Knee Pain
Common Knee Injuries
The knee is a sensitive area of the body and one that can be injured doing almost any activity. The knee is normally exposed and vulnerable and a simple twist can lead to a serious injury as well as ongoing problems and a long recovery time. Therefore, whether your sport is rugby or racquetball, bowling or badminton, you cannot take chances with this body part.
Patellar Tendonitis:
Patellar tendonitis (also known as jumper’s knee) is a common overuse condition associated with running, repeated jumping and landing, and kicking.
Patellar tendonitis occurs most often as a result of stresses placed on the supporting structures of the knee. Running, jumping, and repetitive movements from knee flexion into extension (e.g., rising from a deep squat) contribute to this condition. Overuse injuries from sports activities is the most common cause but anyone can be affected, even those who do not participate in sports or recreational activities.
There are outside factors that are linked with overuse tendon injuries of the knee:
- inappropriate footwear
- training errors (frequency, intensity, duration)
- the surface or ground (hard surface, cement) being used for the sport or event (such as running)
Training errors are summed up by the rule of “toos”: training too much, too far, too fast, or for too long. Advancing the training schedule forward too quickly is a major cause of patellar tendonitis.
Internal factors such as age, flexibility, and joint laxity are also important. Malalignment of the foot, ankle, and leg can play a key role in tendonitis. Flat foot position, tracking abnormalities of the patella, rotation of the tibia (called tibial torsion), and a leg length difference can create increased and often uneven load on the quadriceps mechanism.
Any muscle imbalance of the lower extremity from the hip down to the toes can impact the quadriceps muscle and affect the joint. Individuals who are overweight may have added issues with load and muscle imbalance leading to patellar tendonitis.
Strength of the patellar tendon is in direct proportion to the number, size, and orientation of the collagen fibers that make up the tendon.
Repeated microtrauma at the muscle-tendon junction may overcome the tendon’s ability to heal itself. Tissue breakdown occurs, often triggering an inflammatory response that leads to tendonitis.
Chronic tendonitis is really a problem called tendonosis. Inflammation is not present. Instead, degeneration and/or scarring of the tendon has developed. Chronic tendon injuries are much more common in older athletes (30 to 50 years old).
Because patellar tendonitis is a result of disorganized, weakened collage, Dr. Trinh will utilize Astym therapy, a highly effective tool in stimulating new collagen formation. She will then prescribe a serious of exercises to gradually load the patellar tendon and increase the strength and alignment of the collagen in the correct line of force.
In addition, she will also prescribe stretching and strengthening exercises to correct any muscle imbalances. Eccentric muscle strength training helps prevent and treat injuries that occur when high stresses are placed on the tendon during closed kinetic chain activities. Eccentric contractions occur as the contracted muscle lengthens.
Patellofemoral Problems:
The patella, or kneecap, can be a source of knee pain when it fails to function properly. Alignment or overuse problems of the patella can lead to wear and tear of the cartilage behind the patella. This produces pain, weakness, and swelling of the knee joint. These problems can affect people of all ages.
Problems commonly develop when the patella suffers wear and tear. The underlying cartilage begins to degenerate, a condition sometimes referred to as chondromalacia patella. Wear and tear can develop for several reasons. Degeneration may develop as part of the aging process, like putting a lot of miles on a car. The patellofemoral joint is usually affected as part of osteoarthritis of the knee.
One of the more common causes of knee pain is a problem in the way the patella tracks within the femoral groove as the knee moves. The quadriceps muscle helps control the patella so it stays within this groove. If part of the quadriceps is weak for any reason, a muscle imbalance can occur. When this happens, the pull of the quadriceps muscle may cause the patella to pull more to one side than the other. This in turn causes more pressure on the articular cartilage on one side than the other. In time, this pressure can damage the articular cartilage.
Weakness of the muscles around the hip can also indirectly affect the patella and can lead to patellofemoral joint pain. Weakness of the muscles that pull the hip out and away from the other leg, the hip abductor muscles, can lead to imbalances to the alignment of the entire leg – including the knee joint and the muscle balance of the muscles around the knee. This causes abnormal tracking of the patella within the femoral groove and eventually pain around the patella. Many patients are confused when their Physical Therapist begins exercises to strengthen and balance the hip muscles, but there is a very good reason that the therapist is focusing on this area.
A similar problem can happen when the timing of the quadriceps muscles is off. There are four muscles that form the quadriceps muscle group. As mentioned earlier, the VMO is one of these four muscles. The VMO is the section of muscle on the inside of the front of the thigh. The VL runs down the outside part of the thigh. People with patellofemoral problems sometimes have problems in the timing between the VMO and the VL. The VL contracts first, before the VMO. This tends to pull the patella toward the outside of edge of the knee. The result is abnormal pressure on the articular surface of the patella.
