The knee is a particularly important hinge joint that connects our thigh to our lower leg. The bend available at the knee joint allows us to clear our foot and toes from the ground when we are walking and in conjunction with the hip and ankle, flex and extend at complimentary angles for best motion.
Injury to the knee can be debilitating due to it being a weight baring joint required for all upright locomotion.
Patellofemoral joint pain (PFJ) tends to cause significant pain particularly with deep knee flexion positions and walking down stairs and down hill.
Traumatic knee injuries caused by impact, twist and turn mechanisms while working or playing sport include ligament and cartilage injuries. Sports such as football, netball, rugby, lacrosse and hockey are sports that tends to have a high incidence of ACL and other ligament injuries. Cartilage can also be impacted through excessive use and awkward positions under load.
Total knee replacement is the end result if knee osteoarthritis is so significant that discomfort when weight bearing is close to constant. Arthritic changes are graded 1-4 with 1 being minimial and 4 being full loss of chondral surface cartilage.
For more information on the most common injuries affecting the knee, please click on the buttons below.
There are two types of cartilage inside the knee. Both can be injured in different ways. The lateral and medial menisci are C-shaped and made of tough, rubbery fibrocartilage. They are located within the knee joint and function like washers, helping with shock absorption and aiding joint stability. Joint (articular) cartilage is the solid layer of cartilage that covers the bony surfaces inside the knee joint (between the tibia and femur, and between the kneecap and its groove on the femur).
Tell me more about knee cartilage.
Meniscal injuries are generally classed as sudden onset (acute) or wear and tear (degenerative). Joint (articular) cartilage provides a shiny, smooth, friction-free surface for the joint to glide. It also protects the underlying bone. It can be injured through traumatic injury, wear and tear, or by other conditions. Injuries around growth areas (eg, the epiphyseal plate and apophysis) can occur in children and adolescents.
What causes a knee cartilage injury?
Injuries to the menisci generally fall into two categories:
Injuries to the articular cartilage also occur in several ways:
Trauma or acute injury
If a person’s knee sustains a high force injury (eg, a fall from height or a heavy awkward landing in sport), this can result in chipping of the articular cartilage or a cartilage compression injury.
Via a patellar dislocation
Sometimes when a person sustains a patellar (kneecap) dislocation, a piece of articular cartilage on the surface of the patella can be chipped or fractured.
Conditions such as osteochondritis dissecans (OCD)
This is a condition mainly found in adolescents and young adults in which a small patch of bone beneath a portion of articular cartilage develops a lesion. This is considered a stress injury to the developing articular cartilage, and can cause the cartilage and bone piece to weaken and occasionally separate from the bone beneath it. With unloading, the OCD lesion can heal without any further consequence, but with repeated and sustained loading, the lesion doesn’t heal and can became separated and displaced and lead to ‘locking’ and clicking’ of the knee.
Wear and tear (OA)
Joint surfaces can accumulate injury via the process of ageing. Wear and tear of the articular cartilage can occur earlier in people who have had previous traumatic knee injuries, highly physical jobs, or who have movement patterns (biomechanics) that put extra stress on areas of joint cartilage.
Related to growth and load, this is where the cartilage is transitioning to bone at the tendon insertion, with injury also in the adjacent tendon and bone. Most common around the knee is the attachment of the patella tendon at the tibial tub (Osgood-Schlatters disease) or the bottom of the kneecap.
How do I know if I have a knee cartilage injury?
Your physiotherapist, doctor or surgeon can examine your knee to accurately diagnose your knee symptoms. They may also refer you for imaging (eg, X-ray, ultrasound or MRI) if required. Symptoms of knee cartilage injuries often include:
In acute tears, a person generally remembers the particular movement that caused the injury. It’s often felt as sharp pain and an inability to continue activity. In degenerative tears, there may not be a specific incident. Depending on the severity of the meniscal tear, these injuries are often associated with: mild to moderate swelling; localised, sharp knee joint pain with walking, twisting and turning; reduced knee bending and straightening (‘locking’); clicking or catching sensations, which may or may not be painful; and they may also cause aching at night.
Bucket-handle meniscal injuries are a particular (severe) form of acute meniscal injury where a torn portion folds and gets stuck within the joint. This causes the knee to become locked in a certain position.
Articular cartilage injuries
Symptoms vary depending on the location of the injury within the knee along with its severity and how it occurred.
Those that arise from trauma are generally very painful, especially when trying to weight-bear or in particular joint positions. They are often quite swollen and have restricted range of movement.
