KNEE PAIN & INJURY + PHYSIO

a. ACL

YOUR DIAGNOSIS IS: ACL RUPTURE

Tear of (arguably) the most important ligament that provides stability to the knee joint

It presents like this:

· An acute injury that usually involves landing from a jump, pivoting or decelerating suddenly à most are non-contact

· An audible “pop” or “crack” is usually felt à in these instances ACL injury should be suspected until ruled out via MRI

· Often people will return to activity after the initial event and then have to stop due to lack of confidence or buckling in the knee

 

It feels like this at rest:

· Swelling is usually quite pronounced and can take between 24 and 48 hours to completely develop

· Pain levels are varied and may be compounded by damage to other structures in the knee joint such as the meniscus or lateral ligaments

 


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b. PCL

YOUR DIAGNOSIS IS: PCL RUPTURE

The Posterior cruciate ligament is the primary restrain to posterior movement of the femur on the tibia and secondary restraint to external rotation behind posterolateral corner structures.

PCL tears typically occur as a result of a direct force to the anterior tibia with the knee in a flexed position such as occurs in motor vehicle accidents/ from contact from an opponent during sports or falling on a hyperflexed knee. Hyperextension is another common mechanism of injury resulting in injury to the PCL.

Often the symptoms and pain are poorly defined and vague mostly commonly located to the posterior knee and sometimes involving the calf. As the PCL is an extra synovial structure there is not often a lot of associated swelling that occurs with a PCL tear.

 

 


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c. MCL

YOUR DIAGNOSIS IS: MCL RUPTURE, or, Medial Collateral Ligament Injury

MCL injuries are commonly the result of a valgus stress to the knee when partially flexed.  This can occur during both non-contact and contact incidents.   The severity of a MCL injury is determined by 3 grades:   grade 1 – mild sprain, grade 2 – moderate sprain/ partial tear, and grade 3 – complete tear.  Grade 1 will be characterised by local tenderness over the MCL, with no swelling and or laxity on valgus stress testing.   Grade 2 will often be more symptomatic and demonstrate laxity of the MCL on testing, however with a distinct end feel and stable on extension.   Grade 3 will be characterised by laxity of the MCL on testing and no end feel, with reported instability.  Grade 3 may present swelling if associated capsular tearing is present.    MCL injuries may also present in the occurrence of an ACL injury due to the valgus mechanism.

You can expect to feel local tenderness of the MCL and surrounding area depending on the severity of the injury.   Ligament laxity and instability may be felt with more severe sprains. Walking up and down stairs may be challenging, in addition to changing directions while walking/ running. A history of poor single leg biomechanics, including strength and control may be predisposing factors to develop an MCL injury.

 


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d. LCL

YOUR DIAGNOSIS IS: LCL RUPTURE, or, Lateral Collateral Ligament Injury

The LCL forms part of the posterolateral corner of the knee stretching obliquely downward and backward from the lateral epicondyle of the femur to the head of the fibula acting as the primary varus stabilizer of the knee, also contributing to rotatory stability. The LCL is more mobile than its medial counterpart and is consequently less susceptible to injury.

It presents like this to us:

  • An injury to the LCL is often associated with other ligamentous injury and therefore may result in posterolateral rotatory instability of the knee.
  • LCL sprains are most often due to a severe, high energy direct varus stress on the knee such as occurs with a direct stress on the inside of the knee, twisting the knee or via non- contact hyperextension.

What it feels like to you at rest and with sport with you:

  • Present with pain around the posterolateral aspect of the knee with or without some associated swelling and feelings of instability dependent upon the degree of injury.

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e. Meniscus

YOUR DIAGNOSIS IS: ACUTE MENISCAL TEAR

The menisci (medial and lateral) are fibrocartilaginous discs located between your femur and tibia that act as shock absorbers buffering forces placed on the knee joint. By increasing the concavity of the tibia they also help to stabilize the knee and contribute to joint lubrication and nutrition.

Meniscal tears occurring in the younger population most commonly occur as a twisting injury on a slightly flexed knee with the foot planted on the ground often in sporting situations. However meniscal tears can also occur with minimal trauma in the older adult as a result of degenerative change of the meniscus. Meniscal tears are categorised by their type, tear orientation and zone/ location.

The degree of pain associated with an acute meniscal injury can vary considerably based on the type, location and degree of tear. Acute meniscal tears will be characterised by medial or lateral knee pain and swelling that sometimes develops over the course of 24 hours. In severe cases painful restricted ROM in particular flexion is present and intermittent clicking or locking may also occur as the result of a torn flap of the meniscus impinging between the articular surfaces. Some giving way may also occur but often this is a representation of the resultant swelling and quadriceps inhibition rather than a true ligamentous instability that may occur for example in ACL injuries however it is important to note due to the high occurrence of meniscal tears in association with ACL injuries.

