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Knee pain

The knee joint is a hinge joint, which mainly allows for bend, straightening and a small degree of rotation. The tibiofemoral joint involves the thigh bone (femur) meeting the shin bone (tibia). The patellofemoral joint is where the knee cap (patella) slides on the thigh bone (femur). These joints work together, alongside ligaments, tendons and muscles to provide a stable system to help when standing and walking. 

Common causes of musculoskeletal related pains tend to originate from bones, ligaments, tendons and muscles. These symptoms tend to settle with time and good self-management

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Osteoarthritis

What is it?  

Osteoarthritis refers to joint pain with limitation of movement, which can affect daily activities. Contrary to most thoughts, osteoarthritis is not caused by ageing and does not necessarily get worse. 

In osteoarthritis we see changes to the cartilage of the joint as well as other secondary changes such as inflammationCartilage helps our joints move freely.   Changes to the cartilage can lead to pain, stiffness, and loss of movement. This can in time lead to weakness around the muscles of the joint. Your knees may feel as they will give way due to this weakness. 

Osteoarthritis is the most common type of arthritis, affecting 8.5 million people in the UK.  It most commonly affects people older than 45 and is more common if you are overweight, have a family history of it, or have previously injured the joint in question. 

With arthritis of the knee you may feel pain on either side of the knee at the front or sometimes around the back.  Morning stiffness lasting less than 30 minutes is also very common. 

How to deal with it?  

If you think you have, or have been diagnosed with osteoarthritis of the knee there are several things you can do to help manage your symptoms and stop it from worsening  

Exercise

Exercise has been shown to be beneficial in osteoarthritis. Try to increase your activity levels and consider taking up exercise.  Walking, swimming and cycling are often well tolerated but choose something you enjoy. It is important when starting exercise to start easy and build up slowly. A small increase in your pain when you start is okay. 

Strengthening 

Osteoarthritis can lead to weakness.  Strengthening the muscles around your knee will allow you to do things more easily such as standing up, walking and climbing stairs.  You need to focus on getting your thigh muscles (quadriceps) strong.  Again some pain when starting exercise is okay provided it is tolerable.  Start with simple exercises and build up. Please see this link from versus arthritis for a description of some useful exercises to help your knee:

https://www.versusarthritis.org/about-arthritis/conditions/knee-pain/#knee-pain_knee-exercises

Weight control 

If you are overweight, try to lose some weight. Even a modest weight loss can make quite a difference to your symptoms. 

Using a walking aid such as a stick or walking pole in the opposite hand to the affected knee can also help to take pressure off the painful joint.  

Simple painkillers 

Painkillers like paracetamol will ease the pain, but need to be taken regularly in order to control the pain. Always follow the instructions on the packet.

Anti-inflammatories like ibuprofen can help with swelling, and therefore help you move more freely. Follow the instructions on the packet and discuss using them safely with a pharmacist, especially if you have any underlying health conditions

However, you should not take ibuprofen for 48 hours after an initial injury as it may slow down healing.

Up to date guidelines can be found on the NHS website:

https://www.nhs.uk/medicines/ibuprofen-for-adults/

https://www.nhs.uk/medicines/paracetamol-for-adults/

For up to date guidelines on the government about Ibuprofen use and Coronavirus (COVID-19)

https://www.gov.uk/government/news/ibuprofen-use-and-covid19coronavirus

 Ice or heat therapy 

Heat may be helpful in the form of a hot water bottle, wheat pack or hot shower. This can help to relax the muscles around your hip and may allow exercises to be more effective.  

For ice therapy use a damp cloth containing an icepack (or bag of frozen peas) over the top of the painful area to help numb the pain. Leave it on for up to 20 minutes and use up to three times a day. 

  • You should be cautious using these treatments if you have altered skin sensation or circulatory problems.  
  • Check the skin regularly during and after the ice pack application 
  • Stop if there is excessive pain, numbness or tingling  
  • Do not put ice directly on to the skin as this may cause a burn. 

Physiotherapy 

If you find that you are not improving, assessment and advice from a physiotherapist can be helpful.  

ESCAPE Pain 

Your GP or physiotherapist may refer you to an ESCAPE Pain class.  This is an evidence based programme of 12x one hour sessions over the course of 6 weeks which comprise a 15-20 minute education/discussion element and a 30-45 minute exercise programme. The aims of the course are to help you better manage your symptoms, carry out normal activities, become more active and to continue to exercise. See link below 

Important information to know: 

Being overprotective and doing less can mean that you will get weaker and stiffer and eventually have more symptoms.  