Articular cartilage injuries that occur due to OCD can have variable symptoms such as limping due to pain or pain with higher impact sporting activities. If an OCD lesion is more significant, the knee may swell, click, clunk and have limited movement.
Wear and tear (OA) type of articular cartilage injuries can cause more gradual onset of symptoms. They generally lead to swelling and pain in a portion of the knee, often with long periods of activity. The knee may ache at night or be stiff after periods of rest. When OA is more advanced, the knee might also change in appearance (eg, ‘bow leg’ or ‘knock knee’, depending on the location of the wear and tear). For more information, read about knee osteoarthritis.
How can physiotherapy help with knee cartilage injuries?
Physiotherapy plays an important role in the management of knee cartilage injuries. Treatment will vary depending on the type of cartilage injury an individual has, though commonly includes exercises to optimise knee bending and straightening, exercises to improve muscle strength and coordination of leg position, and advice about general activity and pain management.
The management of meniscal injuries varies between acute and degenerative meniscal tears, and the type of symptoms experienced by the individual.
In the first few weeks following an acute meniscal injury, the knee is often quite inflamed. Your physiotherpist can help you settle your knee using strategies such as ice, activity reduction and gentle stretches, while doing simple pain-free strength exercises to prevent muscle weakness developing. Once your knee has settled, your physiotherapist can guide you through a rehabilitation program of exercises and progressive return to full activity.
If the knee continues to have significant mechanical symptoms (painful clicking, locking or catching) once the initial inflammatory period has settled, and despite a structured program of physiotherapy, your physiotherapist may recommend you consult a sports doctor or orthopaedic surgeon.
In the case of a bucket-handle meniscal tear, early surgical repair of the meniscus is required to allow the joint to regain movement and to preserve the meniscus. Following such surgery, physiotherapy rehabilitation is essential to safely regain full strength and knee function.
Articular cartilage injuries
Physiotherapy is recommended for the management of knee osteoarthritis.
In the case of traumatic articular cartilage injuries, often the opinion of a knee surgeon is required. If surgery is needed, physiotherapy is very important post-operatively to help you fully rehabilitate and return to activity safely.
If the cartilage injury is mainly in the patellofemoral joint (the articular surfaces of the kneecap and its groove), physiotherapy generally includes exercises to strengthen the muscles around the knee, hip and lower leg, and improve the coordination of limb movement. This helps the kneecap track better in its groove, reducing load on the area of injury, and helping to minimise further degeneration.
In stable OCD lesions, physiotherapists can provide advice on activity modification and rest while also prescribing exercises to maintain knee strength and flexibility. This is important to allow the cartilage and bone to heal. Physiotherapy also plays a significant role in rehabilitating a person’s knee after surgery if they have an unstable OCD lesion.
In children with overuse injury (apophysitis), which typically occurs after repetitive activities of the muscles attached to the growth cartilage (apophysis), your physiotherapist can help with managing loading, activity modification, an exercise program, taping and advice on self-massage.
How effective is physiotherapy for treating knee cartilage injuries?
Physiotherapy for meniscal injuries
In the case of degenerative meniscal tears, there is a growing amount of evidence to show that physiotherapy, including specific strength and control exercises, is as effective as keyhole knee surgery (arthroscopy). A study of a 12-week supervised knee strength and neuromuscular control (stability and leg position) exercise program compared to knee arthroscopy (including trimming the torn part of the meniscus) demonstrated no difference in pain, function or quality of life between the groups at two years. At three months following the trial, the exercise group showed improvements in quadriceps muscle strength compared to the arthroscopy group.
One significant review concluded that for degenerative meniscal tears, the first-line treatment should be non-operative. This should include simple pain medications (as recommended by your GP) and physiotherapy in order to improve the mechanics of the knee joint and manage pain. This has been shown to be less-invasive and to have fewer risks than arthroscopic surgery, while being equally effective. This study advises that arthroscopic surgery to trim degenerative meniscal tears should only be used as a last resort for people who have not experienced improvements with a comprehensive well-structured physiotherapy exercise program.
Physiotherapy for knee OA
Many studies have investigated the effect of physiotherapy in knee OA and have shown good results. You can read about them on the knee osteoarthritis page.
What can I do at home?
Once your knee has been assessed by your physiotherapist, GP or surgeon, a home treatment plan can be individually tailored to address the contributing factors to your knee injury. Home management plans for people with cartilage injuries generally include:
How long until I feel better?
