Physiotherapy and rehabilitation
We will present the most common knee injuries in detail. Every pathology or knee injury comes with a description of general facts, causes that led to the development of the injury, characteristics of the symptoms, diagnosis, and the course of treatment.
The anterior cruciate ligament (ACL) is one of the four key ligaments that ensure passive stability to the knee joint. Anterior cruciate ligament is the most commonly injured ligament of the knee and one of the most common injuries in general. The injury of ACL is known as one of the most severe injuries in sports because it is characterised by long and complex rehabilitation.
The injury occurs due to forced, strong hyperextension of the knee (the knee is “pushed” back) or due to rapid pivoting (rotating the body around the fixed foot and shin). A combination of weak muscles of the thigh, landing many jumps, and poor endurance of the hamstrings along with sports activities, suffering blows, awkward landings and falls all pose a risk of injury to the anterior cruciate ligament.
There are two mechanisms of injury to the anterior cruciate ligament – non-contact and contact mechanisms. 70-80% of ACL injuries are non-contact in nature, which means that the cause of injury is not an external force such as an awkward landing, suffering a blow, or falling.
Non-contact injury is a consequence of ligament failure. A great number of ACL injuries can be prevented with adequate physical preparation.
Symptoms of the ACL injury include strong pain in the knee that can spread down the entire extremity, limited mobility of the knee (knee extension and flexion), oedema or swelling that appears several hours after the injury and gradually grows in size, a feeling of instability in the knee, a wobbly, swaying feeling in the knee and gradual loss of muscle mass in quadriceps muscles, especially on the inner side.
About 40% of patients with an ACL injury report a pop in the moment of injury that occurs due to the rupture of the ligaments.
More than half of anterior cruciate ligament injuries co-occur with meniscal injuries of the knee joint. When the injury happens, it is vital to promptly undergo diagnostic testing, namely x-ray and magnetic resonance imaging (MRI) that confirm or refute the diagnosis of ACL and skeletal fractures.
After an ACL injury, it is important to follow the RICE method of acute condition management.
It is obligatory to intensively perform preoperative rehabilitation up to the day of surgery. It is necessary to stop the swelling of the joint, do away with pain symptoms, recover full flexion and extension of the knee, and prevent or reduce muscle atrophy. The success of preoperative rehabilitation depends on the extent of injury and the patient’s participation.
In the event of a full ACL rupture, surgical ligament transplantation is necessary.
If the ACL rupture is partial, we first perform conservative treatment with special exercises to improve muscle strength and knee joint control during movements. If knee instability or intense pain do not disappear, then partial ACL rupture also requires surgical treatment.
Postoperative rehabilitation of the anterior cruciate ligament lasts from 6 to 9 months, depending on the age, level of sports activity, and the extent of the patient’s injury. The first month of rehabilitation includes therapy sessions that lessen the pain and swelling, and gradually we apply special exercises to activate the thigh muscles and regain the full extent of knee joint flexion and extension.
Posterior cruciate ligament prevents the tibia from sliding backwards and its excessive internal rotation. It is thicker, heavier, and twice as strong as the anterior cruciate ligament (ACL). PCL is the strongest ligament of the knee.
Posterior cruciate ligament injuries are less common than ACL injuries; only 19% of knee injuries are PCL injuries, whereas ACL injuries account for 31% of knee injuries every year.
When the posterior cruciate ligament is damaged, it is oftentimes due to a great force that also injures the ligaments, cartilage and/or bones. When the PCL is damaged, posterior translation of the tibia (backward movement of the tibia) increases. At the same time, the external rotation of the tibia is reduced. The PCL injury is considered riskier and more dangerous than ACL injury since poor physical condition of the muscles and accompanying collateral ligament injuries cause bigger limitations when performing daily activities, such as walking.
When the injury to the posterior cruciate ligament happens, it is vital to promptly undergo diagnostic testing, namely x-ray and magnetic resonance imaging (MRI) that confirm or refute the diagnosis of the PCL injury and skeletal fractures.
