An Athletes Guide To Chronic Knee Pain
One of the first basic principles in addressing rehabilitation for the quadriceps mechanism is to make sure that the patient is on an appropriate hamstring stretching program. The role that tight hamstrings can play in increasing the force on the anterior aspect of the knee, and thus causing anterior knee pain, is often not given appropriate recognition by physicians and therapists alike. When a patient shows signs of hamstring bursal irritation, it is important that they be placed on an appropriate hamstring stretching program. This includes stretching several times daily. In the more severe cases, we often recommend an hourly stretching program. Patients must be taught that they can stretch in almost any environment, as long as they keep their ankle dorsiflexed, their knee straight, and their back straight.
The structures in and around the knee are frequently injured in children in athletics as a result of chronic overuse and the special anatomic and morphologic situations in the growing adolescent. This section will focus on common causes of knee pain in the adolescent, but will also emphasize the importance of tumors and referred pain in the diagnostic approach. Traumatic, acute disorders have been covered in the previous sections. Knee pain in adolescents has many etiologies and the clinician must also rule out rare entities (e.g. tumor, referred pain) to establish a thorough diagnosis. Although meniscal injuries are less common in children than in adults, several recent reports indicate an increasing incidence of meniscal lesions in children and adolescents, especially those in competitive sports. De Inocencio i0i investigated the distribution of mus-culoskeletal pain in children. The knee was the most affected joint (33 ), followed by other joints (e.g. ankle, wrist, elbow, in 28 ),...
Fig. 92 Area affected by anterior knee pain Fig. 92 Area affected by anterior knee pain SYMPTOMS Gradual onset of diffuse or localised exercise-induced pain around the anterior part of the knee. Prolonged sitting or squatting often trigger the symptoms (positive 'movie sign' - so named because you are in the same position for a long period when watching a movie at the cinema) as can walking down stairs. AETIOLOGY Anterior knee pain is not a diagnosis but a symptom that can be caused by a number of underlying pathologies. The correct diagnosis must be made before treatment can be successful. This condition often occurs as a result of sudden changes in training habits, such as increase in intensity or amount of impact. PROGNOSIS Because many cases never reach an absolute diagnosis and correct treatment, anterior knee pain ends the career of many young athletes.
Posterolateral knee pain, commonly with weight-bearing and gait, especially walking down stairs or slopes. Patients with remnants of leg pain down the lateral border of the lower leg to the foot. Note the previously described conditions in which MWMs are pain-free and successful.
The extensor mechanism comprises the quadriceps muscle, quadriceps tendon, patella, and patellar tendon. Differential diagnosis of problems in the extensor mechanism is broad, including muscle or tendon rupture, patellar fracture, patellar tendinopathy, patellofemoral syndrome, patellar instability, Osgood-Schlatter's disease, and symptomatic medial plica. Examination of patients with anterior knee pain or extensor mechanism problems should always include a careful evaluation of the lumbar spine and hip to rule out
Anterior knee pain has been variously termed patellofemo-ral syndrome and chondromalacia patellae. When treating anterior knee pain, the physician should identify the specific pathology to initiate targeted treatment. Chondromala-cia patellae, or degenerative changes on the undersurface of the patella, is more common in young females. Pain complaints related to chondromalacia are exacerbated by sitting for an extended period with a flexed knee, doing deep squats, or going up and down stairs. Each of these activities increases the posteriorly directly forces of the patella, directing increased pressure onto the chondral surfaces.
The most common intraoperative complications concern neu-rovascular injury, particularly involving the popliteal artery. Techniques to reduce this are discussed in the preceding section and are especially important during procedures using a transtibial approach. Hematoma formation and drainage from a posterior arthrotomy may occur as a result of gravity drainage or bleeding from inferior geniculate vessels. Because of this, some authors recommend routine ligation of the inferior medial genic-ulate vessels.16 Postoperatively, residual laxity, loss of motion or arthrofibrosis, infection, painful hardware, and anterior knee pain are the most common complications. Reconstructed PCL knees may be slow to regain full flexion this may be worsened by poor tunnel placement.6 As importantly, patient age, severity of trauma, and ability to actively rehabilitate are important factors often beyond the surgeon's control.