Biomechanical issues in the foot can change the alignment and rotation of the tibia and alter the angle of pull of the patella tendon. This too can lead to tracking problems of the patella in the femoral groove or breakdown of the patella tendon itself.
Although the time required for recovery varies, patients with patellofemoral problems often benefit from four to six weeks of Physical Therapy. The aim of treatment is to calm pain and inflammation, to correct muscle imbalances, and to improve function of the patella.
As the pain and inflammation become controlled, Dr. Trinh will work with you to improve flexibility, strength, and muscle balance in the knee.
Muscle imbalances are commonly treated with stretching and strengthening exercises. Flexibility exercises are often designed for the thigh and calf muscles. Dr. Trinh will use guided exercises to maximize control and strength of the quadriceps muscles. Bracing or taping the patella can help you do exercises and activities with less pain.
Iliotibal Band Syndrome:
Iliotibial band (ITB) syndrome is an overuse problem that is often seen in bicyclists, runners, and long-distance walkers. It causes pain on the outside of the knee just above the joint. It rarely gets so bad that it requires surgery, but it can be very bothersome. The discomfort may keep athletes and other active people from participating in the activities they enjoy.
The ITB glides back and forth over the lateral femoral condyle as the knee bends and straightens. Normally, this isn’t a problem. But the bursa between the lateral femoral condyle and the ITB can become irritated and inflamed if the ITB starts to snap over the condyle with repeated knee motions such as those from walking, running, or biking.
People often end up with ITB syndrome from overdoing their activity. They try to push themselves too far, too fast, and they end up running, walking, or biking more than their body can handle. The repeated strain causes the bursa on the side of the knee to become inflamed.
Some experts believe that the problem happens when the knee bows outward.
This can happen in runners if their shoes are worn on the outside edge, or if they run on slanted terrain. Others feel that certain foot abnormalities, such as foot pronation, cause ITB syndrome. (Pronation of the foot occurs when the arch flattens.)
Recently, health experts have found that runners with a weakened or fatigued gluteus medius muscle in the hip are more likely to end up with ITB syndrome. This muscle controls outward movements of the hip. If the gluteus medius isn’t doing its job, the thigh tends to turn inward. This makes the knee angle into a knock-kneed position. The ITB becomes tightened against the bursa on the side of the knee. This is also called a valgus deformity of the knee.
People with bowed legs may also be at risk of developing ITB syndrome. The outward angle of the bowed knee makes the lateral femoral condyle more prominent and can make the snapping worse. This condition is also called a varus deformity of the knee.
Most cases of ITB syndrome can be treated with simple measures. When you begin your treatment at Physioflow Physical Therapy, we will first use Astym treatment to help calm pain and inflammation and stimulate new collagen formation.
Dr. Trinh will evaluate the specific biomechanical problems that are causing your symptoms. Dr. Trinh will be asking you about your sport activities and may give you tips on your warm up and training schedule, footwear, and choices of terrain. A key element of our treatment is examining your training schedule. Dr. Trinh can work with you to adjust the distance you run, your footwear, and the running surfaces you choose.
Dr. Trinh will choose strengthening and stretching exercises to correct muscle imbalances, such as weakness in the gluteus medius muscle or tightness in the ITB. You may require kneecap taping, or shoe inserts to improve muscle balance and joint alignment of the hip and lower limb.
Although recovery time varies, if your treatment is nonsurgical, you should be able to return to normal activity within four to six weeks, if not sooner.
Anterior Cruciate Ligament (ACL) Injuries:
The anterior cruciate ligament (ACL) is probably the most commonly injured ligament of the knee. In most cases, the ligament is injured by people participating in athletic activity. As sports have become an increasingly important part of day-to-day life over the past few decades, the number of ACL injuries has steadily increased. This injury has received a great deal of attention from orthopedic surgeons over the past 15 years, and very successful operations to reconstruct the torn ACL have been developed.
The ACL is located in the center of the knee. It is a tough band of tissue that connect the end of the femur (thighbone) to the front of the tibia (shinbone). The ACL is the main controller of how far forward the tibia moves under the femur. This is called anterior translation of the tibia. If the tibia moves too far, the ACL can rupture. The ACL is also the first ligament that becomes tight when the knee is straightened. If the knee is forced past this point, or hyperextended, the ACL can also be torn.
Other parts of the knee may be injured when the knee is twisted violently, as in a clipping injury in football. It is not uncommon to also see a tear of the medial collateral ligament (MCL) on the inside edge of the knee, and the lateral meniscus, which is the U-shaped cushion between the outer half of the tibia and femur bones.
The mechanism of injury for many ACL ruptures is a sudden deceleration (slowing down or stop), hyperextension, or pivoting in place. Sports-related injuries are the most common.
