Physiotherapy and rehabilitation
Here we present the most common knee injuries. Every knee pathology or injury has a description of general features, the cause of the injury, the characteristics of the symptoms, diagnostics, and the course of treatment.
The anterior cruciate ligament (ACL) is one of four key ligaments that provide passive stability of the knee joint. The anterior cruciate ligament is the most commonly injured ligament in the knee and one of the most common injuries in general. An ACL injury is considered a more serious injury in sports, as it is characterised by a long and complex rehabilitation.
The injury occurs due to forced, strong hyperextension of the knee (the knee is pushed back) or due to sudden pivoting (rotation of the body around a fixed foot and shin). The risk of anterior cruciate ligament injury is a combination of weak thigh muscles and a lot of landings, as well as poor endurance of the hamstring muscles in combination with sports activities, impacts, collisions and falls.
There are two known mechanisms of anterior cruciate ligament injury: a non-contact mechanism and a contact mechanism. Approximately 70% to 80% of ACL injuries are non-contact in nature, meaning that the cause of the injury is not an external force such as a collision, impact, or fall.
Non-contact injury occurs due to ligament failure. A large number of ACL injuries can be prevented by proper physical preparation for sports activities.
Symptoms of an ACL injury include severe knee pain that can radiate to the entire extremity, limited knee mobility (extension and bending of the knee), oedema or swelling that occurs several hours after the injury and gradually increases, a feeling of instability in the knee, a feeling of swaying or floating of the knee, and gradual loss of muscle mass in the quadriceps femoris muscles, especially on its inner section.
Approximately 40% of all patients with ACL injuries report a popping sensation at the moment of injury, which occurs due to a rupture of the ligament.
In more than half of all anterior cruciate ligament injuries, there are associated injuries to the meniscus of the knee joint. When an injury occurs, prompt diagnosis is crucial, specifically X-rays and magnetic resonance imaging (MRI), which confirm or rule out an ACL injury and skeletal fractures.
After an ACL injury, the RICE method of acute management should be applied.
Preoperative rehabilitation is mandatory, which is carried out intensively until the day of surgery. It is necessary to stop the swelling of the joint, eliminate the pain symptoms, regain the full range of motion of flexion and extension of the knee, and prevent or reduce muscle atrophy. The progress of preoperative rehabilitation depends on the extent of the injury and the patient’s participation.
In the case of a complete ACL rupture, surgical transplantation of the ligament is required.
If it is a partial ACL rupture, conservative treatment is first performed with special training to improve muscle strength and control of the knee joint during movements. If knee instability or severe pain symptoms do not subside, surgical treatment is necessary even in the case of a partial ACL rupture.
Postoperative rehabilitation of the anterior cruciate ligament lasts between six and nine months, depending on the patient’s age, level of sports activity, and the extent of the injury. During the first month of rehabilitation, we perform therapies to reduce swelling and pain and gradually apply special exercises to activate the thigh muscles and gain full range of extension and flexion of the knee joint.
The posterior cruciate ligament prevents the tibia from sliding backward and excessive internal rotation of the tibia; it is thicker, heavier, and twice as strong as the anterior cruciate ligament (ACL). The PCL is the strongest ligament of the knee.
Posterior cruciate ligament injuries are less common than ACL injuries, with only 19% of knee injuries involving PCL injuries, while 31% of knee injuries annually are ACL injuries.
When a posterior cruciate ligament injury occurs, it often involves a strong force that also damages the ligaments, cartilage, and/or bones. When the PCL is injured, posterior translation (backwards move of the tibia) increases, while external rotation of the tibia is reduced. A PCL injury is generally considered to be riskier and more dangerous than an ACL injury, as it causes greater limitations in every activities, such as walking, due to poor muscle fitness and associated collateral ligament damage.
When an posterior cruciate ligament injury occurs, prompt diagnosis is crucial, specifically X-rays and magnetic resonance imaging (MRI), which confirm or rule out a PCL injury and skeletal fractures.
Symptoms include swelling, posterior knee pain, and a feeling of instability or knee floating.
The swelling is smaller than with an anterior cruciate ligament injury, but otherwise it has a similar acute phase, which includes pain, reduced knee mobility or traumatic spasm, and difficulty walking.
If the PCL is not accompanied by damage to other joint structures of the knee, the injury is often more difficult to diagnose with clinical tests alone, so magnetic resonance imaging (MRI) is crucial.
Treatment for PCL is mostly surgical, followed by professionally designed rehabilitation with progressive training and physical therapy.
PCL rehabilitation without major complications takes between six and nine months, depending on the extent of the injury. Partial PCL ruptures or strains are treated conservatively with specialised training after the acute phase has subsided; if this does not improve the symptoms of the injury, ligament reconstruction is recommended.