Patellar tendinitis (jumper's knee) Treatment is conservative, including eccentric exercises for at least 3 months. If a well-supervised conservative treatment program fails, surgical excision of the necrotic part of the patellar tendon is indicated. However, only 30-60 98 of competitive athletes return to their original sporting level. Both arthroscopic and open patellar tenotomy provide symptomatic pain relief in most patients with end-stage patellar tendinopathy. After open patellar tenotomy, MRI and ultrasound findings remain abnormal despite clinical recovery. Thus, clinicians should base postoperative management of patients undergoing patellar tenoto-my on clinical grounds rather than imaging findings (Fig. 6.2.20). The prognosis for returning to sport is not favorable, as mentioned above. However, patellar tendinitis does not lead to major arthritis or disability. On the other hand, it may lead to the retirement of the player from sports involving jumping and fast running....
Patients may admit to an audible pop that occurs while cutting or landing from a jump. Early swelling may develop coinciding with severe knee pain. The patient may be unable to fully extend the knee secondary to pain and swelling. Some patients report a sensation of the knee giving way because of instability.
Patients present with lateral knee pain following a traumatic event. Assessing the mechanism of injury is important. Patients may describe a direct blow to the antero-medial aspect of the tibia. Additionally, they may describe a feeling of the knee giving way during pivoting or twisting activities.
Patients usually present with intermittent medial, lateral, or diffuse knee pain and stiffness after a traumatic event. Some patients may not actually recall an inciting event. Others may report an audible pop during the injury. Patients often describe knee joint clicking, catching, locking, or giving way. Frequently, the knee becomes swollen within 24 hours.
Patients complain of an insidious onset of anterior knee pain usually localized to the inferior pole of the patella. Often the pain is described as aching and made worse with activity. Some patients may report a reduction in pain during the course of activity. Severe cases usually involve pain at rest.
Iliotibial band (ITB) syndrome is the most common cause of lateral knee pain among athletes. ITB syndrome is an overuse injury that results from an inflammation of the bursa as the ITB crosses the lateral femoral epicondyle. It is most common in runners and cyclists who require repetitive knee flexion and extension. Predisposing factors include increased running distance, especially downhill and hard-surface running. Patients usually present with an insidious onset of lateral knee pain worse with activity. Initially, the pain will resolve after activity however, in severe cases, the pain will continue during walking. Occasionally, the pain will radiate below the knee or up into the lateral thigh. Some patients will complain of pain worse with ascending stairs or running downhill.
Warden SJ, Hinman RS, Watson MA Jr et al 2007 Patellar taping and bracing for the treatment of chronic knee pain A systematic review and meta-analysis. Arthritis and Rheumatism 59(1) 73-83 The effect of tape on pain, particularly PF pain, has been fairly well established in the literature (Bockrath et al 1993, Cerny 1995, Conway et al 1992, Gilleard et al 1998, Powers et al 1997). Even in an older age group (mean age 70 years) with tibiofemoral osteoarthritis, taping the patella in a medial direction resulted in a 25 reduction in knee pain (Cushnagan et al 1994). However, the mechanism of the effect is still widely debated.
Knee pain, 87-88 eight directions, 55-56 pulse, 13-15 tongue, 12-13 dianhea, 189-190 dysmenonhea, 167-170 ear infections, 142-144 eczema, 195-197 electro-acupuncture, treatments, 104 endometriosis, 177-179 facelifts, 197-199 fibromyalgia, 65-66 headaches, 59-61 healthful lifestyle tips, 251-252 herbal medicine, 47-49 HIV AIDS, 218-219 hypertension, 220-221 IBS, 186-187 indigestion, 191-193 infertility, 156-158 injuries, 101 insomnia, 225-227 jumper's knee, 88-89 knee pain, 87-88 licenses, 244 magnets, 45-46 Margaret Naeset, 75 medical histories, 14-15 menopause, 170-172 moxibustion, 41-42 nasal congestion, 126-127
Witvrouw et al42 prospectively studied the risk factors for the development of anterior knee pain in the athletic population over a 2-year period. A significant difference was noted in the flexibility of the quadriceps and gastrocnemius muscles between the group of subjects who developed patellofemoral pain and the control group, suggesting that athletes exhibiting tightness of specific muscles may be at risk of the development of patellofemoral disorders. 42. Witvrouw EE, Lysens R, Bellemans J, et al Intrinsic risk factors for the development of anterior knee pain in an athletic population. Am J Sports Med 2000 28 480-489.