This is very dependent on the type and severity of cartilage injury that the individual person has in their knee joint. Some people will experience a reduction or resolution of their symptoms within a few weeks or months with appropriate physiotherapy treatment, though others will need to manage their knee symptoms long-term. Your physiotherapist can give you specific advice about what you can expect with your knee condition and how to safely keep active in the meantime. They can also discuss with you whether you might need the opinion of a sports doctor or a surgeon if your knee cartilage injury doesn’t respond to physiotherapy treatment, or if your injury is more significant.
Knee osteoarthritis (OA) is one of the most common chronic musculoskeletal conditions seen by physiotherapists and affects a large number of Australians. It is generally considered a degenerative condition (occurs via wear and tear). OA is a condition in which the hyaline articular cartilage thins, develops cracks and can eventually wear away.
Tell me more about knee osteoarthritis.
Hyaline articular cartilage is a special type of tissue that coats the ends of the bones located inside joints. In the knee, articular cartilage covers the ends of the femur and tibia, and the back of the patella along with its groove. It is made of cartilage cells (chondrocytes), collagen, water and various proteins. Its role is to provide a smooth, friction-free surface to allow the joint to glide, while protecting and helping transmit load to the underlying bone (subchondral bone).
OA is a condition in which the hyaline articular cartilage thins, develops cracks and can eventually wear away. This can result in a rough joint surface and reduce the cartilage’s ability to protect the subchondral bone. However, OA doesn’t just affect the joint cartilage. As OA progresses, bone spurs can form in the joint, the subchondral bone can form cysts and the menisci (washer-type cartilages within the knee joint) often develop degenerative tears. The layer of tissue that surrounds the inside of the knee joint (synovium) can also become inflamed and increase production of joint fluid, leading to swelling. All of these changes are thought to contribute to the pain and various other symptoms of knee OA.
What causes knee osteoarthritis?
The articular cartilage of the knee is kept healthy by movement and load. OA develops when the articular cartilage is either exposed to higher loads than it can withstand, often over a long period of time, or when the cartilage itself isn’t able to withstand relatively normal loads. Knee OA is therefore caused by a variety of factors. These include:
Though knee OA can affect younger people, it is significantly more common with each decade above the age of 45.
Being overweight increases the risk of knee OA, as well as the likelihood of it progressing. This is because the knee is a load bearing joint and as such, loads on the articular cartilage of the knee are relative to body weight.
Before the age of 50, men have slightly higher rates of knee OA, but after the age of 50, the rates are higher in women.
Past history of trauma or surgery to the knee (eg, ligament reconstruction)
This may lead a person to develop knee OA at an earlier age than average due to specific damage to the cartilage at the time of injury, or the strength and stability able to be regained in the knee after an injury.
Family history of knee OA
Some people may have inherited a form of articular cartilage that is less robust than average, reducing its ability to withstand load over time.
Heavily physical occupations
These can place a lot of load on the knees over many years.
Natural leg posture
For example, in a person with ‘bow legs’ the inner aspect (medial compartment) of the knee will bear more load than the outer aspect (lateral compartment). This load accumulates over the years and can cause early wear and tear of the cartilage in the medial compartment of the joint.
For example, in a person with long-term patella (kneecap) maltracking, the repeated rubbing of the patella against its groove can cause early wear and tear to the articular surfaces of the patellofemoral joint.
Especially in the quadriceps (front of thigh) muscles can contribute to increased loads being placed on the joint surfaces.
How do I know if I have knee osteoarthritis?
Knee OA has a variety of symptoms that are related to the main site of OA within the knee, the severity of the OA, the amount of strength and control a person has around their knee, as well as any other conditions present within the knee (eg, a meniscal tear). It is a diagnosis made according to a person’s symptoms and their examination findings.
Symptoms commonly include:
Knee OA symptoms commonly fluctuate, sometimes being better or worse, depending on activity. The symptoms may initially only be with activity but as OA progresses, knee pain may be experienced at rest or during the night.
Imaging techniques such as X-ray and MRI also play a role in diagnosing knee OA, though it is important to note that knee symptoms may not always match the imaging findings. Some people have quite troubling knee symptoms without much change on X-ray, whereas some people may have findings of advanced OA on their scans, though not be troubled much by pain. Treatment is dictated more by the individual person’s symptoms than their scans.
How can physiotherapy help with knee osteoarthritis?
