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A large number of people suffer from knee pain . Our work in the Cambridge Osteopathic Clinic, working with a vast range of physical capabilities, and our athlete work in London, allows us to have very positive contact with such symptom sufferers.

In fact, knee pain (including knee arthritis pain) is currently a common musculoskeletal illnesses, and the burden is most likely underestimated. Musculoskeletal illnesses are believed to generate some of the highest costs to society.

Diagnosis

Some of the most commonly ‘diagnosed’ issues leading to an episode (acute), or multiple episodes (chronic), of knee pain, with or without ‘swelling’ (filling of the knee joint and capsule or fluid around the joint area) are:-

‘Runners knee’ (Patello-femoral pain syndrome (PFPS)), functional instability, chondromalacia patella, ‘housemaids knee’, Osgood schlatters, motor control imbalances, patella tendonitis, ligament sprain, muscle strains, muscle spasms, over use syndromes, degeneration, arthritis, cartilage / meniscal injury, ‘knee sprain’, ‘bakers cyst’, ‘bursitis’, ‘inflammation’, ‘knee pain’, ‘jumpers knee’, ‘iliotibial band syndrome’ (ITBS), anterior cruciate ligament injury (ACL), ‘dislocated knee cap’, ‘subluxed knee cap’, ‘wear and tear’, ‘anterior knee pain’, mechanical knee pain, ‘twisted knee’, knee stiffness, knee swelling, fluid on the knee, ….The list goes on!

The quality of some of these diagnosis concepts, and the actual correlation to your pain, are even more fascinating!

How This May Affect People

When this doesn’t go well, it often leads to a very dissatisfying outcome. This can manifest itself as: deconditioning, disability development, depression, loss of confidence in yourself and your body, which ultimately often leads to a dependency on pain altering medications, and poorer physical health.

So, what are we to do? Are we to:- be immobile?, be mobile?, be active?, or minimally active?, train into pain (‘no pain no gain’)?, or train avoiding pain?, stretch the knee?, or no stretching of the knee?, use medication management?, topical or oral?, use massage?, use mobilisation?, Osteopathy or chiropractic or physiotherapy?, use prescriptive exercise?, regular treatments or minimal treatments?, have imaging or not to have imaging?, surgery?, should we focus on structure or function?, or is it just age?!!!

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I am very grateful for all the help and advice I have received from Michael Parr. A friend of mine recommended him when she heard that I had problems with my knees, resulting from osteoarthritis. Michael guided me through an exercise and diet regime, which led to a remarkable improvement of my condition. He is a dedicated and skilled osteopath; the best in Cambridge! I can highly recommend him.

Investigations

Our understanding of the knee, including its anatomy, is still changing and evolving. Even the ligament structures of the knee, are being reclassified, as functional roles and anatomical normality become clearer.

This ever changing landscape of knowledge, shows how we cannot continue old approaches which did not work well then, and expect a better outcome now!

Imaging

Sometimes additional investigations are needed. However, for ‘non-specific knee pain’, they are rarely needed as a primary input into your assessment and treatment.

Imaging was originally seen by most, as a tool to rule out pathology or disease states, and less to diagnose specific musculoskeletal causes. Often this was due to a poor correlation of images and symptoms

New imaging approaches have developed, and our dependency on them increased.

General Imaging

However, recent studies show that by performing a thorough clinical case history and physical examination you can often, very effectively decide if MRI or additional imaging or other investigations are needed.

There are also recent studies that show that MR Imaging (MRI), may actually increase the patient’s likelihood of continuing in pain or disability status, and elongate their symptom picture.

MRI

When looking at those who are not injured (uninjured), and asymptomatic (no pain or symptoms), there is a prevalence of image findings of up to 44 percent in adults aged 40 and over. Cartilage defects were seen, meniscal tears found, bone marrow lesions present, and osteophytes identified. For most of these the presence of changes seen in mri increased with age. Showing that MRI findings and x-ray Image findings of changes in the knee may not correlate with symptoms. A significant amount of people without symptoms will have all the same findings.

Therefore, magnetic resonance imaging (MRI) requests are reserved for complex or doubtful cases.

