Patient Guide to ACL Reconstruction?                                                           

Johns Hopkins Sports Medicine

What is the Anterior Cruciate Ligament?

The knee is a hinge joint held together by four ligaments. A ligament is a structure in the knee that holds the bones together and helps to control joint movement or motion. There is a ligament on each side of the knee (the collateral ligaments) and two ligaments deep inside the knee. The two ligaments inside the knee "cross" each other are called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). Both ligaments attach on one side to the end of the thigh bone (femur) and on the other to the top of the shin bone (tibia). [Figure 1].

During activity, the ACL controls how far forward the tibia can "slide" relative to the femur: it essentially acts to prevent too much forward movement. While some degree of motion or sliding is normal and is required for knee function, too much motion may damage other structures in the knee which can lead to long term problems in some patients.

How is the ACL injured, and what are the Symptoms? The ACL can be injured or torn in a number of different ways. The most common mechanism is that of a sudden pivoting or cutting maneuver during sporting activity, which is commonly seen in football, basketball, and soccer. The ligament can also tear due to work injuries or automobile accidents. At the time of the injury a "pop" or "snap" can sometimes be felt or heard. The amount of pain experienced at the time of the injury is somewhat variable, but can be quite severe. Typically, the person is unable to continue play or activity, and has the impression that a significant injury has occurred. Immediate swelling of the knee develops at the time of injury (within the first several hours), but the extent of swelling can be limited if the knee is immediately iced or splinted. How is a Tear of the ACL diagnosed? A tear of the anterior cruciate ligament can be diagnosed by a physician through a history and physical examination. On physical examination, the physician can specifically assess the amount of motion present and determine if the ACL torn or not torn. Additionally, evaluation of other structures within the knee is done also, as ACL tears are often found in association with injury to other structures within the knee such as the cartilage and collateral ligaments. X-rays are taken to evaluate for the presence of any fractures. In some, but not all, patients a magnetic resonance imaging scan (MRI) of the knee may be ordered. The MRI can clarify the question of an ACL tear if the history and examination are inconclusive. The MRI is also useful for evaluating the cartilage in the knee if this information is necessary to make decisions regarding the best treatment for a specific patient. What are the options if I have an ACL Tear? The treatment options following an ACL tear are individualized for each patient depending on age, activity level, and the presence or absence of injury to other structures within the knee. In general, surgery is recommended for young patients who are active and for those in whom the ACL tear is associated with injury to other structures in the knee. Nonoperative (nonsurgical) treatment is recommended in older more sedentary patients. The main reason to have surgery is to restore stability to the knee so it no longer gives out or slides too far forward. This is uncomfortable and painful during activity. The other reason (perhaps the most important reason) is to protect the cartilage in the knee from being damaged. It is especially important to protect the meniscus cartilages in the knee. The meniscal cartilage is a fibrous type of cartilage that sits between the ends of the tibia and femur, and is attached to the lining of the joint. There are two separate meniscal cartilages in the knee, each somewhat C-shaped: one on the inner half of the knee (the medial meniscus), and one on the outer half (the lateral meniscus). [Figure 1] The medial and lateral menisci primarily serve as shock-absorbers between the ends of the bones to protect the surface or articular cartilage. With recurrent episodes of giving way, the meniscus can be damaged or torn causing it to loose its shock-absorbing capability. Without a functioning meniscus, the articular cartilage is exposed to increased pressure and "wears" away, leading to arthritis. Additionally, the articular cartilage may be directly injured or damaged with each episode of giving-way. Nonsurgical Treatment Nonsurgical treatment consist of physical therapy, activity modification, and use of a brace. The goal of physical therapy is to strengthen the muscles around the knee in order to compensate for the absence of the ACL. Specifically, strengthening the muscles in the back of the thigh (the hamstrings) is helpful. Activity modification can be very successful. Sports which do not involve cutting (such as jogging, cycling, or swimming) can often be done without difficulty. In addition to therapy and activity modification, use of a hinged sports brace (e.g. DonJoy, CTI, Lennox Hill) can be attempted. While bracing may be effective in a some patients, in others giving-way may continue despite their use. Surgical Treatment Once the ACL tears, it has usually sustained enough damage that attempts to repair it at surgery are not successful. Consequently, better results are obtained if the ACL is surgically