 


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f. Posterolateral Corner Injury (PLC)

Your Diagnosis Is: Posterolateral Corner Injury (PLC)

The posterolateral corner is a collective of 28 individual static and dynamic structures providing varus, posterior and external rotatory stability to the knee. The LCL, PFL and posterolateral capsule being the main static stabilisers working in conjunction with the big dynamic stabilisers of the popliteus complex, biceps femoris and ITB are considered the most important stabilisers of the posterolateral corner.

It presents like this to us:

  • The PLC is most commonly injured following a combined hyperextension and varus force to the knee such that occurs with athletic traumas, MVA and falls.
  • The majority of PLC injuries occur in combination with ACL or PCL rupture with the reported incidence of isolated PLC injuries reported being between 13-28%. It is therefore critical to assess for PLC injury in ACL and PCL ruptures as ongoing increased abnormal rotational forces acting on the knee can cause ongoing pain, instability, and increased risk of graft failure in surgically reconstructed knees.

What It feels like to you at rest and with sport: 

  • Patients often present with pain +/- swelling around the posterolateral aspect of the knee, pain aggravated by weight bearing activities and feelings of instability and giving way around the knee.

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g. Patella

i. Dislocation

YOUR DIAGNOSIS IS: PATELLA DISLOCATION

Patella dislocation occurs when the patella is displaced laterally from within the trochlear groove of the femur. This most often reduces spontaneously however in some cases it may stay out of place for some time causing considerable pain and discomfort. Patella dislocations typically occur with a history of a traumatic force such as that occurs with twisting or jumping or atraumatic which occurs usually with associated ligamentous laxity and without a significant trauma. Patella dislocations are associated with a giving way sensation in the knee, an audible “pop” and the development of severe pain. One often describes a feeling of the knee “going out” or “moving out” of place and is then followed by a relatively immediate onset of intra articular swelling/ hemarthrosis.

During the physical assessment there is often a gross effusion, positive patella apprehension test and tenderness along the medial border of the patella. It is important during initial examination to differentiate from an acute ACL rupture as they both follow similar histories and consequent swelling. During physical examination it is also important to identify the factors which may predispose one to patella dislocation.

We initially manage these with a conservative physiotherapy management plan initially focussing on the resolution of swelling, restoration of knee ROM, in particular extension and quadriceps strength. In some cases such as a second or third dislocation and in the presence of associated injuries such as osteochondral fractures and significant disruption to the medial patellofemoral ligament surgery may be advocated.

Longer term the most important goal of rehabilitation is to prevent and reduce the chances of a recurrence and further patella dislocation. This is achieved through a comprehensive rehab program focussing on the restoration of quadriceps and hamstring strength, lumbopelvic strength and stretching of the lateral structures of the thigh and knee.

As with all injuries an absence of effusion, full ROM, restoration of strength and movement and a full specific return to sport program must be completed before achieving a return to sport clearance.

Long term typically patients will achieve excellent subjective and objective results regardless of the amount of laxity and studies show a good return to sport and full function rates with conservative management.

ii. Fracture

Patella Fracture

The patella is a sesamoid bone whose primary function is knee extension. The patella increases the leverage that the quadricep tendon can exert on the femur. It articulates with the femur and covers and protects the anterior articular surface of the knee providing attachment for the quadriceps femoris tendon and vastii muscles.

It presents like this to us:

  • Patellar fractures most commonly occur either by direct trauma (fall onto the knee or dashboard injury) or a compressive force or indirectly as the result of forceful quadricep contraction in which case the retinaculum and vastus muscles are usually torn.

What It feels like to you at rest and with sport:

  • Patients with patella fractures often present with pain and swelling in the region, a hemarthrosis and an inability to extend the knee indicating a failure of the extensor mechanism.

We look for this in the assessment:

  • In the Physical examination if your physiotherapist suspects a fracture an Xray will be obtained to confirm diagnosis.

We initially manage this by:

  • Undisplaced fractures with normal function of the extensor mechanism can be managed conservatively initially with an extension splint or range of motion brace locked in extension. As healing takes place and the fracture unites knee flexion ROM can be gradually increased and the quadriceps strengthened in inner range with a guided return to full weight bearing.
  • Fractures where there is a significant displacement and extensor mechanism failure typically will require surgical treatment involving fixation with tension band construct.