MR imaging can help in acute injures, such as ligamentous and bony trauma, and after physical examination where ligament disruption diagnosis, imaging can be helpful in demonstrating the extent of associated injury to local structures, such as cartilage and meniscus injuries.

However, it never substitutes for a good physical examination and case history.

X-Ray 

X-ray could be performed in cases of acute knee injury. A large amount of images performed are found to be normal. The main aim for a classic radiograph (x-ray) is to assure no fracture is present. For children, they also help show other changes.

Ultrasound 

Ultrasound examination can help detect complete and partial patellar and quadriceps tendon tears, bursal swellings (bursitis), and identifying where the placement of the swelling.

Degeneration and Osteoarthritis

Studies show as well as x-ray images, MRI investigations are also poor methods at assessing causal patterns of pain. This is due to the large number of asymptomatic findings. Imaging findings looking at osteoarthritis in people with knee pain, has been found to have no correlation between the pain and osteoarthritis.

Then there are studies showing that degeneration changes, are just a part of function and use. These however, have no correlation with pain, or perceptions of illness, or illness behaviour i.e. age and degenerative changes have no clear causal link with pain. There is evidence that radiographic findings of the knee, cannot always be associated with knee pain. Additionally, there may be more relevant things to assess for a productive diagnosis.

Anterior Cruciate Ligament (ACL)

MR imaging as well as a focused clinical examination can help determine what extend of ligament disruption is present.

Posterior Cruciate Ligament (PCL)

‘Following the history and physical examination, radiographs and magnetic resonance imaging (MRI) are often used to assist in the diagnosis. Stress radiographs have been shown to be particularly helpful with both the initial and follow-up diagnosis because of reliable reproducibility and objective assessment of posterior translation. Moreover, examination under anesthesia and arthroscopic evaluation are also critical in the work-up of PCL injuries’. 

Meniscal Tear

MR imaging as well as a clear clinical examination can help determine what changed are present.

Bursitis

Ultrasound imaging is often useful for assessing bursal swellings (bursitis) of the knee and surrounding tissues.

Patellar Tendinopathy

For patellar tendinopathy, ‘while imaging may assist in differential diagnosis, the diagnosis of patellar tendinopathy remains clinical, as asymptomatic tendon pathology may exist in people who have pain from other anterior knee sources. A thorough examination is required to diagnose patellar tendinopathy and contributing factors’

Patellofemoral Pain

One study found that ‘there was no difference in composition of the patellofemoral cartilage, estimated with multiple quantitative MRI techniques, between patients with PFP and healthy control subjects’.

‘Imaging of the patellofemoral joint (PFJ) is useful to evaluate for injury and to better understand the relationship between osseous and soft tissue structures. Interpretation of PFJ imaging findings should be used in the context of patient’s history and physical examination. X-rays and advanced imaging technology can provide information to confirm diagnosis and to help customize individual treatment plans’.

Medial Collateral and Lateral Collateral Ligaments

Advanced imaging can be used to augment a history and examination when necessary, but should not replace a thorough history and physical examination.

 

Physical Assessment

Physical assessment by a clinician is vital in all cases of knee pain.

Practitioners should always screen the ‘biomechanics in both limbs to identify aberrant mechanics’.

In younger patients with knee pain, the patient often may see an incomplete recovery as an acceptable outcome. However, this does not then allow for a return to play at the same standard as originally seen, and perhaps indicating that often the return to play is not at the same standard as perceived. All those who wish to return to play following injury, should pass relevant functional activities tested, and some clinicians testing selection could perhaps improve, to ‘better inform meaningful outcome measurement’, allowing the younger patient to find full recovery as a desirable standard.

During a drop-landing task, the landing sound level heard, can indicate the level of forces transferring through and the amount of motion occurring and the knee joint.

Degeneration and Osteoarthritis

Symptomatic osteoarthritis (OA) of the knee ‘causes substantial physical and psychosocial disability’.

In very late stage osteoarthritis, results have found an associations between co-morbidities (the presence of one or more additional conditions co-occurring), performance-based and self-reported physical functions, and quality of life in patients. Which showed an independent association with pre-sarcopenia (decrease in muscle mass that increases frailty and falls) and diabetes. Testing for pain revealed significant association with degenerative spine disease. This all indicates that it Is not the osteoarthritis alone which leads to symptoms being present.

