Knee osteoarthritis: is it as debilitating as we think?

Osteoarthritis (OA) is the result of wear and tear of the joint cartilage. It can result in pain and stiffness when loading a joint. But is OA always a sign we need to protect our joints and stop certain activities? The answer may surprise you.

What is OA?

Osteoarthritis is a break-down of the cartilage in our joints. It mostly affects weightbearing joints such as hips and knees and these joints are subject to larger forces. It was previously thought that joints with OA were to be ‘protected’ by limiting how much we bend, move and load them. We now know this is not true – in fact exercise is one of the most effective ways of reducing osteoarthritic pain. 

Knees in particular appear to have many connotations around them and it is widely (but incorrectly) thought that exercise is harmful to our knees. In fact it is quite the opposite – weight bearing exercise helps bone, muscles and other soft tissue adapt to make our knees stronger and more robust. This means an improvement in joint range of motion, muscle length and strength and functional capacity. 

How much value should you place on a scan?

It is also important to know that while a scan may show significant osteoarthritic findings, this certainly does not correlate to pain, function or quality of life! Even with ‘severe’ osteoarthritic findings on a scan, very positive functional outcomes can be seen with the above program.  

What will help?

The latest guidelines around osteoarthritis, show the most effective way to slow the progression of the pathology is to perform regular weight bearing, strength based exercise. There is good evidence to say this can also significantly reduce pain and improve function. Anti-inflammatories may also help pain and swelling, however you should always consult your doctor before using medication.

It is recommended to perform land based strength exercises 2-3x weekly, such as squats, steps up or leg press. The sets, reps and weight will initially be determined by strength, function and pain levels. This is nicely complimented by aerobic exercises such as walking, bike riding or pool based exercise, although aerobic exercise is not shown to have the same benefit as land-based strengthening. 

Our physiotherapists can create a knee strengthening program you can perform at home, all tailored to your individual goals and ability. 

The PLC (PosteroLateral Corner) Injury

PosteroLateral Corner (PLC)

What is the PLC?

The PosteroLateral Corner describes 3 main structures at the back and outside corner of the knee that are important for stabilisation. These resist against hyperextension and rotational forces. These structures include the;

1.     Lateral Collateral Ligament (LCL)

2.     Popliteal Fibular Ligament (PFL)

3.     PopLiteus Tendon (PLT)

Also, the Posterolateral Capsule.

How did I get a PLC injury?

Risk factors and causes of a PLC injury can vary, including;

o   Common sports/scenarios; Football, rugby, soccer, high impact motor vehicle accident (MVA).

o   Common concomitant injuries: Occur at the same time as Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL) injuries.

 Where does it hurt?

Do you have pain and/or instability at the back and outside of the knee around the joint line? Is there pain AND clicking or crunching?

Note: A noisy knee without pain isn’t necessarily a bad thing.

Do I need a scan of my knee?

Likely Yes.

In most cases this a physiotherapist will be able to clinically diagnose a PLC and/or other injuries. If there is concern for damage to the cruciate ligaments or posterolateral corner ligament injuries of the knee then you will likely be referred to a GP or Sports Physician for either an X-ray to rule out fracture and/or MRI to confirm PLC injury. Moderate to high grade injuries will likely require onward referral to a surgeon.

What is my prognosis?

Low and moderate grade injuries often have a good prognosis with physiotherapy guidance.

Higher grade injuries may have difficulty returning to change of direction sports within 6 months and upwards of 12 months if there is a cruciate injury.

What will rehab involve?

Early management will include bracing of the knee, proprioception, strength and non-weight bearing cardiovascular exercise such as gentle swimming and cycling.

Longer term rehab will be dependent on the needs of your daily activities or sport requirements.

Talk to your physio about how to get you back on top of your game!

PatelloFemoral Pain Syndrome (PFPS)

What is PFPS?

Patellofemoral pain is the most common cause of pain at the front of the knee.

It occurs with ‘patella mal-tracking’ i.e. when the under surface of the patella (kneecap) slides in the grove of the femur as the knee bends and straightens as the quadriceps contract and relax. 

When the knee is bent, mal tracking often causes the patella to shift laterally, causing pain with squat, moving from sitting to standing and using stairs.                  