The stronger the muscles are that surround the knee, the less the arthritic changes will have an impact on your life 

It is safe to exercise, and exercise doesn’t speed up the osteoarthritic process. 

Many people have signs of osteoarthritis on xrays but no symptoms. These changes are best thought of as normal age related changes. 

Anterior knee pain (AKP)

What is it? 

Anterior knee pain (AKP) is pain in the front of your knee which is very common.  It is usually not related to any significant injury and can arise at various stages of life.  It is related to various structures around your knee becoming sensitive. Things that may be painful may include deep squatting, walking up or down stairs and slopes, or standing up after a prolonged sitting period.  You may notice clicks within the knee, do not worry about these as they are not necessarily a sign of something being wrong. 

How to deal with it?  

Activity modification 

  • If you have significantly increased your activity levels before the onset of the pain try to reduce the activity  
  • Identify any changes in your lifestyle that could have resulted in knee pain, both internally (e.g. have you gained weight?) or externally (e.g. have you started wearing new shoes?) If you do, try reversing the changes and see what effect it has on the pain 
  • Limit as much as possible, activities or postures that you know cause your symptoms to worsen. 
  • As the pain improves, gradually re-introduce any normal day-to-day activities that you have been avoiding, returning to full activity once the pain has gone 

Weight loss 

Losing weight will reduce the amount of pressure the patella (kneecap) is putting on your knee and even a modest loss in weight will improve your symptoms and reduce of the chances of it coming back. 

Exercise

Exercises can be very helpful in this condition but be aware that it may take up to three months before you notice significant improvement. Don’t be disheartened – stick with it! Generally the longer you have had the anterior knee pain, the longer it takes to improve. 

  • Exercises that often help include stretching of the calf muscles and strengthening of the thigh (quadriceps).   
  • The hip and buttock muscles are also key in controlling leg movement while under load (such as going down stairs) and there is evidence to suggest that strengthening of these muscles can also help. 
  • Some pain during exercise is okay but should be tolerable and settle within two hours following exercise 

Please see the following link for exercises to help with anterior knee pain: 

https://www.poole.nhs.uk/pdf/Anterior%20Knee%20Pain%20Exercises.pdf 

Physiotherapy 

If you find that you are not improving, some advice or treatment from a   physiotherapist can be helpful for your particular type of anterior knee pain. 

Ligament/cartilage injuries

What is it? 

Knee ligament injuries are very common and are often sports related, although they can occur from a trauma during everyday activities. The most common are:

  • a sprain/strain – one or more ligaments is overstretched through twisting or pulling
  • a tear – either a partial tear or complete rupture of the muscle
  • damage to the cartilage in your knee – the cartilage is a crescent-shaped disc called a meniscus, that acts as a ‘shock absorber’ in your knee
  • this could be caused by an acute injury or trauma or due to a more gradual onset because of deterioration/wear and tear

Ligaments connect one bone to another. The ligaments outside your knee joint are called the medial collateral ligament (inner knee) and the lateral collateral ligament (outer knee). They provide your knee with stability and limit the amount it can move from side to side.

The medial collateral ligament is strong and can be sprained or completely ruptured (torn) if you twist your straightened leg at the same time as being knocked sideways, for example, when being tackled in rugby.

The ligaments inside your knee joint are called the anterior cruciate ligament (ACL) and the posterior cruciate ligament. These ligaments provide stability to your knee when it is in different positions, particularly in the forward and backward movements of the knee joint. People who sustain an injury to their ACL may complain of symptoms of the knee ‘giving out’.

How to deal with it? 

  • Rest the leg and apply ice for 10/15 minutes every few hours for the first 48 hours after the injury.
  • Take some painkillers so you are comfortable.
  • A simple strain of the medial collateral ligament should settle very quickly over two to four weeks. If things are not improving seek medical advice.
  • For injuries to the cruciate ligaments seek medical advice immediately

 

There are some precautions you can take to try to reduce the risk of damaging your knee.