Longer term management strategies to aid performance and prevention include:

  • Longer term gradual quadricep, hamstring and hip strengthening exercises are introduced in conjunction with guided ROM exercises based upon fracture healing, progressing through to a return to full open and closed kinetic chain exercises, proprioceptive and a return to plyometric and sport specific movements forms the basis of any conservative and post -operative protocol following patella fracture.
  • As with all injuries an absence of effusion, full ROM, restoration of strength and movement and a full specific return to sport program must be completed before achieving a return to sport clearance.

iii. Tendon rupture – quad/ patella tendon

Patella Tendon Rupture

The patella tendon originates at the base of the patella and attaches to the tibial tuberosity with its superficial fibres running continuous over the front of the patella with the quadricep tendon. Its main role in conjunction with the quadricep muscle, tendon and patella is to transfer the force of the quadriceps muscle and extend the knee.

It presents like this to us:

  • Patella tendon ruptures most often occur spontaneously in association with a sudden severe eccentric contraction of the quadriceps muscles which may occur with a stumble, missing a step or landing from a jump and with a powerful take off manoeuvre such as jumping.

What It feels like to you at rest and with sport:

  • Patients often present with a sudden onset of pain over the patella tendon, describing a tearing or popping sensation at the time of injury and difficulty standing and walking.

We look for this in the assessment:

  • On physical assessment your physiotherapist will assess for the presence of a hemarthrosis, elevation of patella height, any palpable gaps defects below the inferior pole of the patella and in the tendon and the ability to perform a SLR and initiate leg extension.

We initially manage this by:

  • Partial patella tendon tears initially may be managed conservatively with a short period of immobilisation in full extension with a progressive weight bearing exercise program and early ROM protocol to allow for biological healing of the torn fibres and subsequent return to full function.
  • Full thickness tears will usually require surgical intervention by way of repair or reconstruction. Supervised and structured post- operative rehabilitation is an integral component to obtaining an optimal outcome following surgery focussed on protection of the post -surgical repair, controlled restoration of knee ROM, quadricep and lower limb strength and motor control.

Longer term management strategies to aid performance and prevention include:

  • For a 100% return to sport full resolution of knee ROM, strength and motor control accompanied by completion of full on field rehabilitation and return to sport specific drills and training must be accomplished.

Quad Tendon Rupture

The quadriceps tendon comes from the muscular junction of the rectus femoris, vastus medialis, vastus lateralis and vastus intermedius at the anterior superior pole of the patella, forming part of the extensor mechanism.

It presents like this to us:

  • Quadriceps tendon rupture is less common than patella tendon rupture.
  • Quadricep tendon ruptures most often occur as a non -contact injury after a sudden forceful contraction of the quadriceps during vertical or horizontal deceleration while landing from a jump or changing direction suddenly. In younger patients a quad tendon rupture may also occur as a result of a direct trauma.

What It feels like to you at rest and with sport:

  • Patients often present with a sudden onset of pain over the quadricep tendon, describing a tearing or popping sensation at the time of injury having fallen and an inability to continue with the activity.

We look for this in the assessment:

  • Physical examination reveals a palpable defect above the superior pole of the patella and tenderness at the site of rupture. The patient is unable to contract the extensor apparatus and extend the knee against resistance or perform a straight leg raise. Palpation should distinguish a quadricep tendon vs patella tendon rupture and it is also important to rule out other potential differential diagnoses of ACL rupture and patella dislocation.

We initially manage this by:

  • Partial quadricep tendon tears initially may be managed conservatively with a short period of immobilisation in full extension followed by a gradual progressive quadricep strengthening program starting with SLR and CKC exercises and progressive regaining of flexion ROM.
  • Full thickness tears will usually require complex surgical repair and extensive supervised and structured post- operative rehabilitation to obtain an optimal outcome following surgery focussed on protection of the post -surgical repair, controlled restoration of knee ROM, quadricep and lower limb strength and motor control.

Longer term management strategies to aid performance and prevention include:

  • For a 100% return to sport full resolution of knee ROM, strength and motor control accompanied by completion of full onfield rehabilitation and return to sport specific drills and training must be accomplished.

iv. Tendinopathy

YOUR DIAGNOSIS IS: PATELLA TENDINOPATHY

The patella tendon is located just below your knee attaching the patella to the tibial tuberosity. It is an important part of the extensor mechanism and transfers the force from the quadriceps muscle to the tibia to extend the leg.