replaced (or reconstructed) with another tendon from around the knee. [Figure 2]There are a number of surgical options for reconstructing the ACL. The type of procedure done may vary from patient to patient depending on a specific surgeon's preference as well a factors unique to an individual patient. The surgical procedure is most commonly performed using arthroscopic techniques. Using one or two small incisions on the knee, the graft is taken from the patellar tendon (most cases) and a tunnel is drilled into both the tibia and femur. The graft is threaded across the knee leaving a piece of bone in each of the tunnels and the patellar tendon in the position of the original ACL (thus reconstructing the ligament). [Figure 2] The graft is then secured in this position, most commonly by "wedging" a screw between the side of the bone and the tunnel. [Figure 3] Alternatively, the graft can be secured by other techniques (staples, sutures, buttons, etc.). These screws and/or staples are left in place permanently. In addition to the ACL reconstruction, additional procedures may be done if injury is present to other structures within the knee. A torn meniscus can be either repaired or trimmed (meniscectomy), and other ligaments can be repaired or reconstructed as well. Allografts most frequently used today are of the bone-patellar tendon-bone type or from the achilles tendon at the heel, and come from cadavers that have been screened for infectious diseases (e.g. the hepatitis and AIDS viruses). The risk of AIDS from one of these grafts is not exactly known, but is generally believed to be 1 out of 500,000. All grafts are carefully screened and tested before they are used in surgery. How long does rehabilitation taek after surgery? The exact course of therapy may vary somewhat depending on the specific type or reconstruction done (particularly if additional meniscus or ligament surgery was done). Physical therapy is done in a supervised setting in conjunction with a trained therapist. Early in the course of recovery, visits may be 2 to 3 times per week, but later once every week or two is often sufficient. Home exercises are done on days not scheduled for a formal therapy session. The rehabilitation following ACL reconstruction includes essentially three phases. The first phase of rehabilitation consists of controlling the pain and swelling in the knee, regaining knee motion, and getting early return of muscle strength. The operated leg is typically placed into a hinged brace after surgery. Initially, weight-bearing is allowed with crutches and is progressed to full weight bearing independent of crutches as swelling, motion, and muscle strength allow. Most patients are on crutches for one week, although some may be on crutches longer and some shorter. This phase typically takes 6 to 8 weeks. The second phase emphasizes continued control of swelling and recovery of full muscle strength. Cycling, treadmill running, and light jogging are started in this phase. In some patients, a sport brace is obtained to replace the postoperative knee brace. This phase typically lasts from 2 to 4 months after surgery. The final phase consists of graduated return to full activity. Full motion, normal muscle strength, and the absence of swelling are required for successful return to activity. A brace may be recommended early in the return to activity. This phase occurs at 4 to 8 months after surgery, depending on the particular patient and the nature of their activities. A patient's rehabilitation is monitored closely by both the therapist and surgeon for evidence of potential problems. Most significantly, patients are cautioned not to attempt too premature return to full activity which may cause the knee to be inflamed or re-injured. In every patient the graft must both heal into place and be incorporated into the knee: too much stress too soon may increase the risk of graft failure. What are the potential complications after surgery? The majority of patients experience no complications and return to full activity between 6 and 8 months after surgery. However, the most common complications include pain in the front of the knee and loss of knee motion. Pain in the front of the knee occurs in 10-20 percent of patients. Fortunately, it can usually be controlled by modification in the physical therapy protocol. Loss of motion occurs in less than 5 percent of patients and is most common in patients with limited motion before surgery. While correctable with more aggressive therapy in most patients, it may necessitate re-operation in rare cases. In some individuals, intermittent pain and swelling occur with activity despite a successful ligament reconstruction. This is often related to the amount of meniscal or cartilage injury that was present and identified at the time of surgery. In the absence of identifiable causes, a small percentage of patients will end up with a persistent detectable increased amount of motion in their knee (a "loose" graft). This may be related to stretching of the graft over time, or due to reinjury. Will I be able to return to my previous sporting activities? Approximately 95 percent of patients return to their previous level of activity without restrictions. In the other 5 percent, full return may be limited by a number of causes: pain, swelling, persistent laxity, change in lifestyle related to age, intentional choice, or other unidentifiable causes.