Physiotherapy can help people with knee OA in many ways. Some physiotherapy management options are common to all people with knee OA, though many are specific to an individual’s type of knee OA, their contributing factors and their lifestyle. Things your physiotherapist can help you with include:
Education about OA
There is evidence to suggest that understanding the condition of OA helps with pain control, coping and ongoing symptom management. It helps a person be an active participant in their knee condition.
Prescribing an exercise program
Physiotherapists can tailor a program to help strengthen the muscles around the knee and improve how a person controls their knee position. This is very important, as people with knee OA commonly have significantly reduced quadriceps strength. Leg weakness results in further limitation to a person being able to continue daily activity and is linked with the progression of knee OA. Your physiotherapist is an expert in exercise prescription and, hence, can teach safe, effective forms of strength exercise for people with knee OA in ways that don’t provoke pain. Physiotherapy-prescribed exercise may also delay the need for knee replacement surgery.
Teaching strategies to allow a person with knee OA to stay active and keep participating in their daily tasks.
Advice regarding weight control
This can include exercise options, such as swimming or bike riding for maintaining healthy weight if walking is painful for a person with knee OA. The OsteoArthritis Research Society International has found that the most-effective conservative treatment for knee OA in people who are overweight is weight-loss.
Physiotherapists can discuss options for bracing and footwear that may help with knee OA symptoms. For example, some people with mainly patellofemoral OA may find forms of taping helpful, whereas those with mainly medial compartment OA may find types of offloading braces (or orthotics) useful.
Techniques such as massage may form part of a treatment program if a person has restricted flexibility in their knee (or hip or ankle) that might be placing increased stress on their knee joint.
Heat or cold
Your physiotherapist can discuss whether using heat or cold packs might provide you with some symptom relief.
Physiotherapists commonly work as part of a team including GPs, surgeons, psychologists, pharmacists, dieticians, sports doctors and surgeons. In this team setting, communication regarding a patient’s progress with knee OA treatment may include whether additional medications or specific dietary advice may be beneficial.
If a person’s OA progresses to the point of needing total knee replacement surgery, physiotherapy-led prehabilitation (a form of specific exercise training and education prior to surgery) has been shown to help patients enter surgery better prepared and recover faster.
If a person with OA does eventually need total knee replacement surgery, physiotherapists are experts in providing post-operative rehabilitation to get a person back to their best level of function.
How effective is physiotherapy for treating knee osteoarthritis?
There is good evidence to support physiotherapy management of knee OA. The main areas supported by research include:
Physiotherapy vs arthroscopy for knee OA: physiotherapy exercise and education, combined with standard medical care (simple pain medication) is equally effective to keyhole knee surgery (arthroscopy) in the management of knee OA. In people with moderate to severe knee OA, it has been found that arthroscopy added no additional benefit in terms of physical function, pain or quality of life, when compared to physiotherapy and simple medication. In addition, physiotherapy has been shown to have minimal risk of negative side effects compared to surgery.
Supervised physiotherapy exercise programs: for example, Good Life with Osteoarthritis in Denmark (GLA:D) research looked at a group of people with knee OA undertaking two sessions of control, stability and strength exercise per week for six weeks, plus three sessions of education regarding knee OA. The results included: participants needing less sick leave from work for knee pain, and reducing their use of pain medications; participants increasing their physical activity at three months and 12 months after finishing the program; participants continuing to experience a 31 per cent pain reduction at three months and a 36 per cent pain reduction at 12 months post-program respectively; 94 per cent of participants enjoyed the program and very few experienced pain flare-ups, none to the point of needing to stop training; and there was a significant improvement in knee-related quality of life and the majority of participants report using their new skills daily. This program is now available in Australia.
Prehabilitation: various studies have looked at programs of strength, movement control and cardiovascular exercise for 6–8 weeks prior to total knee replacement surgery. Most studies have found improvements in post-operative pain and function in the few months following surgery, and some have shown reductions in length of hospital stay. Some of the main reasons for these outcomes include patients entering surgery with a better baseline of physical conditioning and better mental preparedness.
What can I do at home?
It is also important that an exercise program for knee OA not cause a significant increase in knee pain while doing or following the exercises. In order to keep your knee comfortable, and to get the best results from an exercise program, particular attention to technique, leg positioning, amount of weight and range of knee movement may be required.
