Knee pain is a big issue with numerous treatments to consider. We believe that physical therapy is a great way to resolve your knee pain, but not all physical therapists treat the same way. Our team suggests that patients with knee pain consider the following: make sure you get a diagnosis, understand your prognosis, develop a treatment plan, and understand the triggers occurring in your day to day.
Why isn’t your knee pain going away?
You may not remember when you started thinking you had bad knees, but at this point, you start to have an internal debate with yourself about standing up.
Do I really need to go to the bathroom or should I wait?
Or maybe for you, you decided to bike now because running hurts.
Or you may be waiting to get a total knee arthroplasty because a surgeon told you were too young to have a replacement.
Knee pain that does not go away invades every part of the day. Every step you take can be an ordeal. Even sitting can become a nightmare when you try to stand up.
The purpose of this article is to explore your options with knee pain, including an overview of how we think you should use physical therapy and what your current issues mean for successful rehabilitation.
The fact is that knee pain can be treated and you can get back to doing the activities you love. Even for those of you who have been told that your imaging is bone on bone and the worst they have seen.But you need a plan. Without one, you will find yourself in a downward spiral of pain and discomfort. To get started, lets define the problem: why is knee pain such an issue?
Why is knee pain so common?
To begin, you may wonder why you have knee pain.
The knee joint appears simple. The thigh bone connects to the shin bone and hinges into flexion and extension. Like most things that appear simple, the apparent simplicity disguises extreme complexity.
Look at walking- the interweaving of loading and unloading, bending and straightening with every step you take. We do not think about walking, we just do it, to reference NIKE. In a single stride, you will cycle through 8 gait phases of movement. Each phase asks the knee and the muscles that cross and support it, to perform different actions. The ease of walking means an injury rarely gets to recover, instead with every step you take, you may traumatize the knee joint without even realizing it.
You will compensate and alter your walking pattern when pain starts. You unload the knee, keep it a little straighter, get off it a little sooner. Sometimes this helps, but often it hides a progressing knee pathology.
Digging a little deeper, we see that the simple knee flexion and extension actually requires two pieces of rubbery cartilage called the meniscus to deftly dodge the steam roll action between the femur and tibia. As two longest bones in the body, the pressure of your entire body weight can easily tear the meniscus. The connection of the ligaments guide the complex sliding and rolling between the femur and tibia while tendon connections via the quad and semimembranosus (a hamstring muscle) pull the dynamic menisci out of the way. Modern science struggles to explain their mechanics even now with our expensive and technologically advanced imaging.
The interplay of the extensor mechanism, encompassing the quad muscle and the connective tissue crossing the front of the knee, supports your ability to take a step and not collapse due to the forces involved.
Despite the impressive mechanical aspects, the knee regularly develops problems. Anyone of the aforementioned structures – the joint formed by the tibia and femur (referred to as the tibiofemoral joint), the meniscus, the extensor mechanism, the muscles and tendons – can generate pain and dysfunction.
Knee pain is the site for most injuries in the lower extremity.
What can be done about it in physical therapy?
As a physical therapist that treats issues at the knee, I find the typical treatments – ranging from exercises and stretches to injections and medications – lack a plan. Many times there is not a diagnosis or focus on the root problem. Your physical therapist may do numerous different treatments, but they must do the following or you should look for a different practitioner.
Develop a working diagnosis of the pain generator
The first step in getting your knee to feel better is to get an accurate diagnosis. We call it understanding the problem. A working diagnosis in physical therapy means you are constantly updating your mental model of the patient’s knee pain and injury. A physical therapist may encounter a patient with severe knee osteoarthritis but the true pain generator is the patellar tendon that crosses the front of the joint. If you miss the patellar tendinopathy, the patient’s pain will not go away even if the joint motion improves.
Test and retest the diagnosis with a specific treatment to alleviate the symptoms
The second step is to test the diagnosis by developing a treatment that makes it feel better in the same session. This can range from knee traction to a brace like the SERF strap. Our team likes to see a successful treatment in the first visit becomes it is another data point that supports our diagnosis. If there is no change with the treatment you apply, then it is difficult to believe we have the right diagnosis. Most knee injuries (not including those post surgery) can be improved in the first session.
The treatment plan
The third step is to build a treatment plan that amplifies this treatment effect throughout the patients whole week. The physical therapist must consider the triggers that are keeping the knee irritated in the treatment plan and home plan.
The plan needs to be built around you, the knee pain sufferer. You must carry out a home plan that may include using a cane to unload during walking, avoiding end range extension or flexion, or monitoring joint effusion. The treatment plan should not be a long list of exercises that make your knee hurt worse. It is not an exercise program! The focus must be on effectiveness. Hammering wall squats,step ups, and conditioning for 45 minutes can actually increase your symptoms for the majority of the pathologies. This is silly. You waste time and prolong symptoms in your knees.
The mantra of no pain, no gain does not apply here.
Diagnosing knee pathologies
The following are the most common pathologies and conditions seen by our physical therapists:
- Patellar tendinopathy
- Meniscus injury
- Activated Knee Osteoarthritis
- Traumatic Arthritis/Synovitis
- Myofascial pain from quadriceps
- Post Surgical Issues
Other than post surgical, patients walking into the clinic may have one or more of these issues going on with hundreds of pain triggering moments in a single day. The most critical aspect of the subjective is digging into the day to day activities of the patient, hearing the moments that pain occurs and when it feels fine. The imaging and diagnosis from other providers can help, but it can also hinder by biasing the physical therapist to a diagnosis that may not be accurate.
After listening to the patient’s subjective, we go into the exam.
The knee physical therapy exam
The physical therapist performing your exam should assess your walking pattern, the joint range of motion, the ligament stability, meniscus testing, and resistive testing to the muscles. The presentations look like this:
- Missing a lot of knee extension (mostly when trying to straighten my knee) – we start thinking about the anterior horn of the meniscus. This may be getting compressed each time the knee moves into extension.
- Missing a lot of knee flexion (mostly when trying to bring my knee to my butt) – we are considering joint issues like osteoarthritis. It could also be a meniscus lesion.
- Cannot bend or straighten my knee and it just happened – once again, we are thinking osteoarthritis but it could also be meniscus. Our treatment will help to differentiate.
- Lost a lot of knee motion, knee is swollen, hurts very bad, and just happened – This is called a traumatic synovitis. It is like a jammed joint, but unlike a jammed finger, this is a huge joint and you have to walk on it.
- Lost a lot of knee motion, knee is swollen, hurts a lot, and it has been around a long time – The difference between this and the others is the length of time. You probably irritated an underlying osteoarthritis.
- Quad muscle is gone – We know that the ability to stabilize and load the joint is compromised and must be considered in the treatment plan.
- Quad muscle always feels tight and when tested with load it hurts – these are the extensor mechanism injuries, quad myofascial pain, and tendinopathies.
From these common presentations, we start to think about the treatment. Check out our article discussion treatment options.
What are your options for a painful knee?
Our physical therapy team would love to help you with your current knee problem. Even if you cannot come to our facility, we hope this article gives you some questions and expectations on your visit with a physical therapist at a different facility.
To recap, make sure you get the following information from medical provider:
- What is the diagnosis?
- What is the prognosis?
- What is the functional cause?
- What is the home plan (it should not just be exercises)?
- What are your daily triggers to avoid (remember this is not a blanket statement like ‘stop’ running’ – if you already heard this I recommend our article on Trigger management)?