Treatment of pronation consists of using an inner heel wedge or an orthosis that provides the same type of correction. Generally, patients should be discouraged from wearing a high heel if they have symptoms of foot or knee pain. Recommending shoes with little or no heel may be inadvisable, however, because the foot tends to pronate more in a flat-heeled shoe. With a medium heel, the longitudinal arch is increased, and a heel wedge or arch support will help to correct pronation.
Angles can help measure the level of mal-tracking. MRI and arthroscopy may be important for evaluating alternative diagnoses. There is a high risk that cartilage on the kneecap as well as on the femur condyle will have been damaged if there was a previous dislocation. The combination of partial ACL rupture and patellar instability is not uncommon. TREATMENT An athlete with anterior knee pain and recurrent instability of the patella should be seen by an orthopaedic surgeon and a physiotherapist. Most cases can be treated without surgery and with physiotherapy, working in particular on muscle strength and control of the entire kinetic chain. In cases with an increased Q-angle of over 20 degrees, surgical treatment with anterior medialisation of the tuberositas tibia may be indicated if physiotherapy fails. REFERRALS Refer to orthopaedic surgeon for further investigations to verify the diagnosis. Physiotherapists should be involved in close collaboration with the surgeon. SYMPTOMS The...
Anterior cruciate ligament tear (ACL) Anterior knee pain Cartilage injuries Chondromalacia patella Gout arthropathies Iliotibial band friction syndrome Lateral collateral ligament tear (LCL) Medial collateral ligament tear (MCL) Medial plica syndrome Meniscus tear Osgood-Schlatter's disease Osteoarthritis
At 2 weeks, the postoperative splint is removed and the patient is placed into a removable cam walker. The goal at this time is to allow the patient to begin weight bearing with the ankle held in 20 degrees of plantarflexion. This can be accomplished by placing a (-)20 degrees of dorsiflexion block in the boot itself or by placing wedges in the boot to place the ankle in 20 degrees of plantarflexion with the boot itself at neutral. Placing the boot itself in 20 degrees equinus leads to a significant disturbance in the patient's gait. The patient is effectively ambulating with an equinus contracture and lengthened lower extremity. This can lead to knee pain secondary to the recurvatum thrust placed on the knee. Also, contralateral hip and low back pain can ensue secondary to the significant leg-length discrepancy. To prevent this, the boot should be fit in a neutral dorsiflexion block, allowing full plantarflexion and utilizing heel lifts to place the ankle in 20 degrees of...
SYMPTOMS There is gradual onset of diffuse exercise-induced pain around the anterior part of the knee. Prolonged sitting or squatting often trigger the symptoms (positive movie sign). Walking down stairs is more difficult than up. AETIOLOGY Chondromalacia means 'soft cartilage'. The exact aetiology is unknown. The correct diagnosis must be identified, by arthroscopic probing, before treatment can be successful, since this is only one of many diagnoses that result in anterior knee pain.
Improvisation is essential during the rehabilitation of patients who have premorbid impairments that interfere with therapy goals. This patient had a stroke causing right hemiparesis and impaired ambulation. As motor control improved, his chronic knee pain and atrophy of the quadriceps from degenerative joint disease continued to limit ambu-lation. A flexible knee brace and frontwheel walker enabled him to more easily load the knee in the stance phase of gait and he immediately became independent in ambulation. Figure 6-5. Improvisation is essential during the rehabilitation of patients who have premorbid impairments that interfere with therapy goals. This patient had a stroke causing right hemiparesis and impaired ambulation. As motor control improved, his chronic knee pain and atrophy of the quadriceps from degenerative joint disease continued to limit ambu-lation. A flexible knee brace and frontwheel walker enabled him to more easily load the knee in the stance phase of...
Pain is what the patient initially seeks help for. Information and (perhaps also printed) advice about weight loss, shoes with shock-absorbing soles, maintenance of physical activity and training programs and 'over-the-counter' (OTC) analgesics are often effective. The interested and educated physical therapist has an important role in guiding the patient to the right kind of exercises and encouraging compliance. Some reports suggest that quadriceps weakness is a primary risk factor for knee pain, disability and progression of joint damage in persons with osteoarthritis of the knee 85 . Several other studies support the beneficial effects of exercise on OA symptoms 86-90 .