Patella tendinopathy typically occurs as a result of a progressive overload on extensor mechanism typically in the form of a sudden increase in activity and stress on the anterior knee such that occurs in jumping sports like basketball, volleyball and long jumping. The patient will often complain of anterior knee pain aggravated by activities such as jumping, landing, changing direction and decelerating. It is important to distinguish patella tendinopathy from patellofemoral pain and other classic characteristics that define patella tendinopathy include an onset of pain upon rising in the morning and occurring at the start of activity that settles after warm up and returns upon cessation of activity is a classic presentation.

On physical assessment the tendon is typically tender on palpation at the inferior pole of the patella and can be associated with a thickening of the tendon. Pain is characteristically reproduced with squatting and hopping and other possible precipitating factors are also assessed such as quadricep muscle strength and atrophy. A visa-p questionnaire is also another useful tool used to monitor the clinical progress of one with patella tendinopathy.

We initially manage these by appropriate load reduction and management principles first and foremost. This doesn’t mean complete cessation of activity but relative rest and offloading as it is vital for continued load on the tendon to maintain tendon integrity. Strengthening and correcting biomechanical factors to improve the energy absorbing capacity of leg targeting the musculo-tendinous unit and the hip and ankle also forms a very important part of rehab as often one experiencing patella tendinopathy will tend to offload the affected side to avoid pain often leading to weakness and abnormal motor patterns.

Long term a progressive strengthening program is essential beginning with isometric exercise in the load intolerant knee progressing to isotonic strengthening in the form of heavy slow resistance and eccentric training through to plyometric exercise to improve energy storage and release of the patella tendon.

For a 100% return to sport clearance completion of a full and comprehensive strengthening, movement education program, plyometric and return to run program must be completed.


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h. Articular cartilage injury

Articular Cartilage Injury

Articular or hyaline cartilage is a tough layer of smooth white connective tissue made up of collagen, proteoglycans and water which line the end of the bones where they articulate with each other within a joint. The knee joint consists of 3 articulations, tibiofemoral, patellofemoral and tibiofibular joints therefore the tibia, femur and patella are covered in articular cartilage with its primary function to provide a smooth gliding surface for joint motion by reducing friction and also to facilitate the transmission of loads to the underlying subchondral bone. Articular cartilage is avascular meaning it has no bloody supply and instead relies on the nourishment of synovial fluid at the surface and subchondral bone at the base. As such articular cartilage has a very limited ability to repair itself.

It presents like this to us:

  • Articular cartilage damage may occur as an isolated condition in which condral or subchondral damage is the primary pathology or in association with other injuries such as ACL ruptures, meniscal injuries and patella dislocation for example.
  • Acute Articular cartilage damage most commonly can occur through non- contact mechanisms such as a twist or fall or via a direct trauma to the knee. It is important to note also that articular cartilage damage and degenerative processes can occur and worsen through several mechanisms over time through increased abnormal loading on the knee.
  • Chondral injury is typically graded in 4 stages varying from gross, macroscopically evident defects in which the underlying bone is exposed (grade 4) to microscopic damage that appears normal on arthroscopy but soft when probed (grade 1)

What It feels like to you at rest and with sport:

  • Patients often present with pain with wearing activities, swelling, occasionally instability and restricted movement in the knee. If a loose fragment breaks away mechanical locking restricting movement can also be exhibited.

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i. Fat pad impingement

Fat Pad Impingement

The infrapatellar fat pad is a mass of fatty tissue that lies below the knee cap and behind the patella tendon. The fat pad is a richly innervated structure and considered one of the most pain sensitive structures in the knee and as such if irritated can become a great source of pain.

It presents like this to us:

  • Often there is no history of trauma and fat pad impingement is of insidious onset, most commonly occurring through repeated or uncontrolled hyperextension or micro traumas occurring from falls, post-surgical knees and direct blows to the knee causing the fat pad to become swollen and inflamed.
  • There is however also a relatively uncommon sub group of fat pad impingement that occurs as a result of hyperextension injury causing the fat pad to be impinged between the patella and the femoral condyle.

What It feels like to you at rest and with sport:

  • The patient will often complain of retropatellar or infrapatellar anterior knee pain and swelling/ puffiness, pain with straightening of the knee, prolonged walking and standing, squatting or kicking and pain wearing high heels.

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j. Fracture of tibial plateau

Fracture of the Tibial Plateau

The tibial plateau is one of the most critical load bearing areas of the body and a fracture of the tibial plateau can affect the knee joint, stability, alignment and motion.

It presents like this to us:

  • Fractures of the tibial plateau most commonly occur as a result of a varus or valgus force combined with axial loading or weight bearing on the knee.
  • This is commonly seen in the form of high speed injuries such as falls whilst skiing, water sports, MVA and horse riding. In the older population they are usually due to low energy mechanisms in osteoporotic bones.
  • With displaced fractures there can neurovascular compromise and compartment syndrome can occur with more extensive injury and should always be considered. Approximately 50% of the knees with closed tibial plateau fractures have injuries of the menisci and cruciate ligaments.