Symptoms include swelling, posterior knee pain, and a feeling of instability, a swaying feeling in the knee.
There is less swelling than in ACL injuries, but in general, the acute phase is similar; it includes reduced mobility of the knee or traumatic spasms and difficulties walking.
If PCL is not accompanied by injuries to other knee joint structures, then the injury is usually more difficult to diagnose using clinical tests only. Therefore, it is vital to perform magnetic resonance imaging (MRI).
The treatment of PCL is usually surgical, followed by an expertly designed rehabilitation programme with progressive training and physical therapies.
Rehabilitation of PCL without any major complications lasts from 6 to 9 months, depending on the extent of injury. Partial PCL ruptures or strains are treated conservatively, using special exercises after the acute phase subsides; if they do not improve the symptoms of injury, then ligament reconstruction is suggested.
Surgical treatment of PCL is more difficult and longer lasting than surgical treatment of ACL. This requires more limitations during early postoperative rehabilitation and a longer phase of preoperative rehabilitation.
It is advised to perform a preoperative rehabilitation program for at least 12 weeks to ensure endurance in strength and regain the complete extent of movement, which reduce muscle atrophy after ligament reconstruction and accelerate postoperative healing.
Meniscus injuries account for half of all knee joint injuries. The most common surgical procedure for the knee is meniscal lesions.
The meniscus of the knee is a fibrocartilaginous structure in the shape of a crescent moon that is located between the tibia and femur. The knee consists of the medial (internal) meniscus and the lateral (external) meniscus. Injuries to the medial (internal) meniscus are more common. The meniscus injury oftentimes appears when rupturing the anterior cruciate ligament and in knee joint instability. 60% of the population above the age of 65 has degenerative changes of the menisci.
According to the type of injury to the meniscus we differentiate between:
The zone of injury of the meniscus can be:
Symptoms of meniscus injuries include:
Treatment of the PCL is mostly surgical and later followed by an expertly designed rehabilitation programme with progressive exercises and physical therapies.
It is advised to perform a preoperative rehabilitation program for at least 12 weeks to ensure endurance in strength and regain the complete extent of movement, which reduce muscle atrophy after ligament reconstruction and accelerate postoperative healing.
The entire conservative rehabilitation programme includes exercises to strengthen thigh muscles, special exercises for proprioception of the joint, and exercises for mobility and endurance of muscle fibres.
In the event of surgical treatment, preoperative rehabilitation is recommended, using exercises to help prevent muscle atrophy and exercises to strengthen neuromuscular connections. Meniscus injuries pose a risk of accelerated knee wear (arthrosis), which is why it is necessary to begin the primary treatment quickly.
The duration of rehabilitation after meniscus injury depends on the method of treatment, zone of injury on the meniscus, accompanying injuries of other knee structures, the patient’s participation, mechanical symptoms, and possible complications.
The meniscus injury rehabilitation lasts from a few weeks in the case of smaller lesions up to 7 months in the case of surgical treatment of complex lesions, such as bucket-handle or flap tears.
Knee sprain is an umbrella term for stretched or torn ligaments in the knee, which is caused by an awkward landing, a fast change of direction, or a blow to the knee.
The sprain is oftentimes accompanied by pain and swelling; bruising and weakness may also appear.
A professional diagnosis is required first when spraining the knee, because it helps determine which ligaments were injured. An adequate system of rehabilitation is then prescribed based on the diagnosis.
First, it is necessary to rest and keep the area cool to treat the inflammation. Then follows a properly adapted exercise programme, tailored to the injury of individual ligaments, to strengthen the knee and hip muscles.
The choice between conservative rehabilitation treatment or surgical treatment depends on many specifics of the injury that caused the instability. You can read more about those on our website under knee injuries.
The sensation of an unstable knee that gives in while moving is caused by numerous pathological conditions of the knee. There is rarely only one reason for knee instability; it is the general symptoms of the knee joint.