The types of sports that have been associated with ACL tears are numerous. Those sports requiring the foot to be planted and the body to change direction rapidly (such as basketball) carry a high incidence of injury. In this way, most ACL injuries are considered noncontact. However, contact-related injuries can result in ACL tears. For example, a blow to the outside of the knee when the foot is planted is the most likely contact-related injury.
Football is also frequently the source of an ACL tear. Football combines the activity of planting the foot and rapidly changing direction and the threat of bodily contact. Downhill skiing is another frequent source of injury, especially since the introduction of ski boots that come higher up the calf. These boots move the impact of a fall to the knee rather than the ankle or lower leg.
An ACL injury usually occurs when the knee is forcefully twisted or hyperextended while the foot remains in contact with the ground. Many patients recall hearing a loud pop when the ligament is torn, and they feel the knee give way.
The number of women suffering ACL tears has dramatically increased. This is due in part to the rise in women’s athletics. But studies have shown that female athletes are two to four times more likely to suffer ACL tears than male athletes in the same sports.
Recent research has shown several factors that contribute to women’s higher risk of ACL tears. Women athletes seem less able to tighten their thigh muscles to the same degree as men. This means women don’t get their knees to hold as steady, which may give them less knee protection during heavy physical activity. Also, tests show that women’s quadriceps and hamstring muscles work differently than men’s. Women’s quadriceps muscles (on the front of the thigh) work extra hard during knee-bending activities. This pulls the tibia forward, placing the ACL at risk for a tear.
Meanwhile, women’s hamstring muscles (on the back of the thigh) respond more slowly than in men. The hamstring muscles normally protect the tibia from sliding too far forward. Women’s sluggish hamstring response may allow the tibia to slip forward, straining the ACL. Other studies suggest that women’s ACLs may be weakend by the effects of the female hormone estrogen. Taken together, these factors may explain why female athletes have a higher risk of ACL tears.
Here at Physioflow Physical Therapy, we utilize an step evidence-based 12 step approach to rehabilitate the athlete after ACL surgery to maximize their odds of an uncomplicated and complete recovery.
We begin rehabilitation before surgery when possible. It is imperative to reduce swelling, inflammation, and pain, restore normal ROM, normalize gait, and prevent muscle atrophy prior to surgery. In addition, we want to prevent the patient from further injury to their knee (i.e. meniscus, articular cartilage, etc). The goal is to return the knee to its preinjury, normalized state and to obtain tissue homeostasis. Full motion is restored before surgery to reduce the risk of postoperative arthrofibrosis, which is the development of scar tissue in the knee joint restricting motion. The preoperative phase, which we believe is critical to a successful outcome, may require up to several weeks, but generally 21 days is adequate.
Postoperative rehabilitation begins with passive range of motion (PROM) and weight bearing (WB) activities immediately following surgery. Full passive knee extension is emphasized while gradually restoring knee flexion. Immediately following surgery, WB as tolerated in a locked knee brace in full extension is allowed, and the patient is progressed to full WB without crutches 10 to 14 days following surgery.
Despite conflicts in the literature, we recommend a drop-lock knee brace during ambulation to emphasize full knee extension and assist the patient during the gait cycle while the quadriceps are inhibited. The locked brace is used while walking and sleeping during the first 2 weeks after surgery. Studies have also shown that patients achieve improved functional knee scores and proprioception when using a brace after surgery.
At 2 to 3 weeks after surgery, we begin restoring the neuromuscular control of the knee by advancing the athlete to include dynamic stabilization training. Once satisfactory strength and neuromuscular control can be demonstrated, functional activities such as running and cutting may begin. Timeframes for initiating running activities range from 10 to 18 weeks following surgery depending on the surgical procedure performed and overall patient presentation. A gradual return to athletic competition for running and cutting sports, such as baseball, football, tennis, and soccer, occurs approximately 6 months after surgery, once the patient is capable of demonstrating at least 85% strength of quadriceps and hamstring of the surgical knee when compared to the non-surgical knee. Return to jumping sports such as basketball and volleyball, however, may be delayed until 6 to 9 months after surgery.
How Physical Therapy Can Help:
After a car accident, symptoms such as reduced range of motion, headaches, stiffness and pain may not appear right after the accident. This is often because your body responded with high doses of adrenaline, which mask the symptoms early on.
Using specific exercises, manual therapy and stretches, Dr. Trinh can support the recovery process and help keep the pain at bay, assist in gradually improve flexibility, increasing strength and speed up recovery.
If you have just experienced an accident, Physical Therapy can help prevent long-term damage and chronic pain, thereby decreasing the likelihood of pain medications and opioid dependence. If you are dealing with the repercussions of an old car accident injury, Dr. Trinh can still help you restore function with non-invasive treatment.