An exercise program for knee OA should contain a mixture of the following:
Cardiovascular exercise: this is important for maintaining overall fitness and for weight management. Commonly, people with knee OA find an exercise bike to be a good option as it’s non weight-bearing (thus not as aggravating as walking) and encourages knee movement. Cycling has the added benefit of helping flush synovial fluid around the knee, which helps keep the joint surfaces lubricated and is good for the health of the articular cartilage. Swimming is also another cardiovascular exercise option people with knee OA commonly find beneficial.
Strength exercises: this includes exercises for the front of thigh (quadriceps), buttocks (gluteal muscles), calves and hamstrings. There should be a mixture of isolated muscle group exercises (eg, calf raises onto tip toes, or hip exercises with resistance bands) and combined or functional exercises (eg, variations of squats and bridges). As a person improves with their strengthening exercises, it is important they be progressed to provide an ongoing challenge and to stimulate further improvement.
Neuromuscular exercises: this category includes exercises that work on coordination, balance and stability. This is important to help a person with knee OA learn to position their leg well to avoid excessive stress on their knee joint. This type of training also translates well into movements and scenarios encountered in daily living. Examples include exercises on ‘fit balls’ to add a stability component or various leg movements while maintaining trunk and knee alignment.
Stretching: if a person has muscle tightness placing extra load on their knee, they may be shown flexibility exercises (eg, for the calf, hamstring or front of hip).
Additionally, several other strategies form part of a program of self-management for knee OA. These include: very low-calorie diets for weight-loss (under supervision of a dietician) followed by lifestyle modification; using heat or cold packs on the knee; using simple medication (as discussed with your GP) such as paracetamol; and pacing techniques that teach a person how to modify their daily activity to avoid large flare-ups of knee pain followed by periods of inactivity.
How long until I feel better?
Although research into OA and regenerative technology is advancing, there is currently no accepted way to reverse the cartilage changes of OA and, thus, it is a chronic condition. There are many options as discussed above to manage the symptoms of knee OA in order to minimise its impact on lifestyle, however OA is a condition that does need ongoing management.
The nature of the condition is one where symptoms fluctuate and do progress over time, though a long-term management plan incorporating strength exercise, weight management and activity modification, in conjunction with simple pain medications (as required, in discussion with your GP), is the best strategy for slowing the progression of OA, managing symptoms and optimising function. In some cases, though, a surgical opinion will eventually be required to discuss the need for total knee replacement.
A ligament is made of collagen fibres organised into a thick band of tissue, like a rope. Ligaments connect one bone to another and are important stabilisers of joints. The knee joint has four main ligaments. Two are located inside the knee joint (the anterior and posterior cruciate ligaments); the others are located outside the joint (the medial and lateral collateral ligaments).
Tell me more about knee ligament injuries.
The knee ligaments can be injured when stretched suddenly and, depending on the number of collagen fibres damaged, result in a partial ligament injury (called a Grade 1 or 2 sprain or tear) or complete ligament rupture (Grade 3). Symptoms depend on the exact ligament torn and the severity of the injury, but are usually associated with localised pain, bruising and reduced movement. Injured ligaments can also present with a ‘pop’ or tearing noise, swelling and a feeling of giving way or instability when walking.
What causes a knee ligament injury?
The most common and serious knee ligament injuries include those to the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL).
Anterior cruciate ligament (ACL) injuries
An ACL injury usually occurs during cutting or twisting movements, sudden stopping, or incorrect landing from a jump (all called ‘non-contact’ ACL injuries). These movements most commonly occur in sports such as netball, football, basketball, soccer and gymnastics. Less frequently, the ACL can be injured during a tackle or collision with another player (contact ACL injury) or an awkward fall while skiing. ACL injuries usually happen when the athlete’s foot is in contact with the ground and their knee is suddenly forced backwards, or when the knee is slightly bent and collapses inwards.
Young females and people with a family history of ACL injures are statistically at a higher risk of an ACL injury. Australia has the highest incidence in the world of ACL injuries, thought to be due to the sports we play and our climate and grass types.
Medial collateral ligament (MCL) injuries
The MCL is damaged when the lower leg (tibia) is stretched outwards, causing the knee ligaments on the inner aspect of the knee to tear. MCL injuries commonly occur during an awkward landing, a tackle or fall over another player, during skiing or when a foot or ski gets caught, causing the knee to collapse inwards.
Posterior cruciate ligament (PCL) injuries
Posterior cruciate ligament (PCL) injuries are less common than either ACL or MCL injuries. The PCL may be injured during a fall onto a very bent knee, or via the knee hyperextending if a player lands against the front of the knee, forcing the shin backwards relative to the thigh bone. PCL injuries are commonly associated with cartilage injuries.