A common cause of knee instability includes ligament injuries, for example, anterior cruciate ligament rupture, posterior cruciate ligament rupture, or damage to the medial or lateral collateral ligament.
The most common cause of knee instability is medial collateral ligament injury which also has a high potential for self-healing. This is why knee instability is only an acute symptom that eventually disappears with rehabilitation exercises. Contrary to this, anterior cruciate ligament (ACL) injury is often a cause of worse and permanent knee instability. At the same time, ACL has a low potential for self-healing, which is why most ligament ruptures require urgent surgical treatment.
To choose an adequate method of treatment, it is necessary to undergo an examination by an orthopaedic specialist who gives an opinion about the damage to the knee structures using clinical tests. After specialist examination, it is advised to perform magnetic resonance imaging (MRI) which provides accurate information about the extent of knee injuries that caused knee joint instability.
The choice between conservative rehabilitation treatment or surgical treatment depends on many specifics of the injury that caused the instability. You can read more about those on our website under knee injuries.
In general, knee instability is most often caused by injuries to the anterior cruciate ligament, medial collateral ligament, menisci, cartilage, and kneecap.
To choose an adequate method of treatment, it is necessary to undergo an examination by an orthopaedic specialist who gives an opinion about the damage to the knee structures using clinical tests.
The choice between conservative rehabilitation treatment or surgical treatment depends on many specifics of the injury that caused the instability. You can read more about those on our website under knee injuries.
Jumper’s knee or patellar tendinopathy is an overuse injury of the knee joint, which is commonly a reason for sports career regression.
The incidence of the jumper’s knee varies a lot between sports; in volleyball, basketball, and athletics, more than 40% of sportspeople require treatment of patellar tendinopathy at least once in their career.
The general incidence of the jumper’s knee in sports that include jumping is 20%. 55% of athletes that suffer from patellar tendinopathy report career regression.
Even though it is a sports injury, it is also a common injury in physically demanding occupations. 35% of the physically inactive population that suffers from the jumper’s knee reports a strong negative impact on their work productivity.
The jumper’s knee appears often among runners, basketball players, volleyball players, football players, hikers, tennis players, badminton players, handball players, athletes, American football players, and squash players. The jumper’s knee has a high recurrence rate. The symptoms can last for various years if left untreated.
The symptoms most often include pain in the front of the knee in the subpatellar part (right underneath the patella) that can be provoked by the means of palpation.
The pain grows worse if straining the knee by directly pressing on it, for example when kneeling or suffering a blow to the knee.
Patellar tendinopathy is characterised by growing pain from a few hours to several days after putting a strain on the knee, however, the pain may even subside during activities.
What is typical of advanced phases of patellar tendinopathy is the decreased activation in the quadriceps muscle and a generally worse isometric activation compared to the healthy knee.
Patellar tendinopathy has 3 phases:
The complexity of treatment of the jumper’s knee grows according to the phase of tendinopathy, however, all three phases use adapted special exercises which progressively strengthen ligaments and imbalanced groups of muscles as their basic means of treatment. Only 10% of patients in the third phase of the jumper’s knee are suitable for surgical treatment.
Strong pain is characteristic of even the most basic movements, such as walking, sitting down, and standing up; the loss of full knee extension and joint swelling when straining are also typical.
The complexity of treatment of the jumper’s knee grows according to the phase of tendinopathy, however, all three phases use adapted special exercises which progressively strengthen ligaments and imbalanced groups of muscles as their basic means of treatment. Only 10% of patients in the third phase of the jumper’s knee are suitable for surgical treatment.
Patellofemoral pain syndrome (PFPS) denotes the pain in the front of the knee joint that can have multiple causes that are difficult to diagnose. It is often due to the inflammation of the synovial joint sheath, the patella’s subchondral bone lesions, inflammation of the junction spot of the patella, or infrapatellar fat pad inflammation.
The most common reason for patellofemoral pain syndrome (PFPS) is straining the knee in combination with incorrect biomechanics of the lower extremity and improper gliding of the patella.