Anterior Cruciate Ligament (ACL)

The clinical ‘provider training and the tests performed play a role in the accuracy of diagnosis of anterior cruciate ligament (ACL) injuries’. Clinically, ‘it is recommended performing at least two different examinations’.

During sports that have repeat jumping and landing, the most common injured area is to the knee and ankle. Of those injuries, ‘Sprains and ligament damage were the most common type of injury’. Indicating that injury prevention polices should be used.

There are findings which indicate factors affecting knee abduction (the movement of the knee in a direction that can cause injury) during weight-bearing activities in individuals with anterior cruciate ligament reconstruction. Showed less knee flexion/extension strength predicts more knee abduction in women with anterior cruciate ligament reconstruction (ACLR). The iliocostalis muscle (lower back muscles) activation predicted peak knee abduction in hop landing in women.

Posterior Cruciate Ligament (PCL)

‘Posterior cruciate ligament (PCL) tears most commonly result from motor vehicle collisions or sports-related trauma’. ‘The most frequent mechanism of injury is a posteriorly directed blow to the anterior proximal tibia’. ‘Multi-ligament knee injuries involving the PCL are much more common than isolated PCL tears’. ‘The work-up must always begin with a complete history and physical examination. A multitude of special tests have been described to assist in diagnosing PCL injuries and associated medial and lateral ligament damage’.

Meniscal Tear

Meniscal and ligament injuries can be diagnosed through careful physical examination.

‘When treating meniscal tears, it is likely important to take the aetiology of the tear into account. Tears are typically categorised as traumatic or degenerative. Traumatic tears are most often observed in young sports active individuals and present as a tear to an otherwise healthy meniscus. Degenerative lesions are more common in middle-aged and older individuals and considered to be an early sign of knee osteoarthritis’.

Patellar Tendinopathy

A thorough examination is required to diagnose patellar tendinopathy and contributing factors. ‘The hallmark features of patellar tendinopathy are (1) pain localized to the inferior pole of the patella and (2) load-related pain that increases with the demand on the knee extensors, notably in activities that store and release energy in the patellar tendon.’

Patellofemoral Pain

Following lateral patellar dislocation the risk for recurrent instability after primary patellar dislocation can be assessed clinically.

It is clinically possible to perform measuring of the maximum pain-free flexion angle with a performance test in patients with patellofemoral pain. The decline step-down test is a reliable and valid performance-test evaluating knee function in patients with patellofemoral pain. This test supports the set-up of treatment strategy and evaluation of treatment sessions.

Women with patellofemoral pain syndrome (PFPS) ‘exhibited greater pain, worse functional capacity and body balance’. ‘Moderate correlation between both balance tests suggests the use of SEBT’. Which may ‘highlight the importance of clinical diagnosis with regard to postural balance’.

It has been found that the ‘hip rate of force development and strength are impaired in females with patellofemoral pain without signs of altered gluteus medius and maximus morphology’. Females with patellofemoral pain (PFP) have ‘deficits in isometric strength’ and rate of force development (RFD) in hip abduction and hip extension. ‘RFD deficits are greater than strength deficits which may highlight their potential importance. Hip muscle strength and RFD deficits do not appear to be explained by muscle thickness or proportion of non-contractile tissue of the gluteal musculature’.

Medial Collateral and Lateral Collateral Ligaments

‘A thorough history and physical examination of the knee facilitates accurate diagnosis of ligament injury. Several examination techniques for the knee ligaments that were developed before advanced imaging remain as accurate or more accurate than these newer imaging modalities’.

The ‘medial collateral ligament is most commonly injured but injury to the anterior cruciate ligament is most often highlighted in the media due to its prevalence in sports’.

When looking at football related injuries, during the latter stages of match-play and the prevalence of knee joint and hamstring muscular injury. It was found that in fatigue, there are changes in eccentric hamstring strength and knee joint position, showing ‘concurrent changes were observed in knee joint kinematics’. Where ‘knee varus at landing increased with fatigue.’ The conclusion of this was very interesting, ‘The coincident impairment of eccentric hamstring strength and increased knee varus at touchdown predisposes the player to injury, supporting epidemiological observations. Knee varus in these elite male players is in marked contrast to the valgus associated with ACL injury risk in female players’.