How did I get PFPS?

Causes of PFPS can vary, including;

o   Over training i.e. people who over exercise with repetitive type movement i.e. cycling/hopping/jumping and running (especially hills and stairs) with insufficient time for recovery or excessive training loads.

o   Change in training: i.e. changing footwear, running surface or increases in training intensity.

o   Poor motor control at the quadriceps, hip (glutes) and foot/ankle (hyper or hypo-mobility).

o   Abnormal knee/hip size and shape i.e. patella shape, femur shape or whether the patella sits high or low. Variations in an individual’s shape of the femur, tibia and/or hips can affect how the quadriceps muscles pull on the patella.

o   Post-surgery i.e. post ACL surgery or after a lengthy time off

Where does it hurt?

Do you pain at the front of the knee around the kneecap? Is there pain AND clicking/crunching?

Note: A noisy knee without pain isn’t necessarily a bad thing.

Do I need a scan of my knee?

No.

In most cases this should be easily diagnosed by your physiotherapist or sports physician. If you aren’t getting results with your treatment and rehab then you may be referred for a scan.

What should I avoid doing?

-       Complete rest

Repetitive running, cycling or deep squatting is likely contributing to your pain but engaging in physical activity is also helping to keep your muscles strong. Talk to your physio about activity modification.

-       Don’t panic

Your knee will get better with targeted strength, stretching/rolling and other techniques. Note that due to the tissues involved, this can take months rather than weeks, persistence of your home exercise program will be important.

-       Don’t train through high levels of pain, mild pain is usually ok.

Low or mild discomfort can be acceptable during activity, but if you are still sore 24-72 hours later then you may have done too much, too quickly.

-       Exercises such as lunges and deep squats and stairs/hill running may aggravate your knee initially however you these will likely be re-introduced in the later stages of rehab. 

I’ve been having physio and not getting better, what should I do?

Ask yourself;

-       ‘Am I still over doing high impact activities, and/or underdoing strength / control activities?’

-       ‘Am I getting enough recovery between sessions?’

PFPS frequently co-exists with other issues such as patella tendinopathy, fat pad impingement and patella hypermobility. It’s important to distinguish if any of these are involved by asking your physiotherapist.

Other less common diagnosis includes; bursitis, Osgood-Schlatter disease (OSD), Sinding-Larsen-Johansson syndrome and referred pain from the hip.

What’s the best treatment for PFPS?

Best practice for PFPS rehabilitation is a combination of…

-       A short period of rest or de-loading

-       Regular progressive loading

-       Avoid painful knee ranges

-       Taping and braces can help in the short term

-       Your GP or health professional will be able to advise regarding anti-inflammatory use.

 Speak to your physiotherapist who will assess and prescribe the optimum amount and intensity of exercises for you.

Author: Peter Gangemi - Master of Physiotherapy

PREHAB: TAKING CONTROL OF YOUR RECOVERY

Optimising recovery from surgery:

Regardless of what it’s for, surgery can be scary and overwhelming. It is normal to feel a sense of helplessness or feeling as if you don’t have control over the end outcome. However, it is important to understand that you play the single most important role in the outcome of your recovery and it starts long before you meet with your surgeon. Preparing your body and mind for what you are about to encounter is an important aspect of recovery and creates good habits for your post-surgery rehabilitation.

How do you do this, you ask?

We call this Prehab

Prehab is a programme designed to prevent injuries before they actually occur. This can be applied to anyone or any injury however in the context of surgery it is you taking an active approach to prepare yourself physically and mentally for what you are about to go through. It plays a massive part in giving you the power to control the success of your upcoming surgery.

Why should you do Prehab?

Numerous studies have shown that patients who participate in Prehab have significantly better outcomes than those who do not. Those who undergo prehab generally have quicker recovery times, return to sport faster, have less complications and are generally more satisfied with their end outcome.

Does this apply to me?

Prehab is highly recommended for anyone planning to undertake or has been referred for surgery. Research has shown Prehab to be effective in enhancing recovery for patients undergoing total hip and knee replacements, ACL reconstructions, shoulder surgery such as rotator cuff repairs and lower back surgery.