The production of MMP-1, TIMP-1, and gelatinolytic activities in cell cultures from tendinosis samples and controls has been examined in patellar tendinopathy. Tendinosis tissues showed an increased MMP-1 expression and a decrease in TIMP-1.- 2- 63 This condition favors collagen degradation and supports a role of imbalance in collagen homeostasis as a causative factor in tendinopathy that may be applicable to Achilles tendinopathy.
Patients with OA typically complain of knee pain and stiffness with walking, after prolonged sitting, descending stairs, and early in the morning. Swelling of knees and worse symptoms are typical with weather changes. Physical exam findings often reveal decreased ROM (flexion contractures), knee varus or valgus deformity, joint line tenderness, and crepitus with palpation during ROM.
Knee pain in an adolescent is usually the result of trauma. Partial avulsion of the tibial tubercle associated with a painful swelling in that area is called Osgood-Schlatter disease. This common condition is seen more frequently in pubertal boys and is usually self-limited. Knee pain may also be referred from the hip and result from a slipped capital femoral epiphysis (SCFE). Movement of the hip into external rotation as the leg is flexed at knee and hip is very suggestive of SCFE. SCFE is fairly common during the pubertal growth spurt and is especially common in obese adolescents.
Flatback syndrome is a sagittal malalignment syndrome. Radiographically the hallmarks of flatback syndrome include a markedly positive sagittal vertical axis and decreased lumbar lordosis after a spinal fusion procedure. Classically, it has been reported after use of a straight Harrington distraction rod to correct a lumbar or thoracolumbar curvature. When the thoracic and lumbar spine is fused in a nonphysiologic alignment with loss of lumbar lordosis, the patient cannot assume normal erect posture and assumes instead a stooped forward posture. The patient attempts to compensate for this abnormal posture by hyperextending the hip joints and flexing the knee joints. These compensatory mechanisms are ultimately ineffective in maintaining the SVA in a physiologic position and result in symptoms of back pain, knee pain, and inability to maintain an upright posture. Fixed sagittal malalignment of the spine has many etiologies.
TREATMENT Arthroscopic excision of the painful plica shows excellent outcomes. REFERRALS These patients are very much helped by being evaluated clinically by their physician, surgeon and physiotherapist in close collaboration since there are many differential diagnoses (see anterior knee pain).
The technique of swimming is very demanding and often hampers its aerobic and anaerobic effects and thus the time spent in the water. To swim for 30 minutes requires a well-developed technique. Even though there is no direct impact, swimming may cause problems if the training is not precisely defined it is important to recommend or restrict different techniques of swimming for different injuries. For example, swimming the breaststroke can exacerbate knee injuries such as medial meniscus tears, osteoarthritis, anterior knee pain and most shoulder injuries. Most swimming techniques will provoke sub-acromial impingement and patients with multidirectional instability in the shoulder should not be prescribed swimming. Low back pain and neck pain may well be aggravated if the athlete does not lower the head down into the water in the swimming stride but looks up, protecting the face or eyes from the chlorine but hyper-extending the cervical and lumbar spine. Such simple mistakes often mean...
The generation of pain in chronic tendon injuries appears to involve more than just inflammation. A biochemical hypothesis to explain tendon pain states that biochemical agents are leaked from a degenerated tendon and irritate nociceptors (pain receptors) on adjacent structures (Khan and Cook, 2000). In patellar tendinopathy, higher levels of glycosaminoglycans have been found in the infrapatellar fat pad (Khan et al., 1996), and in patients with partial rotator cuff tears higher levels of substance P were found in the adjacent subacromial bursa and were significantly associated with pain (Gotoh et al., 1998).