KNEE/LCA

http://www.emoryhealthcare.org/

When does rehabilitation start after an ACL reconstruction?

On the day of surgery. Patients are given a set of exercises to start immediately in the recovery room.

Will I need to be on crutches after surgery?

Yes, but only initially and only for comfort. Full weight bearing is gradually increased as tolerated by the patient. It typically takes seven to 10 days after the procedure, until the patient is comfortable without the assistance of a crutch. An exception to this rule is if the patient also underwent a meniscal repair or other reconstruction of an additional ligament. In these cases, weight bearing may be restricted for several weeks.

What do I do in the first few weeks after surgery?

The first two weeks after surgery concentrates on decreasing the swelling in the knee and regaining knee extension, with less concern about knee flexion. This is accomplished by elevating/icing the leg and riding the stationary bike.

Two weeks after surgery, the goal is for patients to achieve and maintain full knee extension and increase quadriceps muscle function. While knee flexion of only 90 degrees is the goal for this stage, obtaining full extension is more of a priority.

When can I drive?

Usually by two weeks after surgery, patients are off crutches and demonstrate adequate muscle function, mobility, and comfort to allow driving. This is dependent on what leg has been operated on and how fast the patient recovers.

How is rehabilitation after an ACL reconstruction typically structured?

Although different surgeons and therapists will have slightly different protocols, the goal for all forms of post-operative ACL rehabilitation is the same: to return the patient to a normal and complete level of function in as short a time possible without compromising the integrity of the surgically reconstructed knee.

In order to achieve this goal, therapy is typically broken down into stages (or phases) of activity, with goals for each stage. Here is an example of a standard four-phase protocol:

Phase I - First two weeks after surgery

Emphasis:

• Control of inflammation
• Range of motion - full extension, and 90 degrees of knee flexion
• Achievement of quadriceps control
• Education of patient about rehabilitation process
• Crutches - usually seven to 10 days until patient is comfortable
• Patellar Mobilization - to prevent patellar tendon shortening/contracture and loss of knee motion

Phase II - two to six weeks after surgery

Emphasis:

• Strengthening - light weights and sports cords
• Full range of motion
• Continued protection of the graft from stresses
• Improvement of endurance and proprioception - use of treadmill, step machine and elliptical trainer

Phase III - six weeks to three to four months after surgery

Emphasis:

• Improve patient's confidence in the knee
• Progression in strength, power, and proprioception - preparing for return to sport
• Jogging typically allowed at three months
• Straight ahead running

Phase IV - four to six months after surgery

Emphasis:

• Possible return to sport, depending on type of sporting activity and type of graft
• Full pain free range of motion should be present
• Sufficient strength and proprioception should be present
• Typically, patient is advanced to initiate advanced lifting exercises
• Phase is typically customized to the patient's activity level and competition level in sport.

Phase V - return to sport, usually at six months

Emphasis:

• Patient must meet all the criteria for return to sports
• No soft tissue or range of motion complaints
• Physician must clear the patient to resume full activities
• The goal is safe return to sports
• Education of patient about possible limitations
• Maintenance of strength, endurance, and proprioception
• Functional bracing may be recommended by some physicians for the first one to two years after surgery for psychological confidence.

OTHER QUESTIONS  

Will I need a brace after ACL reconstruction?

Bracing after ACL surgery is purely dependent on patient and surgeon preference. Some surgeons never use bracing, some always use a brace, and others just use a brace during the immediate post-operative or rehabilitation phases. This topic still remains the subject of much debate in sports medicine literature. However, to this date, no long-term benefits have been found with regard to knee laxity, range of motion, or function following ACL surgery. Bottom line: If you feel more comfortable in a brace, then one will be ordered for you.

What type of follow-up is done after an ACL reconstruction?

You will be seen within the first week, at two weeks, six weeks, three months and six-eight months. Specifically, the physician will look at and measure:

• The presence of continued pain and swelling
• Range of motion of the knee
• Laxity of the graftStrength of the leg
• Knee function during routine activities of daily living

What are the possible complications of ACL surgery?

As with any invasive surgical procedure, infection and bleeding are always surgical risks. Infection rates for arthroscopic ACL reconstructions are among the lowest for surgical procedures, with average infection rates typically cited at 0.2 percent. As for bleeding complications, the rates are much less than one percent, and consist mostly of isolated case reports.

Loss of motion following ACL reconstruction is the most commonly cited complication. This can range from minor and inconsequential to severe. Prevention is the first and most effective method for treatment of loss of motion. This is why compliance with post-operative rehabilitation is so vital to the outcome of the procedure, and why range of motion is started immediately post-operatively.

Another risk of ACL reconstruction surgery is continued anterior knee pain post-operatively. Anterior knee pain following ACL reconstruction also has been closely associated with loss of motion. Therefore, range of motion, quadriceps strengthening and patellar mobility are of primary concern during the first two weeks following surgery.

ACL Reconstruction: Hamstring and Bone-Patella Bone Autografts

Weeks 1-3 Begin:__________________

**DO NOT PUSH FLEXION PAST 90 DEGREES FOR THE FIRST SIX WEEKS!

Goals:

1. 90 degrees flexion ROM, full extension

2. Independent quad contraction

3. Gait without crutches by end of week 2

Exercises:

 1. Continue with post-op program, add weight to SLR if

no extension lag

2. Add bike for ROM, strength, and cardio benefit;

pedal as tolerated

3. 4-way hip machine, initiate closed kinetic chain CKC to

include toe and heel raises, dynamic terminal extension,

mini-squats

4. Gait training with mini-hurdles to restore normal 

Weeks 4-6 Begin:__________________

**DO NOT PUSH FLEXION PAST 90 DEGREES FOR THE FIRST SIX WEEKS!

Goals: 

1. ROM 0-120 as tolerated

2. Normal gait cycle by weeks 3-4

3. KT 1000 at 6 weeks post-op

Exercises: 

1. Continue with post-op exercises as home exercise program

2. Advance CKC program to: step-ups, modified lunges

3. Initiate isotonic weight machines

a. Leg extension 90-30 degrees (BPTB – eccentric x 6

weeks, HS concentric starting at week 3)

b. Hamstring curls (start with standing HS curls at week 3

for hamstring graft; progress to weight machine)

c. Leg press

4. Initiate proprioceptive program – single leg stance,

balance board

Weeks 7-12 Begin:__________________

Goals:

 1. Full ROM

2. Swelling < 1-2 cm at midpatella

3. Prevent patella femoral pain with exercises

Test: 1. KT 1000 and isokinetic test at week 12

Exercises: 

1. Continue with above program

2. Leg extension can be concentric 90=30 after week 6 for BPTB

3. Begin isokinetics 90-30 degrees, practice starting at week 8

with progression from fast speed (300d/sec) to slow speed

(60d/sec), practice once per week only

5. Add shuttle for plyometrics at week 10

Return to Activity

Treadmill walking..................week 7

Elliptical .............................week 9

Rowing ...............................week 10

Outdoor biking ....................week 10

Swimming ..........................week 12

Stair stepper .......................week 12

Golf....................................week 16

Running, skiing, basketball ....month 5

Tennis, football, soccer ..........month 6

Chondromalacia Patella

Pain in the Front Part of the Knee

http://www.pamf.org/sports/king/condromaliciapatella.html

Introduction

Pain in the front of the knee is a very common complaint.The pain usually originates from the tissue around the kneecap including the tendons, bones and cartilage surfaces. These tissues are put under high forces during many common activities and especially during sports. Running, jumping, hiking, squatting and lunging can place up to six times an individual's body weight through these tissues. Repetitive high loading eventually leads to tissue breakdown and subsequent pain. Women are more susceptible to these problems because their kneecaps are smaller and often "track" abnormally. High forces in a small distribution area leads to painful "chondromalacia" (chondro=cartilage; malacia=bad).

Back to top

Pathology

The cartilage surfaces behind the kneecap are the thickest in the entire human body and usually begin to wear out after the age of 15. Almost all people have evidence of cartilage damage on kneecap cartilage when we perform arthroscopic surgery. It is interesting to note however that while the pain from chondromalacia is the most common complaint of people between the ages of 15 and 60, these complaints usually disappear after age of 60. In addition, most persons with chondromalacia do not have symptoms.

While the cartilage surfaces do not have any nerve endings, all the tissues around the kneecap cartilage (including the bones) do have nerve endings and can therefore produce pain. The most common finding on examination is tenderness to touch around the kneecap or patella. There can be swelling and often there is grinding with bending or squatting. Often people can hear grinding coming from their knees when squatting and stair climbing.

The most common medical finding is damage to the cartilage behind the kneecap (patella). The cartilage covering, or articular cartilage, that covers the knee cap bone is the thickest cartilage covering in the entire human body. The reason the cartilage covering in this area is so thick is because the knee cap takes more pressure per unit of area than any other joint in the body. With squatting and lunging activities up to six times the body weight is placed into the small bone of the knee cap and the cartilage. With activities this cartilage can begin to breakdown and produce pain.

Back to top

Treatment

The primary treatment of anterior knee pain or chondromalacia of the patella is a strengthening program of the quadriceps muscle. Strengthening of the quadriceps muscle when done properly often results in approximately 90% cure rate for this condition. The reason that strengthening of the quadriceps muscle is effective is that it takes the pressure away from the knee cap cartilage and puts it into the muscular tissue. Also strengthening of the quadriceps muscle assures that the kneecap is tracking properly and distributing the load evenly inside the knee cap-thigh bone joint.

Back to top

Exercises

Exercises involve strengthening-stretching of the quadriceps muscle. All strengthening of the quadriceps muscle should be done within the range that keeps pressure on the kneecap low. This range is between full extension (the knee is completely straight) to approximately 45 degrees of bending of the knee. The exercises should be done with lightweight and high repetition in three sets of 20, or sets of 30 are appropriate. There should be no pain during the exercises. After the exercise program ice should be applied to the front part of the knee for approximately 10-20 minutes.

Anti-inflammatory medicines are also very useful and may be taken on a daily basis. Exercises can be performed on a daily basis, but should be performed at least three times a week. Activities that cause pain should be modified or abandoned temporarily until the pain resolves. With an exercise program most people are able to resolve the pain and return to full activities without difficulty within a three to six month period of time.

Quadriceps Exercises

• Leg Press
• Leg Extension
• Squats

Hamstring Exercises

• Hamstring Curls

Calf Exercises

• Calf Raises

Other

• Bike (seat elevated)
• Stairmaster
• Elliptical Trainer
• Rollerblade

Back to top

Viscosupplementation

If exercise and strengthening are not enough to decrease symptoms lubrication or viscosupplementation injects may be of benefit.

Within the knee joint synovial fluid is highly viscous which provides a friction-free environment. Hyaluronic acid (HA) which is present in our synovial fluid is also found in most body tissues. In a healthy adult, synovial fluid HA has a molecular weight of 4-5 million. As a result of this large size HA molecules entangle, forming coiled configurations which in turn provide elasticity and viscosity to synovial fluid. HA also binds to proteoglycans to stabilize the structure of the articulate cartilage. In patients with OA, the molecular weight of the HA decreases causing the synovial fluid to become less viscous thus leading to increased friction and abnormal joint movement.

Lubrication or Hylagan injections provide the joint extra lubrication and shock absorption, as well as decrease friction or rubbing within the joint which may slow the progression of osteoarthritis. However, of all the patients who receive Hylagan injections, only about 50% have symptomatic relief. One injection is given into the knee each week for three weeks and may be repeated as soon as 6 months. Up to five injections may be given, but studies have shown no difference in symptom relief after 3 or 5 injections.

Back to top

Surgical Treatment

When exercises fail to improve the knee then surgery may be indicated if the symptoms are significant enough to alter activities.

1. This image shows the surface cartilage without chondromalacia.	2. Grade I-II chondromalacia is softening of the cartilage.
3. Grade III is thinning of the surface cartilage.	4. A chondroplasty is when the rough / thin cartilage is smoothed down. This images shows the view of cartilage in image 3 after a chondroplasty.
5. Another image of Grade III chondromalacia.	6. Here is an image of Grade III / IV chondromalacia showing thinning of the surface cartilage (grade III) with areas of exposed bone (grade IV chondromalacia).
7. This is a picture of grade IV chodnromalacia- and area of exposed bone.

Knee Arthritis (Osteoarthritis)

(http://www.physioadvisor.com.au/

(Also known as Knee Osteoarthritis, Osteoarthritis of the Knee, Arthritis of the Knee, Degeneration of the Knee)  

N.B. The term 'knee arthritis' will be used in this document to describe the condition known as knee osteoarthritis. 

What is knee arthritis?

Knee arthritis is a condition characterized by a degenerative process whereby there is gradual wear and tear to the cartilage and bone surfaces of the knee joint with subsequent inflammation. Knee arthritis may occur following a specific injury or due to repetitive forces going through the knee joint beyond what it can withstand over a period of time.

In a normal knee, joint surfaces are smooth and there is cartilage between the bone ends which allows for efficient shock absorption and smooth movement (figure 1).

Figure 1 - Relevant Anatomy for Knee Arthritis

When the knee is damaged or overloaded, particularly with excessive weight-bearing or twisting forces, degeneration of the cartilage can occur, reducing the knee's shock absorbing capacity. As the condition progresses, and the cartilage wears away, the joint space can narrow and there is eventual wearing down of the bone ends so that the surfaces are no longer smooth (figure 2). The bone ends may also develop small bony processes (spurs) called 'osteophytes'. When some or all of these changes occur, the condition is known as knee arthritis.  

Figure 2 - An X-ray Demonstrating Knee Arthritis

Arthritis of the knee usually occurs after the age of 50 years and tends to affect females more frequently than males. It is more common in those patients who are overweight or have a past history of injury, surgery or trauma to the knee.

---

Signs and symptoms of knee arthritis

Patients with this condition usually experience symptoms that develop gradually over time. In patients with minor cases of knee arthritis, little or no symptoms may be present. As the condition progresses, there may be increasing knee pain with weight bearing activity and joint stiffness (particularly after rest or first thing in the morning). Swelling, decreased flexibility (i.e. an inability to fully straighten or bend the knee), severe joint pain, pain at night and a grinding, clicking or locking sensation during certain movements may also be experienced. Symptoms can sometimes fluctuate from month to month with patients reporting an increase in symptoms with colder weather. In more severe cases, muscle wasting (especially of the quadriceps), a visible deformity of the knee joint, and a limp may also be present.

---

Diagnosis of knee arthritis

A thorough subjective and objective examination from a physiotherapist may be sufficient to diagnose knee arthritis. An X-ray is usually required to confirm diagnosis and may demonstrate signs of decreased joint space, irregularities of the bony ends and/or the presence of bony spurs (osteophytes). Sometimes an MRI may also be indicated to assist with diagnosis and rule out other pathologies.

---

Treatment for knee arthritis

For detailed physiotherapy information on the treatment of this condition Become a Member.

Already a Member?

 

View the complete article - Knee Arthritis (Members Only).

---

Prognosis of knee arthritis

Because arthritis of the knee is a progressive condition, complete resolution of symptoms is often not possible. However, in mild to moderate cases, most patients, if managed well, can maintain an active lifestyle with little or no symptoms and delay or prevent the deterioration of the condition. In severe cases that have been unresponsive to appropriate physiotherapy management and where quality of life is significantly affected, knee joint replacement surgery is usually indicated with most patients subsequently experiencing a good outcome following the procedure.

---

Physiotherapy for knee arthritis

For detailed information on physiotherapy treatment of this condition Become a Member.

Already a Member?

 

View the complete article - Knee Arthritis (Members Only).

---

Contributing factors to the development of knee arthritis

For detailed information on factors contributing to the development of this condition Become a Member.

Already a Member?

 

View the complete article - Knee Arthritis (Members Only).

---

Other intervention for knee arthritis

Despite appropriate physiotherapy management, some patients with arthritis of the knee continue to deteriorate. When this occurs, other intervention may be required. This may include pharmaceutical intervention, corticosteroid injection, the use of supplements such as fish oil, glucosamine and chondroitin, investigations such as an X-ray, CT scan, bone scan or MRI, or assessment from a specialist.

In more advanced cases of knee arthritis, where symptoms are severe and quality of life severely affected, patients may require surgical intervention. This may involve a knee arthroscope or partial or complete knee joint replacement surgery. The treating physiotherapist or doctor can advise if this may be required and will refer to an orthopaedic specialist for an assessment and opinion.

Following a total knee joint replacement, patients are normally in hospital for 5 to 10 days afterwards and require physiotherapy treatment and rehabilitation over the following months. Resumption of normal daily activity can usually be achieved 6 – 12 months following surgery.