What Can Help

For lower extremity injury, ‘Prevention of injury remains an important goal for clinicians and researchers’.

Surgery

For some knee conditions, such as meniscal tears and osteoarthritis, the common indoctrinated approach has been to look at surgical measures. However, these perhaps should only be looked at as options when all other methods have not helped. Recent studies show that those who have knee surgery, do not have a better outcome, than those who perform manual therapy and exercise.

Pre-Surgery and Post-Surgery Rehabilitation

When people do undergo surgical intervention of the knee, initially at least, their sex may have a relationship with muscle strength loss and recovery time. After Total Knee Arthroplasty (TKA / knee joint replacement), men and women demonstrate differences in early functional recovery. Early recovery of muscle and physical function in the first month after TKA. ‘Women demonstrated better preservation of quadriceps strength but a greater decline on measures of physical function than did men’. Such aspects need to be understood when implementing a post-surgical rehabilitation programme (knee surgery physical rehabilitation).

When surgery is then an option, having performed corrective manual therapy and exercise, leads to better recovery post-surgery. This shows the ever important need for individual adaptive assistance in preparation and recovery of surgical interventions.

‘Preoperative supervised neuromuscular exercise for 8 weeks was found to be cost-effective in patients scheduled for THR and TKR surgery’, in addition to the finding that one-year clinical effects were statistically significant for quality of life measures.

Following a full quadriceps tendon rupture, early surgical treatment and subsequently a well-structured rehabilitation exercise program can be introduced, in order to ensure rapid recovery and good functional outcomes.

 

Osteopathic Treatment

Manual therapy has been shown to help with knee pain, and protocols can be developed to assist.

Exercise Therapy

Exercise has been shown to help with knee pain (including patellofemoral pain syndrome and osteoarthritis), interestingly these studies do not recommend surgical interventions.

Combination Therapy

More importantly it seems, combined therapy (multimodal therapy) of exercise and osteopathy has an even greater role.

Also, there is evidence indicating that ‘knee specific exercises’ are significantly better for quality of life than an untreated person, with improved symptoms, and more positive outcomes than for those placed on waiting lists for assessments and treatment. However, localised knee training, may only lead to short term outcome measures.

Trigger point dry needling, combined into a multimodal therapy program for patellofemoral pain with manual therapy and an exercise programme, did not result in any additional improved outcomes from that of manual therapy and exercise therapy alone, for pain and disability in individuals with patellofemoral pain.

 

Degeneration and Osteoarthritis

There is evidence, assessment and then treatment of knee osteoarthritis (OA) ‘could be planned according to the clinical features and functional status instead of radiological findings’.

Osteopathy has research data that shows that knee pain is a common presenting issue, for people seeking osteopathic assistance, showing very positive outcomes and satisfaction levels

Exercise therapy has been shown in research to reduce knee pain symptoms, and help restore normal daily activity. More importantly, it seems to have a preventative role.

Interestingly, ‘Age, family history, and surgical history independently predicted an increased risk for hip and knee arthritis in active marathoners, although there was no correlation with running history’. They actually found that ‘the arthritis rate of active marathoners was below that of the general U.S. population’.

There is no need to stop being active just because of some osteoarthritic changes. In fact, ‘individuals 50 years old and older with knee OA, self-selected running is associated with improved knee pain and not with worsening knee pain or radiographically defined structural progression. Therefore, self-selected running, which is likely influenced by knee symptoms and may result in lower intensity and shorter duration sessions of exercise, need not be discouraged in people with knee OA’.

Knee cartilage is not a structure to be avoided. Clinical led therapeutic exercise is good for knee cartilage, not harmful. One study stated ‘Therapeutic exercise relieves pain and does not harm knee cartilage nor trigger inflammation’.

This finding supports how there is evidence to link marathon running with knee joint health, with the finding that there was an ‘Improvement to damaged subchondral bone of the tibial and femoral condyles was found following the marathon in novice runners’.

