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.
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 hip?, or no stretching of the hip?, 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?!!!
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.
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!
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.
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.
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.
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.
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.
What Can Help
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.
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.
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. 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.
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.
Whole Body Integration
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’?!
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.
IAdditionally, 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.
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 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!
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.