How do I know if I need have a knee ligament injury?
Symptoms will vary depending on the actual knee ligament injured and the severity of the ligament injury. Complete ACL injuries are usually accompanied by a ‘pop’ or a crack at the time of injury and are usually initially extremely painful. Most people are unable to play on and report that their knee feels ‘wobbly’ to walk on.
However, some people’s pain settles within a few minutes and they can stand, walk and even run, and sometimes return to the field, without out pain of instability. Then they try to change direction and their knee may give way. The knee usually swells up within a few hours, remains generally painful (especially at the back and outside of the knee) and feels restricted to fully bend and straighten.
MCL injuries present with tenderness on the inner aspect of the knee, slight swelling and restriction of movement, all of which vary in intensity depending on the severity of the ligament injury. A complete rupture (Grade 3 MCL) can be associated with a noise at the time of injury and a feeling of wobbliness of the knee with walking.
Posterior cruciate injuries are usually accompanied by widespread knee pain worse at the back of the knee and calf but minimal swelling unless other structures are damaged as well. Your physiotherapist, GP or surgeon can examine your knee to determine which ligament or combination of ligaments are injured and the severity of the injury and refer you for imaging if required.
How can physiotherapy help with knee ligament injuries?
Your physiotherapist can advise you on the usual management of the knee ligament you have injured, including prescribing a physical rehabilitation program. Common to all knee ligament injuries, you will need to regain your knee movement, reduce any swelling, strengthen the muscles that support your knee and regain your normal walking pattern.
A complete rupture of the ACL does not heal, so treatment involves reconstructing the damaged ligament, usually with the person’s own hamstring or knee-cap tendon, or training the surrounding muscles to try and ‘stabilise’ the knee joint.
Your physiotherapist will discuss with you your sporting goals, occupational requirements and knee function to help you decide what to do next. This will include whether you should undertake a physical rehabilitation program for a period of time to assess what level of knee function you can achieve, or if you should get an early surgical opinion for an ACL knee reconstruction. The rehabilitation program will focus on regaining your muscle strength, particularly of your quadriceps, hamstrings and hip muscles, and normalising your movement patterns of hopping, running, jumping, landing and turning to minimise the risk of knee re-injury. Ideally, you would do a 2-3 month pre-habilitation (‘pre-hab’) program prior to surgery, and how well you respond to this pre-hab provides clues as to whether you should have surgery or stick with conservative management.
Your physiotherapist may fit you with a brace, depending on the severity and grade of the MCL ligament injury, to protect the ligament while it is healing. Gentle pain-free knee movement exercises will help you regain your knee motion, and strengthening exercises for the quadriceps, hamstrings and hip muscles will help to support the knee. Taping to support the MCL will often be applied on return to sport, which varies from 2–6 weeks, post-injury, depending on the severity.
With posterior cruciate injuries, your physiotherapist may prescribe a brace for the first 4–6 weeks depending on the severity of the injury. Gentle pain-free knee movement exercises and a physical rehabilitation program, including quadriceps strengthening exercises, are important in the recovery of this injury.
How effective is physiotherapy for treating knee ligament injuries?
A recent trial in Sweden comparing a structured physical rehabilitation program, or early or delayed ACL reconstructive surgery, has shown no significant difference in outcomes of pain and knee symptoms, activities of daily living and sport and recreation function at two and five years post-injury, for recreational athletes between the treatment groups. Approximately 50 per cent of the isolated ACL patients in this study required an ACL reconstruction because their knee was still unstable, even after completing a physical rehabilitation program.
Patients generally undertake physical rehabilitation programs (with or without surgery) for 9–12 months before they are strong and stable enough to return to their previous sports. It is recommended to participate in a pre-hab program under supervision by a physiotherapist for three months prior to surgery; this allows you, your family, physiotherapist and surgeon to make an informed decision regarding early or delayed surgery, or conservative management, and also improves the outcome of surgery both physically and emotionally.
The long-term outcome of ACL treatment choices is unknown and some researchers have found a higher risk of cartilage tears when ACL reconstructive surgery is delayed. Many people continue to experience some problems with their knee following an ACL injury no matter what treatment option they choose.