Meniscal Tear

There are many aspects to appreciate when looking at the treatment of meniscal tears.

Meniscal injury is associated with increased rates of osteoarthritis, and joint replacement surgery.

When comparing treatment approaches of ‘Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis’, no ‘significant difference was seen between the study groups in functional improvement 6 months after’. Only 30% of the patients who were assigned to physical therapy then went on and underwent surgery within 6 months.

Recent evidence has challenged the clinical dogma of surgery as treatment for meniscal tears in patients aged 40 years or older, with exercise therapy emerging as a valid treatment alternative.

Exercise therapy showed positive effects over surgery in improving thigh muscle strength.

In another study clinical improvements were seen after four to ten weeks, into a 12-week supervised exercise therapy program for young adults with a meniscal tear. Therapist supervision was considered important. No patients wanted surgery up to 6 month after the exercise therapy program.

Anterior Cruciate Ligament Sprain and Tear

Prevention is far more important than management after injury.

Post surgically, ACL Strain and Tensile Forces for weight bearing and non—Weight-Bearing Exercises After ACL Reconstruction have been assessed. ‘The biggest challenge in exercise selection post-ACL reconstruction is the limited knowledge of the optimal amount of stress that should be applied to the ACL graft as it goes through its initial incorporation and eventual maturation process’. Luckily, ‘there is a growing body of evidence documenting loads applied to the anterior cruciate ligament (ACL) for weight-bearing and non—weight-bearing exercises’.

What is great news is when looking at horizontal jumping biomechanics, of those with and without anterior cruciate ligament reconstruction, those who previously had an ACL repair and then managed to rehabilitation to the top level of sports participation (elite player levels) do not seem to possess lasting biomechanical and/or performance deficits 6 years after the original surgical ligament repair.

Perhaps indicating that to get back to elite levels again, we need to ensure a person performs their physical rehabilitation all the way up to the standards they desire.

Progressive strength training restores quadriceps and hamstring muscle strength within 7 months after ACL reconstruction. When looking at soccer players after anterior cruciate ligament reconstruction (ACLR), and they showed good self-reported knee function at 10 months. However, it is worth noting that only sixty-five percent of soccer players after ACLR passed the limb symmetry index threshold of over 90 percent, for quadriceps muscle strength at 10 months.

When there is a rupture of the ACL, there is a need to decide if you would prefer surgical versus conservative interventions for treating anterior cruciate ligament injuries. In young, active adults being treated for acute ACL injury, a study ‘found no difference between surgery and conservative treatment in patient-reported outcomes of knee function at two and five years’. However, ‘many participants with an ACL rupture had unstable knees after structured rehabilitation and opted to have surgery later on’.

What is known is that ‘preserving the meniscus should be a key priority when managing ACL-injured individuals’. The ‘studies highlight the importance of managing ACL injury early to preserve joint health’.

However, ‘they do not provide evidence that early reconstruction is superior to ‘evidence-based rehabilitation’ in reducing subsequent meniscus or cartilage injury rates.’

Furthermore, this common belief that ‘early ACL reconstruction is required to prevent additional knee injury’, is a ‘misconception not supported by high-quality evidence’.

Sometimes a little time to stop and think before deciding most suitable path of care is best.

Reassuringly, there may be indicators of no real rush as ‘In young, active adults with acute ACL tears, a strategy of rehabilitation plus early ACL reconstruction was not superior to a strategy of rehabilitation plus optional delayed ACL reconstruction. The latter strategy substantially reduced the frequency of surgical reconstructions’.

This has been supported by longer periods of assessment that found after a longitudinal assessment of 5 years. That ‘a strategy of rehabilitation plus early ACL reconstruction did not provide better results at five years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear’.

There are many different rehabilitation protocols for post-operative care, including anterior cruciate ligament reconstruction (ACLR).

There also some great guides to exercise selection for ‘Anterior Cruciate Ligament Strain and Tensile Forces for Weight-Bearing and Non–Weight-Bearing Exercises’.

Posterior Cruciate Ligament Sprain and Tear

A women’s menstrual cycle has an effect on ligament injury risks. Indicating a need to train well, train smart, and control the forces through the knee to reduce the risk.

Medial and Lateral Collateral Ligament Sprain and Tear

The ‘mechanism of injury, diagnosis and treatment are based on physical exam as well as imaging. Treatment and overall outcome depends on type of injury and time from the lesion’.

‘Surgical management involves restoring specific anatomy and biomechanical properties of these ligaments’.

‘Rehabilitation is tailored to the specific injury pattern and should be individualized for each patient with the hope to provide a stable functional knee’.

Patellar Tendinopathy

Management of patellar tendinopathy should focus on progressively developing load tolerance of the tendon, the musculoskeletal unit, and the kinetic chain, as well as addressing key biomechanical and other risk factors’.

‘Proprioception plays a role in optimising movements and reducing load to joint-related structures like tendons and ligaments, it is considered an important protection mechanism’. ‘Poor proprioception can be a risk factor for (re)-injury’. The use of a patellar strap provided a small change in proprioception in athletes with patellar tendinopathy.

Patients with patellar tendinopathy have decreased pain in response to resistance training (resistance exercises). They included high load isometric resistance exercise (isometric exercises) or dynamic resistance exercise (dynamic exercises). The contraction mode may not be the most important factor in determining the magnitude of pain relieving effects. Guided exercise selection for acute pain management, can draw on both methods.

Patellofemoral Pain

For some time Vastus medialis obliquus (VMO) retraining or graduated loading programme for patellofemoral pain, have been common. As research ‘identified imbalance in vasti activation in people with patellofemoral pain (PFP) and that vasti retraining programmes could restore motor control and improve outcomes’. ‘However, it might be time to revisit this paradigm’. Vastus medialis obliquus (VMO) onset delay is sometimes evident in people with PFP, however, it is not present in everyone with this condition.

This may mean we need to start to look at the larger picture, and how we can assist more of the population who suffer from symptoms of patellofemoral pain syndrome.

Whole Body Integration

Then we can start to look at more global motor patterns, and treatment plan.

There is a large paradigm shift in how we treat musculoskeletal health. Studies are now concluding, that ‘compared with usual care, a structured education and neuromuscular exercise program improves physical function, quality of life, and the ability to perform activities of daily living’. That ‘compared with usual care, this type of program improves pain’, and that ‘compared with patient education, a structured education and neuromuscular exercise program improves pain and physical function’.

In addition, these structured ‘education and neuromuscular exercise program may be cost-effective for the nonsurgical management of knee osteoarthritis’. Furthermore, ‘structured education and neuromuscular exercise programs are perceived favourably by people with hip and/or knee osteoarthritis’.

The right care can have a very large impact on people’s quality of life. Guideline focused studies with the application of evidence-based education and supervised neuromuscular exercise, have found that for the treatment of knee and hip osteoarthritis in clinical care, there is an ‘improved pain intensity and quality of life’, ‘physical function and physical activity improved’, ‘fewer patients took painkillers following the treatment, and fewer patients were on sick leave at 12 months’.

A dynamic exercise therapy ‘balance training program for people with knee osteoarthritis significantly improved self-reported knee pain, physical function, and fear of movement’.

Foot exercises and combined orthotic use is more effective than knee exercises for patellofemoral joint pain (PFJ pain).

A ‘single session of gait retraining using a 10% increase in step rate resulted in significant improvements in running kinematics, pain, and function in runners’ with patellofemoral pain (PFP). These improvements were maintained at 3-month follow-up.

However, when looking at Lower limb kinematics and muscle activation, these improvement of pain symptoms and functional scores, perhaps are ‘not accompanied with significant biomechanics differences that could entirely explain this clinical improvement after the intervention’. Some of the change could be related to improved neuromuscular motor control and motor timing, as another study noted that ‘gait retraining reduced the muscle activity during stance phase and increased during the late-swing’.

There are a number of identifiable global kinematic (global movement) contributors to common running injuries. Injured runners demonstrate ‘greater contralateral pelvic drop (CPD) and forward trunk lean at mid-stance and a more extended knee and dorsiflexed ankle at initial contact’. The contralateral pelvic drop (CPD) was found to be the most important variable predicting the classification of participants as healthy or injured. As the researchers stated ‘CPD appears to be the variable most strongly associated with common running-related injuries.’