What It feels like to you at rest and with sport:

  • Patients often present with severe pain and swelling, often in the form of a hemarthrosis, loss of knee joint ROM and an inability to weight bear.

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k. Superior tibiofibular injury

Superior Tibiofibular Joint Injury

The Superior tibiofibular joint comprises the articulation between the lateral condyle of the tibia and the fibula head and is surrounded by a joint capsule strengthened by the superior anterior and posterior ligaments. It plays a role in knee stability through its surrounding anatomical structures such as the LCL, arcuate ligament, PFL, biceps femoris and popliteus muscles.

The superior tibiofibular joint dissipates torsional stresses from the ankle and lateral tibial bending moments and tensile weight bearing.

It presents like this to us:

  • Superior tibiofibular joint injury may result from direct trauma resulting in sublaxation or dislocation of the fibula or can be sprained by twisting injuries often involving a combination of rotation and knee flexion such as occurs with cutting and pivoting.
  • They may also result as a secondary consequence of severe ankle injuries. The peroneal nerve wraps around the top of the fibula and can also be implicated in Superior tibiofibular injury.

What It feels like to you at rest and with sport:

  • In the presence of dislocation the patient may present with lateral knee pain, a prominent head of fibula, and lateral knee swelling around the superior tibiofibular joint.
  • Pain may be exacerbated by ankle movement and weight bearing. In cases of a superior tibiofibular joint sprain pain may be localised or refer distally down the lateral calf. The joint is often tender to touch.

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l. Coronary ligament sprain

Coronary Ligament Sprain

The coronary ligaments are the name given to the deep portions of the joint capsule which connect the periphery of each meniscus to the adjacent margin of the tibia (sometimes called the meniscotibial ligaments).

It presents like this to us:

  • Sprains of the coronary ligaments occur typically as a result of a twisting injury, for example in football when the foot is planted firmly on the floor and the player suddenly changes direction twisting the knee in the process.
  • Coronary ligament sprains have very similar symptoms and are difficult to differentiate from a meniscal injury.

What It feels like to you at rest and with sport:

  • Patients often present with sharp pain on twisting movements and with joint line tenderness.

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m. Knee Osteoarthritis

Knee OA

It presents like this to us:

  • Osteoarthritis commonly affects individuals aged over 50 years, however can affect younger adults or adolescents.
  • The condition affects moth the articular cartilage and subchondral bone.
  • Injuries including meniscal, chondral, ligamentous or repetitive loading may increase the risk of developing the condition.
  • Obesity, previous injury and genetic predisposition are risk factors. Impact and power sports such as boxing, weight-lifting, soccer, football and basketball have a greater incidence of the condition.

We look for this in the assessment:

  • X-ray or MRI may be required to determine the severity of the condition. However, Osteoarthritis can also be present in individuals with no knee pain so it’s important for the physiotherapist to assess function of the knee not jus the scan
  • Monitoring of symptoms and the condition is important for maintaining function.

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n. Anterior Knee Pains

i. PFPS

Patellofemoral pain syndrome (PFPS)

Patellofemoral pain syndrome is an umbrella term used to describe anterior knee pain around, behind or under ones knee cap. Your knee cap normally glides in a groove on your femur as you bend and straighten your knee. As you bend your knee the pressure between the groove and your knee cap increases.

It presents like this to us:

  • Most often patellofemoral pain presents following excessive loading of the patellofemoral joint as usually occurs with rapid increases in physical activity that your knee is unaccustomed to.
  • Poor biomechanics and an alteration in patellofemoral tracking which occurs through imbalances between the vmo and vastus lateralis, 2 muscles responsible in maintaining optimal alignment and tracking of the patella within the femoral trochlear, will change the magnitude and distribution of PFJ stress and potentially leading to excessive patellofemoral joint pressure which in time can lead to pain.

What It feels like to you at rest and with sport:

  • Often Patellofemoral pain is less specific than that of patella tendinopathy and aggravating activities such as ascending or descending stairs, running or pain post sitting can help distinguish between the 2 most common forms of anterior knee pain.

We look for this in the assessment:

  • On physical examination pain reproduction with squatting, restricted PFJ mobility, VMO atrophy and wasting and tenderness on the medial or lateral facets of the patella are often common signs of PFPS.
  • It is also important to assess and identify important contributing intrinsic and extrinsic factors in the development of PFPS such as increased femoral internal rotation, knee valgus, tibial rotation, foot pronation, inadequate flexibility, patella position, soft tissue contributions and neuromuscular control of the vasti.

We initially manage this by:

  • This is important as the management of PFPS focusses initially around the reduction of pain through soft tissue modalities improving lateral soft tissue compliance and patellofemoral joint mobilization, recognising and decreasing the aggravating extrinsic load, taping and if indicated foot orthotic prescription.

Longer term management strategies to aid performance and prevention include:

  • Longer term addressing and correcting poor function/ biomechanics and weakness of hip and thigh muscles through targeted strengthening, neuromuscular control, movement patterning and re training of the vasti, hip abductors and external rotators are essential to any evidence guided treatment plan.

ii. Patella tendinopathy

Patella Tendinopathy

The patella tendon is located just below your knee attaching the patella to the tibial tuberosity. It is an important part of the extensor mechanism and transfers the force from the quadriceps muscle to the tibia to extend the leg.

It presents like this to us:

  • Patella tendinopathy typically occurs as a result of a progressive overload on extensor mechanism typically in the form of a sudden increase in activity and stress on the anterior knee such that occurs in jumping sports like basketball, volleyball and long jumping.

What It feels like to you at rest and with sport:

  • The patient will often complain of anterior knee pain aggravated by activities such as jumping, landing, changing direction and decelerating. It is important to distinguish patella tendinopathy from patellofemoral pain and other classic characteristics that define patella tendinopathy include an onset of pain upon rising in the morning and occurring at the start of activity that settles after warm up and returns upon cessation of activity is a classic presentation.

We look for this in the assessment:

  • On physical assessment the tendon is typically tender on palpation at the inferior pole of the patella and can be associated with a thickening of the tendon. Pain is characteristically reproduced with squatting and hopping and other possible precipitating factors are also assessed such as quadricep muscle strength and atrophy. A visa-p questionnaire is also another useful tool used to monitor the clinical progress of one with patella tendinopathy.

We initially manage this by:

  • We initially manage these by appropriate load reduction and management principles first and foremost. This doesn’t mean complete cessation of activity but relative rest and offloading as it is vital for continued load on the tendon to maintain tendon integrity.
  • Strengthening and correcting biomechanical factors to improve the energy absorbing capacity of leg targeting the musculo-tendinous unit and the hip and ankle also forms a very important part of rehab as often one experiencing patella tendinopathy will tend to offload the affected side to avoid pain often leading to weakness and abnormal motor patterns.

 Longer term management strategies to aid performance and prevention include:

  • Long term a progressive strengthening program is essential beginning with isometric exercise in the load intolerant knee progressing to isotonic strengthening in the form of heavy slow resistance and eccentric training through to plyometric exercise to improve energy storage and release of the patella tendon.
  • For a 100% return to sport clearance completion of a full and comprehensive strengthening, movement education program, plyometric and return to run program must be completed.

iii. Osgood-Schlatter lesion

Osgood-Schlatter Lesion

It presents like this to us:

  • Osgood-Schlatter lesion occurs at the tibial tuberosity in males (13-15 years) and females (10-12 years) close to puberty. The condition occurs due to excessive traction of the apophysis of the tibial tuberosity from the patella tendon.
  • Often this is associated with increased or high activity levels during this age of growth.  The condition is self-limiting and the continuation of activity is determined by the severity of symptoms experienced.

What It feels like to you at rest and with sport:

  • You can expect to feel pain below the knee when loaded, especially during squat, single leg squat/ jump/ hop, landing and running activities.

We initially manage this by:

  • We manage this condition with education about the condition, manage the amount of physical activity you’re doing + introduce some ways to decrease symptoms such as through NSAIDS.

Longer term management strategies to aid performance and prevention include:

  • Strengthening and mobility exercises commence as soon as tolerated.
  • Return to activity protocols are introduced longer term once strength and control has been gained.

iv. Sinding-Larsen-Johansson lesion

Sinding-Larsen-Johansson Lesion

It presents like this to us:

  • Sinding-Larsen-Johansson lesion is a rare condition, affecting adolescents. Pain is experienced at the inferior pole (base) of the patella, where the tendon attaches resulting from overuse.

What It feels like to you at rest and with sport:

  • You will usually experience local pain and swelling below the patella.  Muscle tightness of the low limb is often seen, resulting in decreased knee mobility and increased stress of the patellofemoral joint.

We look for this in the assessment:

  • This condition usually presents in young males aged 10-13 years. Symptoms are usually aggravated with activity (stairs, squats, jumping, running), occasionally limping following exercise, relieved with rest, and may present on one leg or both.

