Physical Therapy and Knee Pain
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.
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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 the 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. 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:
- I lost a lot of knee extension (mostly when I try 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.
- Lost a lot of knee flexion (mostly when I try to bring my knee to my butt) – we are considering joint issues like osteoarthritis. It could also be a meniscus lesion.
- I cannot bend or straighten my knee – 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 a lot, and just happened – This is called 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 2 or 3 is the presence of pain and swelling. This is when you irritate a joint that has 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 muscles 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.
Treatment Options for Knee Pain
My bias is to move from the most conservative of treatments to the most invasive. Our team uses a treatment hierarchy:
- Tissue specific treatment like manual therapy to the painful joint or tissue
- Artificial support, bracing, taping or training aids
- Activation and inhibition exercises
- Targeting relative stiffness or laxity in the kinetic chain
- Movement retraining
For a person with an anterior horn meniscus lesion, we would first treat the pain passive range of motion limitation. Once passive extension is pain free, we would start to load their leg with the activity that normally hurts, providing them an exercise like terminal knee extension with the band that will keep their knee extension pain free.
Finally we would dig through all of their daily activities that cause the pain to develop. A common one is walking with big strides. We would replace their walking with uphill walking on a treadmill that limits knee extension, letting the meniscus desensitize. If they are walking outside, we would have them use shorter strides for a few weeks.
We use this type of structure for each injury, focusing on the most effective methods with the least reduction in activity.
Tissue Specific Treatment
The most effective treatment we use for the ‘jammed’ joint is traction.
Click here to see our videos on partner and self traction. Traction can regain motion, reduce pain, and start to improve gait.
When the meniscus is compromised, the smooth operation of moving out of the way of the two long bones doesn’t seem to work as well. The most effective treatment involves regaining passive motion with manual therapy like mobs.
Unloading the painful knee
Using a cane is very effective for knee pain where motion is lost and the joint has swelled. Remember, you can walk so well that it seems like there is minimal load to the knee. This is not true. There is tremendous load to the knee during walking and normal movement.
The single point cane used in the opposite hand reduced the knee abduction moment that occurs at midstance (the middle of stance phase where you are effectively balancing on one leg).
When we give this medical advice, patients will push back because of the stigma associated with using a cane.
Another unloading strategy is to brace the lower extremity For patellofemoral pain, the SERF strap can replicate the gluteus medius action to control hip motion. This reduces stress and load to the knee. Often it resolves the pain that is being driven by the abnormal loading strategy.
Activation and Inhibition Exercises
The traditional knee exercises that you see on youtube or get primarily at other clinics are activation or strengthening exercises. For our physical therapists, actual weakness is less common that inhibition. Inhibition happens when something makes it difficult for a muscle to fire. Typically this occurs from swelling (effusion) in the knee capsule.
Quad activation, exercise selection, and effusion
A special note needs to be made here. There is not a perfect knee exercise that solves each presentation of knee pain. There are numerous knee exercises to choose from, but I will use straight leg raises as an example as it is often prescribed even when it is not the right exercise at the moment.
Straight leg raises require the patient to keep the leg completely straight and lift one leg up from the table while the other stays down. The quad is asked to flex the hip via the rectus femoris with support from the other hip flexors while the knee does not bend. If the knee bends, we call it an extensor lag. Complete knee extension should be present or this exercise can actually cause pain.
A better exercise would be the long arc quad in pain free range of motion.
You could also do terminal knee extension exercise with the band which would help strengthen the quad while helping the rolling and glide mechanics of the tibia and femur.
Once full extension is achieved, we add the straight leg raises into the program.
Knee pain triggers
The most insidious and frustrating triggers are those that cause delayed symptoms. There is no pain with walking, but afterwards there is severe pain that grows like a dull ache until you cannot think about anything else.
Here is a list of the triggers and movements to consider:
- Sitting for long periods of time
- Holding the knee in extension
- Going down steps/ Walking downhill
- Cutting or pivoting
- Jumping (Check out our research on the Tuck Jump Assessment)
Let’s dive into walking and running.
The load to the knee joint with walking is significantly more than you think. The knee joint goes into full knee extension at least two times. This does not happen with running and sometimes means that people can run without knee pain but have issues with walking. Once the knee is traumatized and swollen, the ability of the quad to fire is compromised.
The quad inhibition leads to less force absorption and more trauma to the joint itself. When you watch someone with a swollen (also known as effusion) knee walk, the joint will appear to stay straight the entire time. This is not good and means the quad cannot handle the load of walking. So without conscious thought, you will start to walk with a straight leg.
As a general rule, if you have swelling then you must active the quad muscle with an knee exercise like long arc quads any time you stand up and start to move. Our physical therapists will recommend this even if walking is pain free.
If walking is actually painful, we highly recommend the single point cane to make walking pain free.
Running leads to much larger forces than walking. It is more complicated than the often repeated statement that you have glute weakness. A running analysis must look at more than form and glute strength. There can be a variety of issues including strength, motor control and sensory impairments.
Each of factor can lead to pain and overload at the knee joint. For example, the quadriceps can be fully maxed out in running while walking typically hits around 40% of the maximal muscle contraction.
Like walking, we will see quad inhibition from joint swelling. Since the quad will be fully loaded with running which does not happen in walking, a straight leg gait pattern is very common. This happens when the body does not trust the quad to absorb the force. Instead you transfer the force right though the joint. The result is a spiral of joint swelling leading to less quad strength leading to more joint loading and then more swelling. We call this the doom loop.
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)?
If you would like to see us, you can click below to schedule.
Research on the Knee
If you are interested in original articles and research along with our analysis and the takeaways from our practice, click below: