Knee Pain

Exercise has consistently shown to be beneficial for those with knee pain resulting from varying musculoskeletal conditions including osteoarthritis, total knee replacements, ligament strains, meniscal injuries, patellofemoral pain and iliotibial band syndrome. The benefits of exercise and general guidelines for exercising with these common conditions will be explored below.  

 Patellofemoral pain

Patellofemoral pain (PFP) is a common cause of knee pain, most prevalent in physically active individuals between 15-30 years of age. The cause of patellofemoral pain is multifactorial, whereby altered alignment of the hip, knee and ankle joints causes excessive stress on the knee joint, leading to and pain surrounding the knee cap (patella). This pain is present during activities such as running, squatting and ascending and descending stairs. 

As the contributing factors leading to patellofemoral pain are varied, a tailored exercise program involving specific stretching, releasing and strengthening to improve the altered alignment of the hip, knee and ankle joints should be prescribed. Excessive loading of the knee joint during exercise and daily activities should be avoided in order to prevent the exacerbation of knee pain and discomfort .

Iliotibial Band Syndrome

Iliotibial band syndrome is a common cause of knee pain, seen mostly in endurance athletes and runners. With repeated bending and straightening of the knee joint, the iliotibial band becomes irritated and inflamed, causing pain on the outside of the knee.

High running /walking volumes and muscle imbalance through the hips, knees and ankle joints are the main contributors leading to the irritation of the iliotibial band. Treatment should involve activity modification, reduction in running volume, and prescription of a specific stretching and strengthening exercise program with a focus towards improving the strength of the gluteals. As the iliotibial band is inflamed through repeated knee bending and straightening, exercises involving these motions should be limited to avoid recurrence of pain.

Meniscus Tears/Repairs

The meniscus are tough cartilage located in the knee joint between the shin and thigh bone, responsible for distributing load and shock absorption through the lower limb.  As the thigh bone pivots on the shin bone, it can trap the meniscus, leading to tears. If symptoms are present during daily activities, the meniscal tear may need to be repaired through keyhole surgery.

A rehabilitation program for meniscal tears and repairs should focus on restoring range of motion and strengthening the quadriceps, particularly the vastus medialis obliquus (VMO; the key stabilising quadricep muscle). As pain is exacerbated by the forces of extreme knee bending and rotation, these motions should be avoided in your exercise program and in daily activities. 

 Anterior Cruciate Ligament reconstructions

The anterior cruciate ligament (ACL) prevents the thigh bone from moving forwards on the shin bone and rotation of the knee. It is commonly injured during knee hyperextension, rotation, deceleration, landing and high force contact at the knee joint. The decision the treat an ACL tear with surgery will depend on various factors, however it is common for a completely torn ACL to be surgically repaired. 

As there are a number of successful ACL rehabilitation protocols (for example; accelerated and gradual), your surgeon and treating exercise physiologist or allied health professional will provide direction on the most appropriate. Where reconstruction surgery has taken place, the rehabilitation program will depend on the type of graft used, type of surgery completed, the surgeon’s preferences and any other injuries which may influence the exercise program. The intensity and loading of range of motion, strengthening and functional exercises will be tailored with consideration to the tissue healing timeline in order to ensure safety and maximise outcomes.

 Total Knee Replacement

Total knee replacements are a successful surgical procedure to improve quality of life for those suffering severe osteoarthritis. After total knee replacements, exercise is prescribed to reduce pain and swelling, improve range of motion, strength, walking tolerance and allow a return to pre-surgery functional capacity.

 After surgery, stretching and mobility will commence to regain loss of motion in conjunction with muscle strengthening for the quadriceps. Education will be provided regarding techniques for positional changes such as lying to sitting, sitting to standing and standing to walking to ensure safety during these activities.

Individuals should also comply with using gait aids when prescribed (eg. 4 wheel walker and frames) and follow guidelines on their weight bearing capacity during rehabilitation.

 Osteoarthritis

Osteoarthritis is the most common form of arthritis and is characterised by progressive degeneration of the cartilage, narrowing of the joint space and surrounding muscle weakness. Osteoarthritis is frequently diagnosed in the knee joints and contributes to pain and impaired daily function.

Regular exercise, specifically aerobic conditioning, stretching and strengthening exercises which target the stabilising muscles of the knee and hip have been shown to improve the symptoms of osteoarthritis. Water based exercise has also been shown to reduced pain and discomfort and improve function. It is recommended that individuals with knee osteoarthritis avoid high impact and repetitive force type exercises such as running and jumping as the elevated joint load may cause joint swelling and pain.

Exercise prescription

Self-myofascial release (spikey ball and foam rolling), and stretching/mobility exercise for the hip, knee and ankle can assist the restoration of range of motion, reduce muscular tension and improve patella (knee cap) alignment which may be a contributing factor to knee pain. The gluteals, iliotibial hand, tensor fascia late, quadriceps, hamstrings and calves are commonly targeted muscles for stretching, myofascial release and mobility exercises when addressing knee pain.

Strengthening of the quadriceps muscle group, primarily the VMO, will assist in stabilising the patella and improve its ability to maintain proper alignment during activity. Gluteal and core strength is also an integral part of any lower limb exercise program given their impact on knee alignment and pelvic stability in functional tasks such as walking. Improving the strength of remaining lower limb muscles (eg. hamstrings, calves, foot muscles) will also produce positive effects for knee pain through providing support to the knee in daily activities. Balance and proprioception exercises will be added to ensure safety in return to activity, improve muscular control and reduce risk of falls. Depending on client history and goals, plyometric and activity/sport specific exercises will commence following the strengthening phase of rehabilitation.

 It is important to remember that differing types of exercises (eg. closed vs open chain, isometric vs isotonic muscle contractions, eccentric vs concentric contractions) provide different stress to the knee joint and thus should be prescribed according to the pathology and its evidence based rehabilitation protocols. An exercise physiologist is a tertiary qualified health professional who delivers evidence based exercise prescription to assist the management of acute or chronic medical conditions, injuries or disabilities. Following an initial assessment, your exercise physiologist will prescribe, monitor and progress your tailored exercise program according to your specific condition, capabilities and goals in order to achieve optimal outcomes.  

For more information please contact PACE Health Management and speak to one of our team members. 

Ph: 9770 6770

References 

Houglum, P. (2016). Therapeutic Exercise for Musculoskeletal Injuries, 4th edition, USA, Human Kinetics.

Anderson, M., Parr, G.P. (2013). Foundations of Athletic Training; Prevention, Assessment and Management, 5th edition, Philadelphia, Lippincott Williams & Wilkins.

Harmer, A.R., Naylor, J.M., Crosbie, J., Russell, T. (2009).Land-based versus water-based rehabilitation following total knee replacement: A randomized, single-blind trial. Arthritis Care & Research. 61(2):184-91.

López-Liria, R., Padilla-Góngora, D., Catalan-Matamoros, D., Rocamora-Pérez, P., Pérez-de la Cruz, P., Fernández-Sánchez, M., (2015). Home-Based versus Hospital-Based RehabilitationProgram after Total Knee Replacement. BioMed Research International. 2015, (Article ID 450421) 1-9

Focht, B.C., (2006) Effectiveness of Exercise Interventions in Reducing Pain Symptoms Among Older Adults With Knee Osteoarthritis: A Review. Journal of Aging & Physical Activity. 14(2): p. 212-235.

Wu, S.F., Kao, M.J., Wu, M.P., Tsai, M.W., Chang, W.W.,(2011) Effects of an osteoarthritis self-management programme. Journal of Advanced Nursing, 67(7), 1491-501.

Vincent, K.R. and Vincent, H.K.,(2012) Resistance exercise for knee osteoarthritis. American Academy of Physical Medicine and Rehabilitation, 4(5), S45-52.

 For more information and guidance on exercising with Knee Pain please contact us at PACE Health Management and speak to one of our exercise physiologists Ph 9770 6770.