Medial ligament injury (MCL)
Studies have shown physical rehabilitation is as effective as surgery for return to sport, even for complete ruptures of the MCL. The MCL is occasionally repaired surgically in conjunction with ACL reconstructive surgery. Generally, rehabilitation from MCL injury takes between 2–6 weeks depending on the severity of the initial injury.
Posterior cruciate injury (PCL)
PCL injuries are usually managed with a physical rehabilitation program, with or without a splint depending on the severity of the injury. Surgery is usually only considered if the PCL is damaged along with other important knee structures. Healing is variable depending on the severity of damage but generally from 4–12 weeks.
What can I do at home?
A physical rehabilitation program is very important for recovery from all knee ligament injuries, even if surgery has repaired or reconstructed the damaged ligament. The rehabilitation program is specific to the actual ligament damaged, the severity of damage and the sport you are returning to. You can optimise your recovery by completing the exercises specifically prescribed to you by your physiotherapist. You also need to take the recovery advice given to you by your physiotherapist or surgeon and ensure you rest and ice your knee, in addition to taking care with twisting movements that may stretch your healing ligament.
How long until I feel better?
Discuss with your physiotherapist alternative exercise and sports that are safe for you to participate in while you are recovering from your knee ligament injury.
Patellofemoral pain (PFP) is a condition where pain is felt on the front of the knee, either around or behind the patella. The patellofemoral joint is part of the knee joint, where the kneecap (patella) sits within its groove (trochlea) on the front of the thigh bone (femur). A smooth layer of joint cartilage covers the trochlea and the back of the patella to help the joint surfaces glide without friction. There are ligaments that help hold the patella centred on the trochlea, and also several muscles attaching to the patella that move it along the trochlea groove. The patellofemoral joint functions as a pulley system to help the quadriceps muscles straighten the knee most efficiently.
Tell me more about patellofemoral pain.
PFP is a condition where pain is felt on the front of the knee, either around or behind the patella. It is commonly felt with activities such as squatting, running, jumping and going up or down stairs; often limits a person’s ability to participate in their chosen activity or work; forms 25–40 per cent of all knee presentations to a sports injury clinic, and can affect people of any age, though studies have shown up to one-third of adolescents report PFP.
What causes patellofemoral pain?
Patellofemoral pain occurs due to a variety of reasons. In some cases, there is no particular trigger or injury, though in others, pain may arise after a change in knee loading (eg, suddenly increasing sporting activity, running more on hills or after a growth spurt). In other people, their PFP arises after a separate injury or surgery (eg, following an ACL reconstruction).
Though each person with PFP may have different contributing factors to their condition, there is strong evidence for the most-common reasons. These include:
Though not classically PFP, there are two other conditions affecting the patellofemoral joint that can cause pain in the same area and lead to similar functional limitations:
How do I know if I have patellofemoral pain?
PFP generally causes a fairly typical pattern of symptoms, though there is no single test used to diagnose PFP. As such, the Patellofemoral Consensus Statement says that the definition of patellofemoral pain is: pain around or behind the patella, or pain that is made worse by at least one activity involving a bent knee and body weight on the leg (eg, jumping, hopping, running, going up or down stairs, or squatting).
Though not required for a diagnosis, people with PFP also commonly experience: grinding sensations from the patellofemoral joint with knee bending, tenderness when the back of the kneecap is touched during an examination of your knee, mild knee swelling, front-of-knee pain while sitting, getting out of a chair, or on straightening your knee after prolonged sitting.
Scans (including X-rays and MRI) are not required to diagnose PFP and your physiotherapist or sports doctor can diagnose PFP with an assessment in the clinic.
How can physiotherapy help with patellofemoral pain?
One of the most important parts of managing PFP is to first have an accurate diagnosis of your knee symptoms. Your physiotherapist can ensure your symptoms are coming from your patellofemoral joint and not due to a different condition (knee osteoarthritis, a cartilage injury or a tendon condition). Following diagnosis, 2015’s evidence-based ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’ states that the key components of PFP treatment include:
This allows each person to understand their condition and their individual contributing factors in order to have realistic expectations of rehabilitation, to manage their activity appropriately, and to actively participate in their treatment.
Individually tailored treatment
This is a physiotherapy program that targets the individual person’s PFP and each of their contributing factors. There is strong evidence to support tailored physiotherapy (including exercise, education, taping and moulded shoe inserts), compared to placebo (flat shoe inserts) in the short (six weeks) and long-term (one year).