---

Exercises for knee arthritis

The following exercises are commonly prescribed to patients with arthritis of the knee. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily once the physiotherapist has indicated it is safe to do so and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.

---

Initial Exercises

Knee Bend to Straighten 

Lying on your back, slowly bend and straighten your knee as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 3). Repeat 10 times. 

Figure 3 – Knee Bend to Straighten (right leg)

Static Quadriceps Contraction 

With your knee relatively straight, slowly tighten the muscle at the front of your thigh (quadriceps) by pushing your knee down into a small rolled up towel (figure 4). Put your fingers on your quadriceps to feel the muscle tighten during the contraction. Hold for 5 seconds and repeat 10 times as firmly as possible without increasing your symptoms.

Figure 4 – Static Quadriceps Contraction (left leg)

---

More Initial Exercises

For More Initial Exercises that are a vital component of rehabilitation for this condition Become a Member.

 

Already a Member?

 

View the complete article - Knee Arthritis (Members Only).

 

---

Intermediate Exercises

For Intermediate Exercises that are a vital component of rehabilitation for this condition Become a Member.

 

Already a Member?

 

View the complete article - Knee Arthritis (Members Only).

---

Advanced Exercises

For Advanced Exercises that are a vital component of rehabilitation for this conditionBecome a Member.

 

Already a Member?

Chiropractic Treatment and Knee Pain

Knee pain is an increasingly more common problem in our society and as a result we see more and more patients with knee problems in our centres.

The most common complaints relate to 'wear and tear' or osteoarthritis and although a condition such as osteoarthritisis not curable, the symptoms can be reduced and the progression of the problem can be helped thanks to our unique approach to treatment.

Chiropractic treatment is also very effective for many other knee problems.

Please read on to find out how!

Chiropractic treatment may well be the answer if:

• knee pain is limiting your day-to-day or sporting activities,
• you have been given painkillers and been told to rest with no long-term improvement, or
• you have been told you have arthritis and there is nothing that can be done?

The Knee Joint

The knee is a complex joint that relies heavily on ligaments and muscles for stability.

The knee is a major weight bearing joint and is composed of:

• the tibio-femoral joint (between the thigh and lower leg)
• the patello-femoral joint (between the knee cap and the thigh),
• muscles and ligaments, which gives active and passive stability to the knee.
• two ring shaped cartilage discs in the knee, called the menisci (one meniscus).

Examination of the Knee Joint

When pain is perceived as coming from the knee, all the anatomical components need to be examined and in addition to the knee joint, the low back, pelvis, hip, ankle and foot need to be examined due to the direct influence they have on the knee, and vice versa.

As chiropractors we take a comprehensive medical history and perform a thorough physical and biomechanical examination in order to make an accurate diagnosis - without an accurate diagnosis, the treatment will not be successful.

Our approach of assessing and treating the knee includes the evaluation of the other joints and muscles relating to the knee.

This is for several reasons:

• Firstly, pain can be referred from other structures in the low back, pelvis and hip into the knee, in certain conditions.
• Secondly, if other joints in the lower limb are not working correctly they can put increased stress on the knee joint, resulting in injury over time. Therefore to resolve the knee pain chiropractors may also treat other areas, to maximise long-term improvement.

Chiropractic treatment of knee pain

We have outlined the process of our treatment below to give you an idea of our approach. We would normally modify the treatment to suit each patient and their specific conditions. So the type of treatment that is most appropriate for one person is not necessarily right for another.

Stage 1: Reduce joint inflammation and reduce pain.

How?

• Avoidance of aggravating factors, use of a support, sports tape
• Ice to reduce inflammation, muscle spasm and pain
• Soft tissue healing: laser, ultrasound and interferential therapy

Stage 2: Normalise joint function

How?

• Specific chiropractic manipulation and mobilisation techniques to areas of restricted movement in the knee and surrounding joints, to increase movement, improve the function and reduce pain
• Deep soft tissue massage, trigger-point therapy and cross-friction.

Stage 3: Rehabilitation exercise programme.

• When appropriate we introduce exercises to improve strength, endurance and stability. We also work on improving your balance and your sense of joint position (proprioception). This will help you to return to normal and also prevent new injuries.

Read more about common causes of knee pain seen in chiropractic practice and read in more detail about specific conditions.