The most common risk factors for the development of patellofemoral pain syndrome are:
The risk factors listed above cause the improper gliding of the patella, which causes pain and joint inflammations. Patients who suffer from PFPS bear a higher risk of developing osteoarthrosis of the knee joint.
Since PFPS can have different origins, the symptoms also differ. The pain can appear just above or below the patella; even the entire joint may be symptomatic.
Spontaneous but dull pain that the individual feels during rest and that typically worsens after straining the leg is typical of chronic overuse of soft structures next to the patella.
A sharp, stabbing pain that appears with individual activities or movements and grows more intense during straining, is commonly associated with acute joint injury.
The pain that the patient feels at night can be a consequence of either chronic strains or fresh injuries to the knee joint.
If the pain appears when mildly bending the knee (20-40°, for example when landing a jump or running), this points to improper gliding of the patella, which is not ideally situated in the trochlear groove; most commonly it is the case of lateral subluxation of the patella.
Treatment begins with a diagnosis and a history of knee pain. It is recommended to perform clinical testing and magnetic resonance imaging (MRI) which help to determine the origin of PFPS. The treatment of PFPS is based on rehabilitation exercises that aim to improve the biomechanics of the knee joint, strengthen the thigh muscles, and stabilise the patella.
The treatment of PFPS is based on rehabilitation exercises that aim to improve the biomechanics of the knee joint, strengthen the thigh muscles, and stabilise the patella. If the patterns of walking, running or jumping were broken, it is necessary to technically correct these patterns and thus prevent the recurrence of PFPS.
During the acute phase, we use instrumental physiotherapy and manual techniques of relaxing the stiff muscle structures and alleviating the pain.
Bedrest relieves the pain, but this does not eliminate the cause of the development of PFPS, namely biomechanically poor patterns, muscle imbalance, and improper gliding of the patella. Special rehabilitation exercises aim to optimise the muscular coordination of the heads of the quadriceps and to establish dynamic symmetries between agonists and antagonists in the hips, knees, and feet.
Patellar instability is a common cause for the development of patellofemoral pain syndrome. This means that while moving, the patella pops out of the trochlear groove in the knee and causes pain.
This condition can be a consequence of a congenitally abnormal trochlear groove (an uneven shallow groove) and/or a congenital malposition of the patella that may be too high or too low in the trochlear groove. It can also be a consequence of acute dislocation of the patella in the knee while landing, falling or rapidly rotating it. It can also be caused by imbalance in muscle tension and activation.
There are various types of patellar instability, and they are also accompanied by different symptoms.
The patella might simply be placed incorrectly in the knee joint, however, chronic patellar dislocation is also possible.
Symptoms of patellar instability include knee swelling, popping and moving during movement, pain when sitting, knee stiffness with loss of mobility, externally visible knee deformation or complete loss of strength. Only one of the symptoms might appear, or it can be a combination and progression of multiple symptoms.
The most common symptom of patellar instability is pain underneath the patella when bending the knee above 120° and slight patellar dislocation when bending the knee.
It is important to clinically examine the knee, undergo x-ray imaging that shows the location of the patella in the joint, and magnetic resonance imaging (MRI) that is used to estimate the extent of damage to knee structures.
When treating a complete dislocation of the patella, it is important to reposition it back into the trochlear groove, which oftentimes occurs spontaneously.
When treating a complete dislocation of the patella, it is important to reposition it back into the trochlear groove, which oftentimes occurs spontaneously. Dislocating the patella often injures the cartilaginous plate under the patella and ruptures the medial patellofemoral ligament, which stabilises it.
In most cases of patellar instability due to its incorrect position in the trochlear groove, we achieve the best results by using conservative individual therapy and rehabilitation training.
Conservative treatment consists of two phases:
Runner’s knee or iliotibial band syndrome (ITBS) is a common overuse injury of runners and cyclists. It is characterised by pain on the outer side of the knee during movement. The pain appears due to the iliotibial band (ITB) rubbing against the lateral femoral condyle, which causes inflammation and local tissue injuries. It is oftentimes described as a friction syndrome.