There is very strong evidence to support thigh muscle (quadriceps) strengthening exercise and growing evidence to support buttock muscle (gluteal) strength exercise. Results include large reductions in PFP and improved knee function. Good technique with exercise is important, hence mirrors and supervision can help with exercise in the short term. It is very important that a person do their home exercises regularly as prescribed in order to get the best effect. Neuromuscular control (coordination and leg positioning) exercises, especially combining hip and knee alignment, help to learn correct movement patterns. There is evidence to show benefit of trunk/abdominal and calf muscle strengthening exercise in people who have shown weakness in these areas on assessment. There is also a role for stretching, especially of hamstrings and calf muscles if these are found to be tight on assessment.
Patella taping and bracing has been shown to help provide immediate pain relief in many individuals, hence your physiotherpist can show you how to do this yourself.
Shoe inserts (foot orthoses)
These have been shown to help with short-term pain relief in patients with certain foot types. Your physiotherapist can discuss whether orthotics are suitable for you and either provide them or refer you to a podiatrist.
Massage and dry needling can be considered in people with excessive muscle tightness (eg, of the outer thigh muscles) to improve kneecap positioning and gliding.
The expert physiotherapists contributing to the Best Practice Guide discussed the potential role for retraining an individual person’s walking and running technique if required, though evidence for this is currently lacking.
How effective is physiotherapy for treating patellofemoral pain?
There is a large and growing amount of research evidence to support the use of physiotherapy in the treatment of PFP. Although this evidence can’t provide a one-size-fits-all recipe for the treatment of PFP, as each person is unique, there are definitely components of PFP management that apply to most cases and are supported by high-quality research.
The International Patellofemoral research group made six consensus statements based on the current scientific evidence and their expert opinions. These are:
The research also states that PFP treatment is most effective if a person takes an active role in managing their PFP, rather than relying on a healthcare professional to just apply passive treatment to them. If a person completes their home exercise program regularly, as prescribed, and is sensible about building up their activity gradually, this is also effective. Additionally, as PFP normally has several contributing factors, a combined physiotherapy approach best allows each of these contributors to be addressed. This may also include patellofemoral taping, bracing or running retraining.
What can I do at home?
Once you have been diagnosed with PFP there are a few important things to consider in terms of home management.
It’s important to have a good understanding of your PFP in order to appropriately manage your symptoms and activity levels. It is always better to progress daily activity and sport gradually, as sudden increases can lead to flare-ups of pain. Following pain flare-ups, people tend to completely rest and, once settled, they rapidly increase their activity again. This ‘rollercoaster-ing’ cycle of pain and activity is important to break in order to make real progress with your PFP.
In the short term, you may need to reduce certain activities that are aggravating your PFP in order to allow it to settle. This may include reducing running and jumping exercise or taking the lift instead of the stairs.
It is important that any home exercises prescribed by your physiotherapist are done regularly (as prescribed). Research has found a link between the number of rehabilitation exercise sessions done per week at home with a reduction in symptoms.
People who have a foot contribution to their PFP (flat feet) may have shoe inserts prescribed by their physiotherapist or podiatrist. In this case, it’s important to wear the shoe inserts and well-fitting shoes while you’re being active (eg, these people sometimes notice a flare-up of their PFP if they wear thongs all summer).
If your physiotherapist has taught you to tape your patellofemoral joint, you can do this yourself for pain relief (while playing sport or with daily activity).
As there is evidence demonstrating that PFP can go on for many months or even years in some cases, it’s important to maintain a good level of strength in your quadriceps and gluteal muscles to keep your patellofemoral joint functioning as well as possible and reduce the chance of your PFP recurring. As such, once you have finished treatment with your physiotherapist, make sure you have a plan for ongoing maintenance. This may include gym or home exercises to prevent losing the strength and control that you’ve worked hard to build.
How long until I feel better?
As our understanding has grown, it has become clear that PFP is not necessarily something that will disappear on its own, and some people can have episodes on and off for many years. As such, in order to have the best chance of recovering from your PFP and reducing the likelihood of it recurring, it is important to understand your condition, your individual contributing factors and what you can do.
For many people, a program of ongoing and progressive exercise (as prescribed by your physiotherapist) is necessary to build and maintain muscle strength, and good movement coordination. Additionally, there is evidence suggesting that people with PFP may have an increased risk of going on to develop patellofemoral osteoarthritis (OA). Therefore, seeing an experienced physiotherapist for a management program will help you keep your patellofemoral joints functioning as well as possible, and keep you as active as you’d like to be now and into the future.