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Knee pain

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Knee problems are a huge frustration for many, from competitive athletes to those who simply enjoy gardening, and can place unwanted restrictions on your daily life. There are many causes, but accurate management of the problem relies upon accurate diagnosis.

Osteoarthritis (OA):

A degenerative condition commonly known as 'wear and tear' of a joint. OA typically affects those over 45 and produces a pattern of fluctuating stiffness, swelling and pain. 'Wear and tear' can develop gradually over the years as a result of overuse of a joint, where the protective hyaline cartilage within the joint gradually becomes worn and the joint surfaces are left to effectively 'rub' on one another. Trauma to the joint at an earlier stage of an individual's life is thought to predispose them to earlier degeneration within that joint. Injuries such as ligament damage (for example, ACL injury) may show earlier joint changes on xray / MRI scan than the uninjured side due to the altered joint mechanics and stresses that are produced within the knee joint following such an injury. It's important to mention that not all individuals with degenerative changes within their joints experience pain or any other symptoms, and therefore osteoarthritis affects people differently.

Although there is no cure for osteoarthritis and it is a progressive disease of the joint, there are certain management strategies that can improve the symptoms, and indeed prolong the integrity of the joint.

Strengthening the muscles around the joint (the quadriceps and hamstrings), has been proven to provide increased support to the joint, thereby reducing any associated joint pain and improving its function, and prolonging the 'life' of the knee. Mick can issue a progressive strengthening programme for O.A knee, working specifically on functional rehabilitation which is specific to an individual's aims. O.A of the knee does not mean that return to sport is impossible, nor that an individual is old! Degeneration can affect individuals directly as a result of a sporty lifestyle, and therefore it should be appreciated when formulating a rehabilitation programme that exercises may need to be dynamic and be aimed at restoring a high level of functional activity.

These are often sustained during sport or from a sudden twisting injury, 'sprain', or direct blow to the joint. Common mechanisms of injury would be a forced hyperextension (over-straightening) or valgus strain of the knee (where the knee is forced to 'bow' inwards from impact to the outside of the knee), or a sudden inward twisting of the knee when the foot is fixed on the ground. Commonly injured knee ligaments include the anterior cruciate ligament (ACL) and medical collateral ligament (MCL), and less commonly the posterior cruciate ligament (PCL) and lateral collateral ligament (LCL). On occasions, injury to multiple ligaments can occur, particularly in high velocity, high impact sports such as Gaa rugby, American football and soccer. Ligament injuries may also occur with or without cartilage injuries, depending upon the mechanism and magnitude of the injury. These injuries can affect anyone of any age, and symptoms upon injury include sudden swelling, acute pain, loss of movement, instability (giving way) and altered function.

Some ligament injuries can go undiagnosed or may be incorrectly diagnosed at the time of the injury. You may find that although your knee has been diagnosed with a simple 'sprain', you are experiencing giving way or locking (getting stuck) from the knee when your leg is in certain positions or when turning whilst walking or running.

Instabilities of the knee joint that do not settle can often mean that the knee is lacking the support from a specific ligament. It may be therefore that one (or more) of the ligaments has been injured and can no longer stabilise the knee joint adequately. It is important that a knee behaving in this way is assessed fully, to establish whether or not there is a tear / rupture to a ligament that is causing the joint to lose its control.

Stabilising a knee joint through appropriate management can help to prevent further damage to the inside of the knee. Unstable knees that repeatedly give way because of previous ligament damage, can place further stresses on the knee joint, and in turn may cause damage to the cartilage of the knee.

Unstable joints with ligament damage may require conservative (non-surgical) management only, through progressive physiotherapy rehabilitation, or may require surgical intervention to reconstruct the incompetent (ruptured) ligament. Physiotherapy to manage ligament injuries with associated joint instability, involves a rehabilitation programme which focuses on gaining increased control around the knee joint by training specific muscles and improving joint 'reactions'. If joint control can be restored, there may be no need for surgical intervention.

However, it is important to point out that injuries to the ACL (anterior cruciate ligament) do often require surgical reconstruction if the aim of that individual is to return to sports such as football or . The very nature of these types of sports requires an individual to be able to suddenly twist or turn from their knees, and therefore unfortunately, even with intense physiotherapy rehabilitation, the knee joint cannot usually stabilise adequately to be able to perform at this level. Individuals with ACL injuries who intend to return to high-impact and rotational sports, do therefore tend to require surgical intervention in order to stabilise their knee joint sufficiently. Individuals who take part in sports that involve no impact, and minimal twisting such as road running, cycling and gym-based exercise, do not generally require their knees to suddenly twist or turn. If the knee can be stabilised with physiotherapy rehabilitation alone, and your sport involves 'straight line' movement only, there may be no need for any surgical procedures.

Post-surgical physiotherapy management following specific rehabilitation protocols is essential in order to have the best outcome. Ligament reconstructive surgery provides the essential internal 'structural' support to the joint, and the physiotherapy then retrains the movement, muscles strength and joint 'position sense' whilst respecting the healing rates requirements of the surgical procedure carried out.

Post-operative rehabilitation may require several sessions of physiotherapy spread out over a number of months, the latter stages of which can focus on safe return to sport, including high impact and rotational (twisting) sports.

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