 

  • Exercise regularly to maintain a good level of fitness. This will mean your muscles are stronger and better able to support your joints, including your knees. If you haven’t been active for a while, start gently and gradually increase the intensity.
  • Spend five to 10 minutes warming up before exercise to increase blood flow to your muscles and reduce the chance of an injury. Many sports professionals advise stretching your muscles after warming up and again after cooling down; however the benefit of stretching before or after exercise is unproven.
  • Vary your knee movements: Anterior knee pain (pain in the front of your knee) is generally the result of overusing the joint, so it is important to try and vary the stresses you place on your knee. For example, runners should make sure they mix up the surfaces they run on to include uphill runs and flat ground
  • Stretch regularly: Keep the muscles in your legs as flexible as possible by regular stretching.
  • Strengthen your leg muscles: Perform regular exercises such as squats and lunges to strengthen and keep your leg muscles in good condition.
  • Footwear: Ensure sports shoes are appropriate for the activity and are replaced regularly to avoid excessive wear. In osteoarthritis of the knee good, cushioned footwear has also been shown to be beneficial

Patella tendinopathy

Coming soon.

Other causes of knee pain

There are a lot of other causes of knee pain. These may include muscular injuries, ligament sprains or tears, tendon issues and meniscal (cartilage) problems.   See link to soft tissue injuries 

If after an injury you are having difficulty weight bearing or have significant swelling immediately then you should seek advice from a medical professional.  Likewise if you have had a direct impact or trauma to your knee and cannot move your knee past a right angle or are older than 55, seek the advice of a health care professional.  

How to avoid it? 

Simple strategies such as keeping the knee moving, strengthening your muscles, becoming active and keeping your weight under control will help 

If you follow the advice above you can make some very positive measures to prevent future episodes of anterior knee pain. If you have any concerns please contact your GP or local NHS physiotherapist. 

Lateral knee pain

Lateral (outer)  knee pain can be caused by several things, but the most common cause is Iliotibial Band Syndrome, an overuse injury due to the Iliotibial band rubbing on the outside of the joint.

This pain on the outside of your knee, is also called Runner’s Knee.

The iliotibial band, a thick band of fibrous tissue that runs down the outside of the leg, works in coordination with several of the thigh muscles to provide stability to the knee and to help in flexion of the knee joint. When irritated, movement of the knee joint becomes painful. Usually the pain worsens with continued movement, and resolves with rest.

How to deal with it? 

Reducing inflammation is key to decreasing pain. This involves rest, ice, and anti-inflammatory medications. This should improve pain, swelling and tenderness.

Stretching the muscles on the outside of your leg will also help to increase flexibility of the Iliotibial Band, quadriceps, hamstrings, gluteals and calf muscles. The final phase of treatment includes a strengthening program and a progressive return to activities, such as running, once pain free.

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Soft tissue injuries

Knee injuries

Minor injuries to the knee, such as a mild sprain or strain should settle with time and can be managed at home. 

A soft tissue injury to the knee may result in the following: 

  • Pain
  • Swelling
  • Bruising
  • Stiffness and loss of function 

The pain can be particularly strong in the first three weeks as this is the inflammatory phase of your body healing itself. Typically, these injuries last 4 to 6 weeks depending on the severity.  

Painkillers like paracetamol will ease the pain, but need to be taken regularly in order to control the pain. Always follow the instructions on the packet. 

Anti-inflammatories like ibuprofen can help with swelling, and therefore help you move more freely. Follow the instructions on the packet and discuss using them safely with a pharmacist, especially if you have any underlying health conditions

However, you should not take ibuprofen for 48 hours after an initial injury as it may slow down healing.

Up to date guidelines can be found on the NHS website:

https://www.nhs.uk/medicines/ibuprofen-for-adults/

https://www.nhs.uk/medicines/paracetamol-for-adults/

For up to date guidelines on the government about Ibuprofen use and Coronavirus (COVID-19)

https://www.gov.uk/government/news/ibuprofen-use-and-covid19coronavirus

DAY 1 – Early Management

Protect by minimising use of the affected area and initially avoiding stretching the area which could cause further injury. You may require the use of a walking aid to offload pressure on the affected side. You may find it easier to go upstairs leading with good leg first, and downstairs with the affected leg first.   

Rest can be beneficial in the very early stages of the injury (days 1-4). Complete rest, however, is not advisable. In the early stages, gentle active movements and specific exercises can help decrease pain and swelling, they also promote good tissue healing with less unwanted scar tissue and joint stiffness. It is important to make sure you keep your hip and ankle moving as able, so they do not stiffen up. 