Quadriceps muscle strength can be trained with leg press, squats or leg extension manoeuvres. The vastus medialis muscles require special attention after patella (kneecap) dislocation or in mal-tracking conditions that cause anterior knee pain. If the patella is subluxated or out of place and knee extensions cause pain, a soft knee brace can be useful and give very good results. The quadriceps muscles are essential for knee stability in activities such as jumping, sprinting, twisting and turning. The rectus femoris muscle, the most
Anterior Knee Pain Difficulties with patellofemoral tracking can result in acute injuries (patellar subluxation or dislocation) or overuse problems (patellofemoral stress syndrome or anterior knee pain). Patellar subluxation and dislocation are discussed in detail in Chapter 57 and are not covered in this section. Patellofemoral stress syndrome is a name given to the syndrome of anterior knee pain or patellofemoral pain associated with diffuse anterior knee pain that increases with such activities as squatting, kneeling, running, walking down steps, or walking downhill and is common in women athletes, especially young women. The diagnosis of patellofemoral stress is based on history and clinical examination (Table 8-1). Squats and lunges (i.e., those activities that increase patellofemoral forces) frequently enhance symptoms. Swelling is rarely present. Other symptoms of this syndrome include popping, catching, and snapping. Athletes may experience acute episodes of the knee giving...
Key considerations in the postoperative care of PLC reconstructions are prevention of (1) varus and external rotation of the tibia, (2) active knee flexion against gravity, and (3) extension hyperextension of the tibia to protect the grafts. Therefore, no active knee flexion against gravity is done until 12 weeks post-operatively due to the internal rotation of the tibia during the first 10 degrees of flexion and the posterior translation, which places tensile forces on the graft. Passive extension to 0 degrees with gravity eliminated and without overpressure is advocated. Additionally, full hyperextension is not emphasized until up to 3 months postoperatively. Hyperextension should be based on bilateral comparison of the uninvolved limb. Achieving extension of the involved limb should be based on the uninvolved. Contrary to isolated ACL reconstruction in which hyperextension is emphasized immediately, hyperextension after PLC reconstruction can potentially lead to graft failure,30...
Petitive rugby players with isolated PCL injuries were able to return to preinjury levels of play, some patients took as long as 7 months to recover and nearly all reported subjective sensations of impaired ability, most commonly manifesting in highspeed running (slower acceleration and delayed response) and while turning.18 Long-term follow-ups have found that as many as 90 of patients with isolated PCL injuries may have persistent pain while walking, 45 report episodic instability, 65 report limitations of activity, and more than 50 demonstrate evidence of degenerative changes.4,7 Increasing literature points to a significant incidence of knee pain, patellofemoral symptoms, and medial compartment degeneration in the PCL-deficient knee. This is likely due to altered knee kinematics, with increased quadriceps activity, altered articular contact pressures (especially patellofemoral) and abnormal tibial translation and rotation noted under complex muscle loads in the PCL-deficient
Knee pain in adolescents is most often a problem of overload in bone (Osgood-Schlatter), tendons or cartilage (osteochondritis) and is generally treated with decrease of load and active rehabilitation. Referred pain from the hip or pain from tumors must always be kept in mind.
The use of therapeutic methods to stimulate collagen repair is also a major focus in the treatment of tendinopa-thy. Common strategies to induce collagen remodeling include manual therapies such as deep-friction massage, eccentric conditioning of the tendon, tenotomy (needling a degenerated tendon), and injection of autologous growth factors. Eccentric strengthening programs have shown favorable results for patients with chronic Achilles tendinopathy as well as for athletes with chronic patellar tendinopathy (Alfredson et al., 1998 Purdam et al., 2004). When conservative treatments such as physical therapy fail, treatment options are limited and often lead to either the discontinuation of exercise or surgery. In competitive athletics, chronic tendon injuries can lead to persistent pain, lost time from participation, and suboptimal performance. In occupational injuries, chronic tendon trauma leads to significant cost and morbidity.
Muscle and tendon injuries occur from repetitive microtrauma or a single traumatic event that causes overload to the tensile strength of the myotendinous unit or muscle fiber itself. Eccentric loads, produced when the muscle is contracting and lengthening at the same time, are a common mechanism of injury and can produce higher forces compared with concentric contractions (Stanton and Purdam, 1989). Sports activities with repetitive eccentric demands place the athlete at higher risk of injury. In sprinters, for example, hamstring muscle strains typically occur during the late swing phase of the running cycle as the hamstring muscle contracts while lengthening in an attempt to decelerate the lower leg in preparation for foot strike (Stanton and Purdam, 1989). Achilles tendinopathy and patellar tendinopathy (jumper's knee)
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