We initially manage this by:

  • Management of the condition commences with education and activity modification to reduce aggravating factors initially. Strengthening and mobility exercises commence as soon as tolerated.  NSAIDs may be beneficial in the acute phase.

Longer term management strategies to aid performance and prevention include:

  • Return to activity protocols are introduced longer term once strength and control has been gained.

v. Bursitis

Bursitis

It presents like this to us:

  • The Bursa around the knee may become inflamed (bursitis), most commonly affecting the pre-patellar bursa.

What It feels like to you at rest and with sport:

  • You will often experience superficial swelling at the front of the knee.  We often see this bursitis in individuals who kneel regularly.  Bursitis of the infrapatellar bursa can present similarly to patellar tendinopathy due to the location, requiring specific diagnosis to treat.

We initially manage this by:

Management of bursitis will commonly include NSAIDs, ice and compression, de-loading, and return to sport once symptoms have settled. Severe presentations may require aspiration.

vi. Synovial plica

Synovial Plica

It presents like this to us:

  • Synovial plica is found on the inner knee, however is not present in all individuals.

What It feels like to you at rest and with sport:

  • An aggravated synovial plica will often present as a sharp pain during squatting. Individuals present with palpable tenderness over the plica on the inner knee.

We look for this in the assessment:

  • Diagnosis is often concluded following failure to improve from management of patellofemoral pain, due to the location of symptoms.

We initially manage this by:

  • NSAIDS may be used to manage acute symptoms. Arthroscopy may be performed to remove the plica if severe.

Longer term management strategies to aid performance and prevention include:

  • Once symptoms have settled a further strength and return to sport protocol will be introduced to decrease knee issues in the future.

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o. Medial Knee Pains

i. Pes anserinus tendinopathy/bursitis

Pes Anserinus Tendinopathy/Bursitis

It presents like this to us:

  • Pes anserinus tendinopathy/ bursitis is a condition affecting the tendon insertion of semitendinosus, gracilis and Sartorius at the attachment to the tibia.

What It feels like to you at rest and with sport:

  • The per anserinus tendons are at risk of excessive load during valgus (knee-in) movements, often as a result during medial ligament sprains, muscle imbalances, deformity or meniscal pathologies. The tendons or bursa may be aggravated due to overuse, commonly seen in breast stroke swimmers, cyclists and runners.

What It feels like to you at rest and with sport:

  • You can expect to feel pain and swelling at the medial (inner) knee joint line, and can simulate a medial meniscus tear.

We look for this in the assessment:

  • Resisted knee flexion and activation of the medial hamstrings can reproduce pain.

We initially manage this by:

  • Management for this condition includes standard tendinopathy and bursitis management, with NSAIDs or cortisone injections useful to manage symptoms.

Longer term management strategies to aid performance and prevention include:

  • Managing underlying biomechanical dysfunction and muscle imbalances is important for longer term prevention.

ii. Pellegrini-Stieda Syndrome

Pellegrini-Stieda Syndrome

It presents like this to us:

  • Pellegrini-Stieda Syndrome is a condition affecting the femoral origin of the medical collateral ligament (MCL), involving calcification of the site. The condition may occur following trauma or grade II-III sprain of the MCL.

What It feels like to you at rest and with sport:

  • You can expect to experience difficulty straightening the leg and twisting.

We look for this in the assessment:

  • In clinic, we expect to see reduced range of motion, in addition to a painful lump on the upper MCL.

We initially manage this by:

  • Management usually consists of knee mobilisation, soft tissue therapy, and the use of corticosteroid to the area if pain persists.
  • Orthopaedic review and surgery may be required in severe or unresponsive cases.

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p. Lateral Knee Pains

i. ITBS

ITBS

Iliotibial band friction syndrome (ITBS) is an overuse condition experienced at the outside of the knee that is aggravated during activity.

It presents like this to us:

  • The condition is seen in cyclists, runners and endurance athletes.
  • The source of pain is attributed to the bursa between the ITB and the femoral epicondyle, with the bursa highly innervated and vascular, with irritation of this structure the probable cause of symptoms.
  • Underlying muscular imbalance and control issues have been associated with the development of the condition.

What It feels like to you at rest and with sport:

  • You can expect to feel pain on the outside of the knee during exercise, that may linger following cessation of exercise depending on severity.

We look for this in the assessment:

  • Tenderness on the lateral side of the knee often at the ITB insertion.
  • Pain after exercise.
  • Weakness in quadricep, gluteal or hamstring muscles

We initially manage this by:

  • Management for ITBS typically includes manual therapy, exercise for strength and mobility, with a longer-term return to sport protocols introduced.
  • Hip and foot mechanics will be looked at to rule out contribution to development of the condition and long-term prevention.

ii. Bicep femoris tendinopathy

Bicep Femoris Tendinopathy

It presents like this to us:

  • Biceps femoris tendinopathy is commonly seen in activities requiring acceleration and deceleration, associated in cycling and running.

