduated exercise program to help speed up your recovery. Stretches are important to restore the flexibility of the whole leg and strengthening is important to help overcome any weakness or strength deficits identified. It is important to address any underlying biomechanics issues such as poor foot posture, hip or knee control, and balance issues.
Advice and education are very important as well. There could be training errors like a rapid increase in the amount of training or a sudden increase in the intensity of training. Rest periods between training sessions are very important for recovery and injury prevention and your physiotherapist can advise you as to what is appropriate for you. The playing surface can have an impact as well if it is too hard. Poor flexibility of the quadriceps, hamstrings and calves can also play a role. Your Physiotherapist will identify which factors may have contributed to your injury and give advice on how to prevent future injuries.