Ice pack/frozen peas wrapped in a damp cloth, placed on the swollen area for up to 20 minutes at a time, 3 times a day. So long as there is swelling you will need to continue ice therapy, often beyond the third week.   

  • Please note only use ice if you have normal skin sensation  
  • Check the skin regularly  
  • Stop if there is excessive pain, numbness or tingling  
  • Do not put ice directly on to the skin as this may cause a burn. 

Compression of the of the knee can be achieved by using a tubigrip or crepe bandage. It should compress firmly but not restrict blood flow and create a tourniquet.  Remove if there are signs of poor circulation, or if you start to experience pins and needles or numbness.   

Elevation. If you have swelling in your knee, try to keep it level or slightly higher than your hip. You can help achieve this with use of pillows. 

WEEK 1 – Early Mobilisation

After 72 hours is important to start using your knee as your pain allows. Start to do normal everyday activities. You should also try doing these exercises 3 – 4 times a day. Repeat each one 10 times. 

Knee exercises 

1. Lying on your back, bend your knee up towards you, sliding your foot and then let it return

2. Sitting on a chair bend your knee back as far as it can comfortably go

3. Sitting on a chair, slowly straighten your knee as high as it can go and slowly lower it down again. 

Hip exercises 

1. Lying on your back, lift your knee towards you and then let it come back down 

2. Lying on your back, slide your whole leg out to the side in an arc and return

WEEK 2 – Strengthening Exercises

You can start these when pain is starting to settle.  

Knee exercises 

1. Lying on your back, squeeze your knee in to the bed.  Hold up to 5 seconds and relax

2. Lying on your back, lift your leg up straight approximately 30 cm off the floor / bed.  Hold up to 10 seconds and slowly lower it down.

 

 

 

3. Sitting in a chair.  Stand up and sit down slowly.  Try not to use your hands if possible.  Make this harder by: 

a) moving the foot of your affected knee closer to you and then progress to 

b) standing from a lower height.

 

4. In standing with feet apart, hold on to something in front to steady yourself. Keeping your back upright, slowly let your knees bend and return to upright. To begin with you may not do much of a dip and that is ok, the important thing is to be in control. Gradually progress to a deeper dip or a 5 second hold at the deepest part. 

Hip exercises 

1. Standing up and holding on to something if you need to.  Take your leg out to the side and return.

2. Standing up and holding on to something if you need to.  Take your leg behind you and return. Remember to keep your back up right and don’t lean forward. 

As you start to do these exercises you may feel there is some discomfort, however, this is okay and you should continue. If you have discomfort and pain for more than 2 hours after these exercises, then you should reduce the number and gradually build up again. 

Further progression on exercises can be found following the link below: 

https://www.poole.nhs.uk/a-z-services/t/therapy-services/therapy-outpatients/patient-information-leaflets.aspx 

Recovery time and returning to activity 

It usually takes 6 weeks to heal from simple soft tissue injuries to the hip or knee.  However, everyone recovers from injuries at different rates. Some may be back in 2 weeks however for some it can take up to 3 months.    

Returning to work – Gradually build up your strength and function, practice doing similar tasks that you would do at work before returning. Start doing this little and often ensuring there is minimal pain or swelling. 

Returning to hobbies/sport – it is advised not to return to these activities until you have full strength and range of movement without pain or swelling. Try to practice the specific movements of your hobby / sport in a controlled manner and build up the time and intensity that you do the movements before returning to your activity fully.    

Go to an urgent treatment centre or A&E if you: 

  • have severe pain or feel faint, dizzy or sick from the pain  
  • heard a snap, grinding or popping noise at the time of the injury 
  • had a large amount of swelling which appeared instantly after the injury (within an hour) 
  • you are unable to weight bear because of the pain 

These might be signs of a more severe injury which may need medical attention. 

See a GP or physiotherapist if: 

  • the pain is severe or stopping you doing normal activities 
  • the pain is getting worse and/or keeps coming back 
  • the pain has not improved in any capacity after treating it at home for weeks 
  • you have ongoing symptoms of giving way or locking 

Further links 

External links for further information on knee pain 

https://www.csp.org.uk/conditions/managing-your-bone-joint-or-muscle-pain/managing-your-knee-pain  

https://www.versusarthritis.org/about-arthritis/conditions/knee-pain/ 

https://www.nhs.uk/conditions/knee-pain/ 

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