THE KNEE JOINT

The knee joint is the point at which the thigh meets the lower part of your leg. It is also a joint that commonly causes problems for people of all ages. The ends of the bones are covered in cartilage and, in between the bones, are cartilages called “menisci”.  These menisci are often injured in footballers. The knee joint is supported by four ligaments (i) one on  either side of the joint and (ii) the cruciate ligaments deep inside the joint. The whole joint is enclosed by a strong capsule which contains “synovial fluid” – a substance which acts as a joint lubricant. This is what causes swelling in the joint after injury.

Knee Pain

Knee pain can either (i) develop insidiously, often caused by osteoarthritis, which is itself a normal ageing condition but can be precipitated by a previous injury, or (ii) be brought about by a traumatic event such, for example, as a sporting injury. Footballers, racquet players and skiers are especially prone to knee injuries.

The assessment will be carried out either by your doctor or by your physiotherapist, by performing a series of tests designed to identify which structure is at fault and to enable an accurate diagnosis to be given..

An  X-ray will be helpful if there is a history of the patient falling, or if the doctor or physiotherapist suspects the presence of osteoarthritis.

Some knee problems cause night pain (when the joint is warm) and others only when weight bearing.

Knee Ligaments

A.  The ligaments on either side of the knee are the “medial” and the “lateral” collateral ligaments.

The inner ligament (the medial) is the larger ligament and is the one which is most often injured.

Ligament injuries are graded on a Scale of 1 to 3:-

Scale 1 –  a mild, incomplete tear

Scale 2 –  a moderate, incomplete tear

Scale 3 –  a rupture of the ligament

Depending on the Scale of the injury, your physiotherapist will decide whether you require further investigations such as an MRI scan or a referral to an orthopaedic consultant or to your GP

B.   The ligaments which lie deeper inside your knee joint are the “anterior” (front) and the “posterior” (rear) cruciate ligaments.

The anterior cruciate ligament (“ACL”) is the one most frequently injured.

What are the symptoms of a cruciate injury?   

(a)  Swelling – this normally occurs very soon after the injury has happened

(b)  Instability – the knee may feel as though it will not hold you up properly

(c)  Pain – this is felt deep inside the knee joint

(d)  Heat – the knee may feel warm to the touch

Cartilage/Menisci

Minor meniscal problems can be treated by your physiotherapist. At your initial assessment your physiotherapist can both diagnose and treat the problem or, if it were felt to be necessary, could refer you for further investigations.

What are the symptoms of a meniscal injury?  

(a) Stiffness  –  your knee may feel locked and you may not be able to bend  or straighten it fully

(b)  Pain –  this is felt deep inside the knee joint

(c)  Swelling –  there is a gradual increase in swelling during the next 24 hours post injury.

Osteoarthritis

This is “wear and tear” of the knee joint.

What are the symptoms of osteoarthritis?      

(a)  Stiffness – especially in the morning, and after sitting in one position for a prolonged length of time.

(b)  Pain –  more of an ache, but it can be sharp.

(c)  Swelling

(d)  Noisy – there can be grating sounds on movement of the knee joint, and these are sometimes very loud

Patella femoral joint problems (“PFJ”) 

The knee cap (patella) sits on the front of the knee. Problems with the Patella Femoral Joint (PFJ) may give rise to anterior knee pain (i.e pain at the front of the knee).

This is especially common in teenagers, when the rate of growth of bones is not always matched by an appropriate increase in muscle length.

Problems can be caused by overuse eg excessive kneeling (often seen in carpet fitters, for example).

Physiotherapy can reduce the pain and can improve the biomechanics of the joint.

What are the symptoms of Anterior Knee Pain?   

(a)  Pain –  after sitting –  especially, for example, in the back of a car or at the cinema, and when climbing stairs and running

(b)  Stiffness – after sitting

The Knee Joint – what can I do to help myself?

Following an injury the advice below should be followed.

“R.I.C.E”   i.e  Rest….after an injury it is important to stop what you are doing and to rest

Ice…..apply ice – eg in the form of frozen peas/ice pack – but take great care to place a layer of material between your body and the ice to avoid an ice burn.  Keep it in place for no more than 10 minutes and repeat regularly.

Compression…….A bandage or tubigrip helps to minimise swelling.

Elevation…………Keep the joint elevated to minimise swelling.

Exercise is important

(a)  to strengthen the muscles which support the knee joint – this can help to prevent further injuries

(b)  to maintain and improve the range of movement of the knee joint.

(c)  to assist in the reduction of weight   –  because carrying excess weight can place unwanted additional pressure on the knee joint and can increase the levels of  wear and tear.

With knee pain, the most important muscle to strengthen is the “quadriceps” muscle. This is the large muscle on the front of the top half of the leg.

How should this quadriceps strengthening be done? 

(Remember – these exercises should be carried out “little and often”)

  1.  Standing  knee extensions  –  when standing, brace your knees and back and feel the tension in your thighs. Get into the habit of doing this at any time of the day, eg if you are waiting for a kettle to boil, or for a bus to arrive!
  2. Lying down leg extensions  –  when lying down, place a rolled up towel under your knee. Then slowly straighten the knee as much as possible. Hold the straight position for 5 seconds and repeat this exercise 10 times as hard as possible. Look at your thigh to see the tension in the muscle.
  3. Sitting Extensions  –  sit well back in the chair, then straighten and raise one leg. When doing this, make sure that you pull your foot towards you at the ankle as this makes the muscle work much better. Hold for 5 seconds. Repeat 10 times. Then have a short rest – and repeat.

 Medication

 Your doctor can prescribe various tablets and topical creams to assist you. Your pharmacist can also suggest certain “over the counter” medications that can be helpful.

 Physiotherapy

When you decide that you wish to have physiotherapy treatment, you can immediately self refer direct to a physiotherapy clinic if you intend to pay privately. If you have medical insurance and wish to use it, however, you will need instead to speak first to your insurance company and you might also need to be referred by your GP.  If you want physiotherapy treatment on the NHS, then you will always have to be referred by your GP. It is common practice for the GP to be required to wait until you have had the pain for a period of 6 weeks first before referring you under the NHS scheme for treatment.

A physiotherapist will, firstly, carry out a careful examination and an assessment of your problem, and will discuss matters with you before your treatment commences.

Treatment may include “hands on” treatment such as massage and manipulation, or electrotherapy such as laser or ultrasound, and/or  the designing of a personal, individually tailored exercise programme so that you can contribute to the management of your condition at home.

With knee pain, the most important muscle to strengthen is the “quadriceps” muscle. This is the large muscle on the front of the top half of the leg.

Surgery

In a few cases, surgery will be required.  However, the majority of patients suffering knee pain will not require surgery.

Sportsmen and women, particularly, may require surgery to repair damaged menisci or cruciate ligaments.

In cases of osteoarthritis, if surgery occurs it will commonly take the form of a total knee replacement.

Following any kind of knee surgery, a short course of physiotherapy is very important to ensure that the fullest and quickest sustainable recovery is achieved. It is also advisable to see a physiotherapist prior to any planned surgery to ensure that the muscles are as strong as possible before any operation.

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