What It feels like to you at rest and with sport:

  • Initial symptoms may not limit participation in sport, leading to the chronic development of the condition if not managed early.

We look for this in the assessment:

  • You can expect to experience pain around the back and side of the knee, that typically reduces at rest.
  • Morning stiffness following exercise is a common symptom.

We look for this in the assessment:

  • Reproduction of pain in resisted knee flexion and palpation of the tendon insertion is usually present.

We initially manage this by:

  • Management of this condition includes manual therapy, strength and mobility exercises, and load modification.   Orthopaedic intervention may be required for severe, non-responsive individuals.

Longer term management strategies to aid performance and prevention include:

  • Managing underlying biomechanical dysfunction and muscle imbalances is important for longer term prevention.
  • Longer term, a return to sport protocol is introduced.

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q. Posterior Knee Pains

i. Popliteus tendinopathy

Popliteus Tendinopathy

It presents like this to us:

  • Popliteus tendinopathy is an uncommon knee condition causing pain at the back/outside of the knee.
  • The popliteus muscle helps to ‘unlock’ the knee when it is fully straight and to help stabilise the knee.
  • It can become painful in runners who increase their hill training or have a knee trauma where the knee is knocked inwards whilst the leg is straight.

What It feels like to you at rest and with sport:

  • Pain is generally acute in onset, redness + swelling can occur on the back/outside of the knee, crunching can occur and pain occurs when trying to unlock the knee or load it (eg stairs/hills/running).

We look for this in the assessment:

  • Your physio will assess your knee to rule out other conditions that present in a similar manner such as posterior meniscus tear, Baker’s cyst or ITB related conditions.
  • Imaging is generally not required.

We initially manage this by:

  • Management requires the correct amount of unloading, specific taping/bracing, and anti-inflammatories.
  • Once the pain is controlled eccentric strengthening can begin and your physio will advise you on return to running but avoiding downhill training.

Longer term management strategies to aid performance and prevention include:

  • Managing underlying biomechanical dysfunction and muscle imbalances is important for longer term prevention.
  • Longer term, a return to sport protocol is introduced.

 

ii. Gastrocnemius tendinopathy

Gastrocnemius Tendinopathy

It presents like this to us:

Gastrocnemius tendinopathy is common amongst runners, as a result from acutely increased running loads or excessive hill running.

What It feels like to you at rest and with sport:

  • You can expect to feel tenderness at the medial (inner) gastrocnemius muscle, symptoms reproduced on resisted knee flexion, calf raise, jump and hop.

We look for this in the assessment:

  • We often look for underlying mechanical factors that may have led to the development of the condition, reviewing the hip, knee and ankle.  Footwear and orthotics may be considered to assist symptoms and longer-term management.

We initially manage this by:

  • Management initially includes load modifications, ice, manual therapy and strengthening.

Longer term management strategies to aid performance and prevention include:

  • Longer term return to running/ sport protocols are introduced as symptoms settle.
  • Further global strengthening exercises are introduced to improve the lower limbs ability to tolerate load.

iii. Baker’s cyst

Baker’s Cyst

It presents like this to us:

A Baker’s cyst (also known as a popliteal cyst) is a fluid filled sac at the back of the knee. It is on the inside portion of your knee between the bottom of one of your hamstring muscles (semimembranosus) and the top of your calf muscle (gastrocnemius) and can be small and cause no symptoms to very large and uncomfortable.

Large cysts can be seen whilst your knee is straight and you are lying on your stomach and can restrict your ability to fully bend your knee.

What It feels like to you at rest and with sport:

  • It is associated with a vague sense of tightness and discomfort at the back of the knee and can become sorer with activity.
  • There is a potential the bursa can rupture which leads to higher levels of pain in the back of the calf and can mimic a deep vein thrombosis.

We look for this in the assessment

  • Baker’s cysts in adults are often associated with joint abnormalities such as meniscus injuries, arthritis or loose bodies in the knee and these need to be adequately assessed and managed.

We initially manage this by:

  • Baker’s cysts can resolve spontaneously but should be as sessed to understand why it has occurred. Pain management can include short term solutions like anti-inflammatories, ice and injections however

Longer term management strategies to aid performance and prevention include:

  • long-term management requires stretching hamstrings, strengthening and fixing the cause of the cyst.

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