What we treat - Knee Pain

Arthroscopy is a minimally invasive, surgical procedure, done to diagnose and treat any painful joint, most frequently the knee. It is reported to have a greater than 90% success rate, which is a statistic that relates to the incidence of surgical complications, such as infection or blood clots. It’s a great procedure for diagnosis, but has limited applications for treatment.

It works for conditions like meniscal tears, tight bands of tissue and some ligament tears but overall, as a treatment, research reports indicate it doesn’t offer great odds on long term results. Part of the poor research results relate to the high number of older clients who have findings of moderate to advanced osteoarthritis, which tend to get worse until they’re ripe for replacement. Based on the accounts of many clients who report long histories and multiple interventions for anterior knee pain, many young people are not improved or cured by the procedure either.

With respect to anterior knee pain, arthroscopy is very good for diagnosis. Included in this category are patellofemoral pain syndrome, runner’s knee, jumper’s knee and by some accounts, the most common of all, chondromalacia patellae. It is most commonly reported by youth, aged 16 to 25; and more females than males. Anterior pain may be related to structural issues, such as wide hips or tilted patellae; and associated muscle imbalances. Anterior knee pain is often associated with overuse.

So, why would physio be of benefit following a scope if it hadn’t helped before? There are at least four reasons:

• When a client has pain, there’s a natural tendency to avoid things which cause pain – one of which could well be the exercises that are prescribed as treatment. The ‘right’ exercises can be done incorrectly; and cause pain. There’s often some discomfort associated with new exercise; so even the ‘right’ exercises, done correctly can cause initial discomfort. Very often a physiotherapist will prescribe exercise, but has limited time to see that they’re done and done well.
• There’s a tendency to want to know what is actually wrong with your knee before you commit too much to exercises, any treatment, really. We all do better when we know what’s going on. This is especially true when it is known a scope is scheduled, which will determine or confirm a diagnosis. Could be, there wasn’t sufficient commitment to the exercise prescription pre-scope to effect sufficient change.
• There’s a strong likelihood that no internal knee pathology will be found and poor alignment will be the diagnosis post scope. In these instances, a possible cure in fact lies with renewed focus on stretching the tight muscles and soft tissue and correcting movement balance and strength throughout the legs. Physio treatment post-scope can provide clear direction and assist with the motivation required to achieve muscle changes.
• Perhaps most importantly, if the diagnosis is early stage chondromalacia, or softening/blistering of the cartilage behind the patella, low intensity laser can reverse the cartilage damage. This is supported by research. A caveat here, though, is that it really needs any muscle imbalance issues to also be corrected to experience a lasting cure. The opposite is not true: exercise alone can’t restore the integrity of cartilage behind the knee-cap or patella.

From the viewpoint of our clinicians, it seems rare that post-arthroscopy clients avail of physiotherapy. This seems particularly harsh for young people with chondromalacia patella, who could have experienced relief, even permanent relief with treatment which included laser therapy. Without treatment they can expect more pain and limited function, as the cartilage behind their kneecap continues to deteriorate.

While any muscle weakness or imbalance is important, Vastus Medialis Oblique (VMO), might be the most important muscle of them all. It is certainly the most universally afflicted. While individual weaknesses, etc will reflect underlying structure, and require different rehab strategies, most all require activation and strengthening of the VMO. This muscle is very active during gait, being responsible for the last few degrees of straightening the knee before heel strike. It is quickly affected by knee pain and swelling. It manifests itself in difficulty achieving the last bit of straightening and in a soft and poorly defined muscle on the inside of the knee.

Two exercises which address this muscle are:

Isometric knee extension: From the starting position in the picture, pull toes towards your head, lift heels one at a time or both together so that knees are straight, and hold for 10 seconds. Repeat 10 times

Partial knee squat: Stand with your feet slightly apart, and bend knees to lower to the partial squat position shown in the picture. Hold for 30 seconds. Repeat 3 times