Physiotherapy management of some common knee problems
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The document outlines the physiotherapy management of common knee problems, emphasizing contemporary treatment models for conditions like osteoarthritis, tendinopathies, and ligament injuries. It discusses necessary rehabilitation phases, exercise recommendations, and various management strategies aimed at restoring function, preventing re-injury, and optimizing patient outcomes. Key recommendations include self-management, weight loss for patients with osteoarthritis, and the importance of pre-operative and post-operative physiotherapy for conditions like ACL tears.
Physiotherapy management of some common knee problems
- 1. Knee Talk Physiotherapy Management of Common Knee Problems Cameron Bulluss c.bulluss@advancedphysio.com.au
- 2. Take • ROM Brace • EMG • Goniometer • Ipad • Clinical Sports Medicine • Business Cards • Compex
- 3. Useful Resources • AAOS website www.aaos.org • Advanced physio website www.newcastle-physiotherapy.com.au/newcastle-physiotherapy- referrers/patient-handout-sheets
- 4. Pre-requisites for effective knee rehabilitation • Interest in this area • EMG • Rehabilitation area • HD slow motion video • Regular review • Access to braces, splints if needed
- 5. Contemporary Physiotherapy Model • Diagnosis • Goal setting • Pain Management and education • Protection of Injured Structure • Psychosocial Management • Restoration of Movement • Restoration of Motor control and Strength • Restoration of Proprioception • Prevention of Re-injury • Ergonomics and biomechanics • Fitness and functional testing
- 6. Modern Physio Skills • Pathology and diagnosis • Anatomy, functional anatomy and biomechanics • Manual therapy • Strapping • Psychology • Goal Setting and communication • Strength and conditioning • Fitness and functional testing • Literature searching and evaluation
- 7. Phases of Treatment • Acute • Functional Recovery • Prevention
- 9. Subchondral Bone • Much of the pain comes from the subchondral bone (Hunter 2009 Radiological Clinics North America 2009 (539 -531)
- 10. Osteoarthritis • Acute Phase • Protect injured structures • Strapping, Bracing, Crutches • Modalities for pain relief – ?TENS, ?Ultrasound • Advice/Education
- 11. Osteoarthritis • Functional Recovery Phase • Exercises and Mobilisation to restore range of motion • Exercises to restore local muscle function in particular quadriceps (especially VMO) • Exercises to restore other muscles – load sharing throughout kinetic chain • Advice and Education • Substitution of impact activity for lower impact
- 12. Osteoarthritis • Prevention • Exercises to strengthen whole kinetic chain • Instruction in non-risky exercise • Weight loss measures • For every 2 units of BMI increase there is a 36% increase in the risk of developing knee OA • For every 5 kg decrease in body weight during the preceeding 10 years the risk of OA of the knee declines by more than 50%. (MJA 2004)
- 13. Weight Loss Programs • Diet + Exercise • Exercise needs to be of a low impact nature • Low-med intensity bike • Swimming • Upper body • ?walking
- 16. AAOS Recommedations for OA Knee • RECOMMENDATION 1 • We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines. Strength of Recommendation: Strong
- 17. AAOS Recommendations for OA Knee • RECOMMENDATION 2 • We suggest weight loss for patients with symptomatic osteoarthritis of the knee and a BMI ≥ 25. • Implications: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.
- 19. Tendinopathies • Most are tendinoses • Most Common one in the knee is patellar tendinopathy • Not self limiting (Young et al 2005) • As with all other tendinopathies the greatest risk factor for patellar tendinopathy is Adiposity (Gaida 2009) • And this includes rotator cuff tendon pathologies
- 20. Physiotherapy Treatment of Patellar Tendinopathy • BMI optimisation • Rest is not always required • Improve biomechanics and technique • Exercises to produce adaptive changes in the tendon • 100 days to produce a new tenocyte • 3 – 12 months to treat a tendon
- 22. Anterior Cruciate Ligament Tears Common • 50% of patients will have OA changes at 10 years • Natural history • Reconstruction dependent on • Degree of functional instability • Physical condition of rest of knee • Age of patient • Ability or willingness of patient to undergo 12 months rehabilitation • Surgical Philosophy
- 23. Pre-operative Physio • Restore range of motion • Improve function • And will result in lower post surgical morbidity • Faster Recovery
- 24. Post-operative Physiotherapy ACL Tear • 6 -12 months • Approximately 150 rehab sessions to restore range, strength and neuromuscular control of which approximately 20 - 30 should be fully supervised • Preventative program very important • PEP • FIFA 11+
- 25. Anterior Cruciate Ligament Injury Prevention – PEP program Santa Monica Orthopaedic and Sports Medicine Research Foundation • 1041 female subjects, RCT • Results: During the 2000 season, there was an 88% decrease in anterior cruciate ligament injury in the enrolled subjects compared to the control group.
- 29. Collateral Ligament Tears • Medial Collateral ligament is most common • These do not require reconstruction in most cases and will heal well with a conservative approach in 4 – 16 weeks
- 30. Show ROM Brace
- 31. Acute Meniscal Tears Adolescent • Place on crutches NWB and refer for immediate orthopaedic opinion • These are repairable in some situations if seen early Adult • Unless acute locked knee (indicating bucket handle tear) , refer to Physio with concurrent orthopaedic referral
- 32. Degenerative Meniscal Tears • Older patient (> 45 yo) • Slow onset of symptoms • Trial 6 weeks of Physio first • Strengthening • BMI/adiposity optimisation • Menisectomy followed by 6-8 weeks of exercises if conservative care fails
- 33. Meniscal Tear with Osteoarthritis – Evidence • Katz (2013) 351 patients Surgery + Physio and Physio Only • Both groups showed improvement, but not statistically significant • 35% of Physio only patients elected for surgery due at 12 months • Surgery is always an option but 65% may not need it • Even if they do pre-operative Physio is likely to assist surgical outcomes
- 34. Patellofemoral Pain • Variety of causes • Generally Physiotherapy referral will suffice and treatment typically consists of • Quadriceps strengthening • Stretching exercises • Patella tape • Biomechanical correction • Hip strengthening • Correction of sporting technique