Latest research shows that, in addition to rubbing, the innervated adipose (fatty) tissue that lays between the lateral femoral condyle and the ITB is compressed. An angle of 30° of knee flexion causes the greatest compression of the adipose tissue between the femur and the ITB. This is the angle of running and cycling.
The runner’s knee is most commonly caused by excessive amounts of monotonous stress, the change in running surface, muscle imbalance of the thighs, knee and hip valgus, and poor choice of footwear. Iliotibial band syndrome (ITBS) is an injury of the young since it most often develops before 35 years of age. It affects women more frequently.
Runner’s knee is an overuse type of injury of runners and cyclists. The nature of causes for the development of the ITB syndrome is most often related to muscles and training. Weak hip abductor muscles and pelvic stabilisers (especially gluteus medius) transmit the forces to the ITB, which becomes overburdened.
When active stabilizers (muscles) are weak, the force is always transmitted to the passive stabilisers – the iliotibial band (ITB), which becomes too tense. Consequently, it irritates the adipose fat pad on the outer side of the knee, causing sharp and burning pain.
The strongest pain often appears when the heel touches the ground (running, walking). The pain appears after a few minutes of walking or running. The pain usually disappears when the activity ends and reappears when increasing the load once again.
The diagnosis is based on clinical examination. The patient with ITB syndrome is sensitive to palpation above the lateral outgrowth of the femur.
It is recommended to perform magnetic resonance imaging (MRI) which reveals the swelling around the adipose (fatty) tissue. In the chronic ITB syndrome, MR imaging shows structural changes of the adipose (fatty tissue) and bone changes.
The rehabilitation training programme strengthens hip adductors and improves dynamic muscle imbalances and proprioceptive mechanisms of hip and knee joints. It is important to perform a biomechanical analysis of walking and running and then correct the abnormalities that could lead to the recurrence of ITB syndrome.
Osgood-Schlatter disease is classified as osteochondrosis characterised by disturbances in the normal process of bone growth. It appears most often during the accelerated skeletal growth during puberty. When straining, repetitive mechanical pulling of the junction where the patellar ligament grows attached to the tibia causes avascular necrosis and inflammation. Continuous straining leads to micro-injuries and weakening of the growth plate.
Osgood-Schlatter lesion is only a superficial defect of the patellar ligament junction or apophysis. At the pathophysiological level, this is a local disruption of blood supply due to micro-injuries of the growth plate, caused by high forces. The disease can also develop as a consequence of acute knee joint ligament injury or knee dislocations or fractures. Adolescents of male sex between 7 and 18 years of age and children who rapidly gain body weight or grow in height suffer from this disease most often.
The pain appears at the spot of tibial tuberosity and typically grows stronger after sports activity or straining.
It most commonly affects young sportspeople who do a lot of jumping, change directions, and stop. The pain can be unilateral or bilateral; it intensifies when increasing the load and improves when resting.
What is also typical of Osgood-Schlatter disease is redness and change in skin temperature underneath the knee. An externally visible lump may also appear. X-ray images show bone changes and swelling of the soft tissues. The symptoms usually disappear at the end of the growth period. The lump underneath the knee is often hard to the touch. During the advanced phases of the disease, it is typical to lose full mobility.
To rule out fractures, it is necessary to carry out X-ray imaging, followed by clinical testing by an orthopedic specialist.
Treatment is conservative, using physical therapy and rehabilitation exercises after the suspected Osgood-Schlatter disease has been diagnosed or confirmed.
The second phase of treatment includes a progressive exercise programme that gradually prepares the sportsperson to return to the regular training process.
The treatment of Osgood-Schlatter disease is long-lasting and can take from 4 months to several years, however, the athlete can gradually return performing activities once the acute symptoms subside and the progressive exercise programme strengthens the muscle tissues of the knee.
