There are two types of cartilage inside the knee. Both can be injured in different ways.
The lateral and medial menisci are C-shaped and made of tough, rubbery fibrocartilage. They are located within the knee joint and function like washers, helping with shock absorption and aiding joint stability.
Joint (articular) cartilage is the solid layer of cartilage that covers the bony surfaces inside the knee joint.
HOW DO I KNOW IF I HAVE A KNEE CARTILAGE INJURY?
Your physiotherapist can examine your knee to accurately diagnose your knee symptoms. They may also refer you for imaging or to a specialist, if required.
In acute tears, a person generally remembers the particular movement that caused the injury. It’s often felt as sharp pain and an inability to continue activity. In degenerative tears, there may not be a specific incident. Depending on the severity of the meniscal tear, these injuries are often associated with:
mild to moderate swelling;
localised, sharp knee joint pain with walking, twisting and turning;
reduced knee bending and straightening (‘locking’);
clicking or catching sensations, which may or may not be painful;
Often cause aching at night.
How EFFECTIVE IS PHYSIOTHERAPY FOR TREATING KNEE CARTILAGE INJURIES?
In the case of degenerative meniscal tears, there is a growing amount of evidence to show that physiotherapy, including specific strength and control exercises, is as effective as keyhole knee surgery (arthroscopy). A study of a 12-week supervised knee strength and neuromuscular control (stability and leg position) exercise program compared to knee arthroscopy (including trimming the torn part of the meniscus) demonstrated no difference in pain, function or quality of life between the groups at two years. At three months following the trial, the exercise group showed improvements in quadriceps muscle strength compared to the arthroscopy group. One significant review concluded that for degenerative meniscal tears, the first-line treatment should be non-operative. This should include simple pain medications (as recommended by your GP) and physiotherapy in order to improve the mechanics of the knee joint and manage pain. This has been shown to be less-invasive and to have fewer risks than arthroscopic surgery, while being equally effective. This study advises that arthroscopic surgery to trim degenerative meniscal tears should only be used as a last resort for people who have not experienced improvements with a comprehensive well-structured physiotherapy exercise program.
WHAT IS KNEE OSTEOARTHRITIS?
Knee osteoarthritis (OA) is one of the most common chronic conditions seen at Optimise Physio and affects a large number of Hawke’s Bay community. OA is a condition in which the hyaline articular cartilage thins, develops cracks and can eventually wear away.
HOW DO I KNOW IF I HAVE A KNEE OSTEOARTHRITIS?
Knee OA has a variety of symptoms that are related to the main site of OA within the knee, the severity of the OA, the amount of strength and control a person has around their knee, as well as any other conditions present within the knee (eg, a meniscal tear).
Symptoms commonly include:
stiffness in the morning or after prolonged sitting
pain with prolonged periods of walking or standing
difficulty with activities such as stair climbing and stair descending
clicking, clunking, crunching or catching within the joint
reduced joint flexibility (bending or straightening)
altered joint shape and size
altered leg posture (eg, ‘knock knees’ or ‘bow legs’)
a feeling of instability or giving way in the knee
feeling of weakness in the leg muscles, especially the quadriceps (front of thigh).
Knee OA symptoms commonly fluctuate, sometimes being better or worse, depending on activity. The symptoms may initially only be with activity but as OA progresses, knee pain may be experienced at rest or during the night.
How EFFECTIVE IS PHYSIOTHERAPY FOR TREATING KNEE OSTEOARTHRITIS?
There is good evidence to support physiotherapy management of knee OA. The main areas supported by research include:
Physiotherapy vs arthroscopy for knee OA: physiotherapy exercise and education, combined with standard medical care (simple pain medication) is equally effective to keyhole knee surgery (arthroscopy) in the management of knee OA. In people with moderate to severe knee OA, it has been found that arthroscopy added no additional benefit in terms of physical function, pain or quality of life, when compared to physiotherapy and simple medication. In addition, physiotherapy has been shown to have minimal risk of negative side effects compared to surgery.
Supervised physiotherapy exercise programs: for example, Good Life with Osteoarthritis in Denmark (GLA:D) research looked at a group of people with knee OA undertaking two sessions of control, stability and strength exercise per week for six weeks, plus three sessions of education regarding knee OA. The results included: participants needing less sick leave from work for knee pain, and reducing their use of pain medications; participants increasing their physical activity at three months and 12 months after finishing the program; participants continuing to experience a 31 per cent pain reduction at three months and a 36 per cent pain reduction at 12 months post-program respectively; 94 per cent of participants enjoyed the program and very few experienced pain flare-ups, none to the point of needing to stop training; and there was a significant improvement in knee-related quality of life and the majority of participants report using their new skills daily. This program is now available in Australia. Prehabilitation: various studies have looked at programs of strength, movement control and cardiovascular exercise for 6–8 weeks prior to total knee replacement surgery. Most studies have found improvements in post-operative pain and function in the few months following surgery, and some have shown reductions in length of hospital stay. Some of the main reasons for these outcomes include patients entering surgery with a better baseline of physical conditioning and better mental preparedness.
WHAT IS KNEE LIGAMENT INJURY?
A ligament is made of collagen fibres organised into a thick band of tissue, like a rope. Ligaments connect one bone to another and are important stabilisers of joints. The knee joint has four main ligaments. Two are located inside the knee joint (the anterior and posterior cruciate ligaments); the others are located outside the joint (the medial and lateral collateral ligaments).