Components of core stability are risk factors for lower extremity injuries, and ‘clinicians are encouraged to evaluate core stability when screening an athlete’, due to the relationship between core stability and injuries.

Interestingly, you can also help reduce knee pain by treatment of other areas of the body. If this helped reduce the knee pain…. Maybe the knee pain was secondary to another problem, seemingly ‘unrelated’?!

‘Exercise therapy, has been shown to be effective in the treatment of patellofemoral pain, although some patients continue to experience pain and dysfunction despite treatment. To address this, recent research has started to investigate the lumbo‐pelvic and hip girdle in patellofemoral pain’. These studies have started to find that, ‘proximal interventions provide relief of pain and improved function in the short and long term and therefore physical therapists should consider using proximal interventions for treatment of patellofemoral pain.’

Patellofemoral pain can be reduced with proximal hip muscle strengthening. Progressive training ‘targeting proximal muscle strength and power’, it was found that a ‘12-week progressive resistance training program targeting proximal muscle strength and power is feasible and associated with moderate-large improvements in pain (reduced pain and symptoms), function, and hip muscle capacity in people with patellofemoral pain (PFP)’ Indicating that when looking at an exercise-therapy program for the knee, the increases in hip muscle capacity, including dynamic strength and power, are a very useful approach.

In women with patellofemoral pain syndrome (PFPS) the effects of core neuromuscular training on pain, balance, and performance was assessed. With the study finding that a ‘4-week core neuromuscular training plus routine physiotherapy exercise was more effective than routine physiotherapy exercise alone for improving pain, balance, and functional performance in individuals with PFPS’.

As prevention is far more important than management after injury, we need to look at all the options to help prevent injury of the Anterior cruciate ligament.

Verbal and visual augmented feedback can improve learning of safer ways to perform high ACL injury risk movements. Additionally, am individualised approach to this training is recommended.

Anterior cruciate ligament injury reduction training programs work! They are seeing a reduction of injuries of non-contact ACL in females by half. Most importantly motor control is key. One study states, ‘conclusive evidence that ACL injury prevention programs reduce the risk of all ACL injuries by half in all athletes and non‐contact ACL injuries by two‐thirds in female athletes’.

‘Neural alterations after anterior cruciate ligament reconstruction (ACLR) may initiate a maladaptive neurocognitive response (learned helplessness [LH])’. ‘LH is related to both measures of physical function and neural outcomes and varies across recovery’.

Sadly, a prior history of anterior cruciate ligament (ACL) reconstruction is associated with a greater risk of subsequent ACL injury. In female athletes with a prior history of ACLR, they were 6 times more likely to experience an ACL injury than controls. Suboptimal performance on a battery of tests was also associated with a greater risk of lower quadrant injury. However performance on these tests was not associated with ACL injury. Indicating that perhaps other aspects are at play regarding the ACL subsequent injuries.

Even 1 year of ACL reconstruction ‘young women display weaker quadriceps less able to generate torque quickly compared to men’ (women displayed bilateral quadriceps weakness and slower involved limb quadriceps RTD). The ‘female participants experience reduced neural drive and contractile capacity’.

‘Focus on facilitating quadriceps hypertrophy and improving neural drive to the quadriceps is indicated when treating female patients attempting to make a return to sport after ACLR’.

Perhaps, heavy resistance and eccentric exercises may be required, ‘to promote muscle hypertrophy and enhance neural drive’.

There is a need to understand this further, kinesiophobia (fear of movement) after ACL reconstruction is often present. Greater kinesiophobia was associated with worse clinical outcomes after ACLR. Greater kinesiophobia was associated with lower hamstrings strength, poorer performance on hop performance, and patient-reported function. 