Medial and lateral collateral ligaments are important lateral knee joint stabilisers.
Medial collateral ligament (MCL) injury oftentimes occurs in isolation, whereas lateral collateral ligament (LCL) injuries are frequently accompanied by injuries to other knee structures.
40% of all serious knee injuries include the MCL injury (medial collateral ligament), which is the most frequently injured anatomical structure of the knee, after ACL (anterior cruciate ligament).
Lateral ligament injuries are characterised by intense pain in the medial and/or lateral part of the knee joint.
Collateral ligament injuries do not cause joint swelling unless other accompanying injuries to knee structures that cause joint inflammation are present. Bleeding in the joint is common after an LCL injury. The peculiarity of the LCL injury is that stretching the ligament causes more pain than fully rupturing it.
Before starting treatment, it is important to undergo x-ray (RTG) imaging to exclude skeletal injuries and diagnostic magnetic resonance imaging (MRI) to confirm the suspected lateral knee ligament rupture.
The valgus stress test is positive in most MCL injuries (mostly grade I). The varus stress test is positive mostly in the case of severe injuries to the lateral side of the knee.
Conservative treatment is usually successful in treating the medial collateral ligament (MCL), whereas the injury to lateral collateral ligament (LCL) requires the surgical method of treatment in the majority of cases.
Arthrosis or osteoarthrosis is a degenerative process that starts on the joint cartilage during the initial phases and continues on the bone during the later stages of joint wear.
Arthrosis denotes the general progressive loss of joint cartilage. Out of all joints, knee cartilage is injured most often.
Joint cartilage is dense connective tissue that reduces friction and thus ensures smooth movement of joint structures and protects the bone. What is typical of cartilage is that it is avascular, which is why it has a low potential for healing. Cartilage is regenerated or nourished exclusively by the means of diffusion or movement of nutrients and oxygen through the synovial fluid. This means that the movement of joint conditions its regeneration.
Knee arthrosis is a chronic degenerative condition that causes ossification of joint cartilage. During the first phase of cartilage degeneration or joint wear, the changes appear only on the surface of cartilage like a disruption of upper layers. Such cartilage loses its natural form and is no longer smooth or flat.
As osteoarthrosis progresses, the process of degeneration spreads deeper into cartilaginous structures to the subchondral bone. Defective cartilage has low healing potential, however, it does somewhat regenerate on the edges with softer tissue, which is less resistant to high forces, which inevitably leads to the spread of cartilage wear.
Before beginning the treatment of knee arthrosis, it is important to perform diagnostic testing using magnetic resonance imaging (MRI) to accurately assess the extent of joint damage.
Some effective measures that improve the symptoms of arthrosis include:
Knee arthroplasty is a technical term for surgically inserting an artificial knee joint into the lower extremity.
The goal of total knee replacement is to eliminate pain, improve the quality of life and repair the knee mechanics. Total knee replacement is performed in the case of advanced cartilage wear or injury on one or multiple cartilage surfaces due to various reasons – most often it is a consequence of osteoarthrosis or inflammatory arthritis. In Slovenia, there are 4,000 total knee replacements per year.
Symptoms in the final stages of cartilage wear include chronic pain:
Before surgically inserting the knee joint prosthesis, it is recommended to undergo conservative preparations for surgery. Before surgery, the patient should follow a 3-month regime of special exercises to improve proprioceptive knee mechanisms, exercises to strengthen thigh muscles in a predominantly isometric regime in angles that do not provoke symptoms, and a regime to improve general physical fitness.
The approach to preoperative rehabilitation should be holistic, because improving general physical fitness and local muscle capacities accelerates the mechanism of soft tissue regeneration. In the period of six to nine months after surgically inserting the knee joint prosthesis, the majority of patients can begin with normal physical activities.
Postoperative rehabilitation is finally completed in a period between nine and twelve months. In the first postoperative months, it should be carried out in the progressive regime of special exercises with physical therapy, and then it should continue with professionally guided individual training during the second phase of rehabilitation.