HOW DO I KNOW IF I HAVE A KNEE LIGAMENT INJURY?
Symptoms depend on the exact ligament torn and the severity of the injury, but are usually associated with localised pain, bruising and reduced movement. Injured ligaments can also present with a ‘pop’ or tearing noise, swelling and a feeling of giving way or instability when walking.
The most common and serious knee ligament injuries include those to the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL).
An ACL injury usually occurs during cutting or twisting movements, sudden stopping, or incorrect landing from a jump. Complete ACL injuries are usually accompanied by a ‘pop’ or a crack at the time of injury and are usually initially extremely painful. Most people are unable to play on and report that their knee feels ‘wobbly’ to walk on or it they try to change direction suddenly their knee may give way. The knee usually swells up within a few hours.
MCL injuries present with tenderness on the inner aspect of the knee, slight swelling and restriction of movement, all of which vary in intensity depending on the severity of the ligament injury.
Posterior cruciate injuries are usually accompanied by widespread knee pain worse at the back of the knee and calf but minimal swelling unless other structures are damaged as well. Your physiotherapist can examine your knee to determine which ligament or combination of ligaments are injured and the severity of the injury and refer you for imaging if required.
How EFFECTIVE IS PHYSIOTHERAPY FOR TREATING KNEE LIGAMENT INJURIES?
ACL injuries A recent trial in Sweden comparing a structured physical rehabilitation program, or early or delayed ACL reconstructive surgery, has shown no significant difference in outcomes of pain and knee symptoms, activities of daily living and sport and recreation function at two and five years post-injury, for recreational athletes between the treatment groups. Approximately 50 per cent of the isolated ACL patients in this study required an ACL reconstruction because their knee was still unstable, even after completing a physical rehabilitation program.
Patients generally undertake physical rehabilitation programs (with or without surgery) for 9–12 months before they are strong and stable enough to return to their previous sports. It is recommended to participate in a pre-hab program under supervision by a physiotherapist for three months prior to surgery; this allows you, your family, physiotherapist and surgeon to make an informed decision regarding early or delayed surgery, or conservative management, and also improves the outcome of surgery both physically and emotionally.
The long-term outcome of ACL treatment choices is unknown and some researchers have found a higher risk of cartilage tears when ACL reconstructive surgery is delayed. Many people continue to experience some problems with their knee following an ACL injury no matter what treatment option they choose.
Medial ligament injury (MCL) Studies have shown physical rehabilitation is as effective as surgery for return to sport, even for complete ruptures of the MCL. The MCL is occasionally repaired surgically in conjunction with ACL reconstructive surgery. Generally, rehabilitation from MCL injury takes between 2–6 weeks depending on the severity of the initial injury. Posterior cruciate injury (PCL) PCL injuries are usually managed with a physical rehabilitation program, with or without a splint depending on the severity of the injury. Surgery is usually only considered if the PCL is damaged along with other important knee structures. Healing is variable depending on the severity of damage but generally from 4–12 weeks.
Patellofemoral pain (knee cap pain)
WHAT IS PATELLOFEMORAL PAIN?
Patellofemoral pain (PFP) is a condition where pain is felt on the front of the knee, either around or behind the patella. It is commonly felt with activities such as squatting, running, jumping, hopping and going up or down stairs; often limits a person’s ability to participate in their chosen activity or work; forms on average 30 per cent of all knee presentations to our clinic, and can affect people of any age.
HOW DO I KNOW IF I HAVE PATELLOFEMORAL PAIN?
People with patellofemoral pain commonly experience: grinding sensations from the patellofemoral joint with knee bending, tenderness when the back of the kneecap is touched during an examination of your knee, mild knee swelling, front-of-knee pain while sitting, getting out of a chair, or on straightening your knee after prolonged sitting.
How EFFECTIVE IS PHYSIOTHERAPY FOR PATELLOFEMORAL PAIN?
There is a large and growing amount of research evidence to support the use of physiotherapy in the treatment of patellofemoral pain. The International Patellofemoral research group made six consensus statements based on the current scientific evidence and their expert opinions. These are:
Exercise therapy has been shown to reduce patellofemoral pain in the short (less than six months), medium (6–12months) and long-term (greater than 12 months). It has also been shown to improve knee function in the medium and long-term.
A combination of hip and knee exercise has demonstrated better effectiveness than knee exercise alone. This combination has been shown to improve function and reduce pain in the short, medium and long-term.
Physiotherapy consisting of a combination of methods is recommended to reduce PFP in the short and medium term.
Short-term pain relief has been demonstrated with the use of shoe inserts.
There is no evidence to support the use of patellofemoral or knee mobilisation (hands-on movement of the kneecap) or lower back mobilisation, and, as such, these are not recommended for the treatment of PFP.
Electrotherapy (ultrasound and other electrical machines) are not recommended as part of the management of PFP.
The research also states that PFP treatment is most effective if a person takes an active role in managing their PFP, rather than relying on a healthcare professional to just apply passive treatment to them. If a person completes their home exercise program regularly, as prescribed, and is sensible about building up their activity gradually, this is also effective. Additionally, as PFP normally has several contributing factors, a combined physiotherapy approach best allows each of these contributors to be addressed. This may also include patellofemoral taping, bracing or running retraining. At Optimise Physio, we follow the latest scientific evidence in the treatment of this condition.