What does it involve and how long for?

Ideally, undergoing 6-12 weeks of Prehab prior to surgery will optimise post-surgical outcomes. In most situations this is not possible due to availability with your surgeon. This does not mean that Prehab won’t help be helpful for you. As they say, something is better than nothing and there are still many meaningful benefits to be gained with only 2 weeks of preparation.

5 reasons to Prehab:

1.     Get control of your pain:

 A prehab program should give you the tools to minimise pain. Reducing pain early will enable normal muscle activity and put you in a good head space leading up to surgery.

2.     Get in optimal physical shape:

Through a specific exercise program, you can improve muscle strength, flexibility, balance and coordination which has shown to optimise and speed up the recovery process post-surgery. Additionally, improving general fitness and wellbeing has many added benefits such as weight loss and improving mental resilience which is extremely important to recovery.

3.     Create good habits and kick the bad habits

Firstly, creating good habits beforehand will make your life so much easier once you have been discharged from hospital. Good habits start with getting in a healthy exercise regime This extends to healthy sleep, nutrition and lifestyle habits which your physiotherapist and health practitioners can guide you on.

Conversely, bad habits will have the opposite effect, so you can imagine the importance in changing these prior to surgery.

4.     Manage anxiety/stress

It is completely normal to feel anxious or stressed prior to surgery. In addition to physically preparing yourself you must also get yourself in the right headspace. Prehab will help mentally prepare you by getting you in a good mindset for the upcoming rehabilitation process. It will also teach you appropriate coping strategies to deal with pain and stress associated with the injury.

5.     Speed up your recovery and reduce post-operative complications

Prehab sets you up for a successful recovery leading to quicker recovery and return to sport times. It also reduces the risk of common complications associated with surgery.

Please feel free to contact our team at East Vic Park Physio on 9361 3777 if you have any questions or would like to find out if Prehab is appropriate for you.

THE IMPORTANCE OF MUSCULOSKELETAL SCREENING

Finals time for most winter sports is fast approaching and from a physiotherapy perspective this is the time of year that we see a spike in sporting injuries. A lot of these injuries tend to be to parts of the body that have some sort of deficit, be it strength, length or control. It is quite hard to be able to identify these areas yourself and even physiotherapists would find it hard to accurate identify these deficits purely through observation.

This is why screening is so widely utilised for athletes from amateur to elite. Screening usually involves a battery of tests that give objective measurements that are then compared to the normal values for an athlete in a specific sport. Screening can also involve questionnaires that focus on general health and previous injury history.

An article by Sanders, Blackburn and Boucher (2013), looked at the use of pre-participation physicals (PPE) for athletic participation. They found PPE’s to be useful, comprehensive and cost effective. They explained that PPE’s can be modified to meet the major objectives of identification of athletes at risk.

An article by Maffey and Emery (2006) looked at the ability of pre-participation examinations to contribute to identifying risk factors for injury. They found limited evidence for examinations in terms of the ability to reduce injury rates among athletes. However, they were effective in the identification of previous injury (such as ankle sprains) and providing appropriate prevention strategies (such as balance training). From this it has been shown to reduce the risk of recurrent injury. It may also be useful in identifying known risk factors which can be addressed by specific injury prevention interventions.

An example of a screening measure that is typically used in screening protocols includes a knee to wall test (KTW). This test is used for ankle dorsiflexion as well as soleus muscle length (one of your calf muscles). The test is performed using a ruler which is placed perpendicular to a wall with no skirting board. The athlete puts their foot flat on the ground next to the ruler and as far from the wall as possible as long as their knee is touching the wall. Distance from the wall to the end of the big toe is noted by looking at the ruler. An example of a normal distance for netball players is greater than 15cm on each side.

Here at East Vic Park Physiotherapy we have developed a number of specific musculoskeletal screens for a variety of sports including netball, running, swimming and throwing sports. They comprehensively identify the key risk factors that are seen in injuries sustained in each sport. If you are interested in preventing injury for the upcoming sports season, then contact the clinic on 9361 3777 and book your screening appointment today!

UNDERSTANDING PAIN

An excellent video on what our understanding of pain currently is and in particular the complexities of chronic pain.