There may be some undesirable consequences from surgical ACL reconstruction. It seems that when assessing postural stability and regulation, between before and after anterior cruciate ligament reconstruction (ACLR). That ACLR patients showed significant improvements (pre-operative vs. two-year postoperative) in several areas of postural regulation. They also found that it can take up to two years post-surgery to improve load distribution of the foot again. The study concluded ‘ACLR and rehabilitation influence postural subsystems, postural stability, weight distribution and foot synchronization. Normalization of mediolateral weight distribution requires one year following ACLR’. Additionally, and most importantly, that ‘the ACLR leads to a suppression of the somatosensory and cerebellar system which was compensated by a higher activity of the visual and nigrostriatal systems’.

Indicating there is a large amount of whole body, neuromuscular changes, that need whole body neural and neuro-motor retraining following reconstruction.

Postural stability deficits may contribute to ACL re-injury when athletes return to sport. The good news is, there are indicators to suggest that post-ACLR rehabilitation programs, may have the capacity to adequately restored postural stability.

Studies focusing just on this, found that when assessing trunk and hip control neuromuscular training (NMT) to target inter limb asymmetry deficits associated with anterior cruciate ligament injury, that dynamic stability and limb symmetry index (LSI) deficits are the most critical risk factors for ACL injuries in female athletes. Suggesting the implementation of NMT programs to teach female athletes safely landing techniques to prevent ACL injuries. As the NMT program could decrease associated risk factors for non-contact ACL injury by altered neuromuscular control. Thus, prevent ACL injury and enhance performance in athletes by improving limb deficits (LD). They found that, a significant improvement was observed in the neuromuscular training (NMT) group ‘for the peak torque and time to peak torque in hip and knee muscles in both concentric and eccentric states’. With the conclusions that, an ‘NMT program can significantly improve muscle strength, hop tests scores, and the inter limb asymmetry’, and that ‘NMT may be used in ACL prevention in those with lower limb asymmetry’.

Ankle motion is the same on both side after surgery. However, it’s all about perception! Self-perceived function seems more relevant. There is more to lower limb function than just the joints locally. Findings indicate that ‘self-reported ankle and knee function are correlated in post-ACLR participants’, however, ‘clinician and laboratory measures of ankle function between limbs are not different’. Therefore, ‘self-perceived ankle function should be evaluated in post-ACLR patients’. The ankle holds more correclations to the knee than ordinarailly discussed.

Whole body placement and mechanics matter. ‘Foot rotation influences the activity of medial and lateral hamstrings during conventional rehabilitation exercises in patients following anterior cruciate ligament reconstruction’.

This perhaps shows why whole body assessment and treatment, is reported anecdotally in clinic to be so effective.

These positive effects from manual therapy and exercise, may be due to the increasing body of evidence, that pain is a brain interpretation of data, and the local structure itself, cannot consistently be linked with pain or general function.

Additionally, manual therapy of the knee by an osteopath including the use mobilization and manipulation, and prescription exercise therapy, are all safer than long, or even short term medication treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs).

The point here is that there are many opinions and many solutions, to knee pain (Genu nociception). Perhaps some, in our opinion, are more rational than others and some statistically safer than others, and some more empowering than others.

With all treatments, it’s important to get the diagnosis, advice, and treatment programme from people who are trained, skilled and prepared to aid your musculoskeletal needs.

Treatment Options

The NICE guideline for ‘non-specific knee pain’, includes the guidance to remain as active as normal, seek support and advice at a specialist clinic, for education, management advice, weight loss when required, manual therapy including mobilisation and manipulation, mobilisation and soft tissue treatment by an osteopath, hydrotherapy application, increase in muscle strength and specialist exercise therapy for rehabilitation.

At Elementary Health we provide a seamlessly layered combination approach, of education and therapeutic application. This includes diagnosis, education of anatomy and pain theories, manual therapy, osteopathy, posture advice and training, lifestyle advice, hydrotherapy guidance, dietary overviews, and dynamic exercise therapy with motor control training rehabilitation. All of these work together to provide a uniquely structured approach, towards the aim of restoring your brain’s interpretation, or ‘mapping’ of your healthy functioning body, giving you back the control!

Next Steps

If there are any other questions, or, you wish to book a consultation with Michael Parr the consulting osteopath in Cambridge, based at Elementary Health. Please don’t hesitate to call or email.

Cambridge Osteopathy
& Rehabilitation Clinic

8c Romsey Terrace
Cambridge
CB1 3NH