Surgical treatment of PCL is more demanding and time-consuming compared to surgical treatment of ACL, as it requires more limitations in early postoperative rehabilitation and a longer preoperative rehabilitation phase.
At least a 12-week preoperative rehabilitation programme is recommended to maintain strength and regain full range of motion, thereby reducing muscle atrophy after ligament reconstruction and accelerating postoperative healing.
Half of all knee joint injuries are meniscus injuries, with meniscal lesions the most common reason for knee surgery.
The knee meniscus is a crescent-shaped fibrocartilaginous anatomical structure located between the tibia and femur. The knee contains a medial (inner) meniscus and a lateral (outer) meniscus. Injuries to the medial (inner) meniscus are more common. Meniscus injury often occurs with anterior cruciate ligament rupture and knee instability. As much as 60% of the population over the age of 65 has degenerative meniscus changes.
Depending on the type of meniscus injury, we distinguish:
The area of meniscus damage is divided into:
Symptoms of meniscus injuries include:
Meniscus injuries can be treated surgically or conservatively. Surgical treatment can be performed as a partial meniscectomy (removal of the damaged part) or as meniscus suturing. Meniscectomy is chosen when there is damage to a part of the meniscus that has very poor blood supply and is therefore likely to heal poorly after suturing.
Surgery is not necessary for most injuries, because as much as 75% of meniscus injuries are successfully treated with modern physiotherapy methods.
Surgery is recommended for injured individuals who experience knee catching or painful skipping. Surgery is also recommended for patients who had undergone at least three months of physiotherapy treatment that was unsuccessful.
Surgical removal of the meniscus significantly increases the risk of subsequent degenerative changes in the knee and the development of arthrosis, which is why physiotherapy rehabilitation is primarily recommended for all minor meniscus injuries.
The comprehensive conservative rehabilitation programme includes exercises to strengthen the thigh muscles, special exercises for joint proprioception, and exercises for mobility and muscle fibre endurance.
In the event of surgery, preoperative rehabilitation is recommended, which uses exercises to prevent muscle atrophy and exercises to strengthen neuromuscular connections. Because meniscus injuries pose a risk of accelerated wear (arthrosis) of the knee, immediate start of appropriate treatment is essential.
The duration of rehabilitation after a meniscus injury depends on the treatment method, the area of injury to the meniscus, concurrent injuries to other knee structures, patient participation, mechanical symptoms, and the presence of complications.
Rehabilitation of a meniscus injury lasts from a few weeks for minor lesions to seven months after surgical treatment of complex lesions, such as bucket handle or flap type meniscus injuries.
A knee sprain is a term for strained or torn ligaments in the knee, which occurs due to an incorrect landing, a rapid change of direction, or a blow to the knee.
A sprain is often accompanied by pain and swelling, and bruising and a feeling of weakness may also occur.
In the event of a sprain, an expert diagnosis is first required to determine which ligaments have been damaged, and then, based on the findings, an appropriate rehabilitation system is prescribed.
To eliminate inflammation, rest and cooling are first necessary, followed by appropriately designed training for strength, especially for the knee and hip muscles, which is tailored to the specific ligament injury.
The choice of conservative rehabilitation treatment or surgical treatment depends on many specifics of the injury that caused the instability, which you can read more about on our website under ‘Knee injuries’.
The feeling of knee instability or buckling knee that gives way during movement is caused by numerous pathological conditions in the knee. A buckling knee rarely has a single cause; it is a general symptom of knee joint injuries.
A common cause of knee instability is ligament damage, such as rupture of the anterior cruciate ligament, posterior cruciate ligament, or medial or lateral collateral ligament.
The most common cause of knee instability is damage to the medial collateral ligament, which also has a high potential for self-healing, so knee instability is just an acute symptom that eventually subsides with the application of rehabilitation training. In contrast, anterior cruciate ligament (ACL) injury is often the cause of more severe and permanent knee instability; additionally, the ACL has a low self-healing potential, so surgical treatment is necessary for most ligament ruptures.
To choose the appropriate treatment method, an examination by an orthopaedic specialist is required, who uses clinical tests to provide an opinion on the damage to the knee structures. It is advisable to perform magnetic resonance imaging (MRI) diagnostics after a specialist examination, which provides an accurate picture of the extent of damage to the knee structures that caused the instability of the knee joint.
The choice of conservative rehabilitation treatment or surgical treatment depends on many specifics of the injury that caused the instability, which you can read more about on our website under ‘Knee injuries’.
In general, knee instability is most often caused by injuries to the anterior cruciate ligament, medial collateral ligament, meniscus, cartilage, and patella.
To choose the appropriate treatment method, an examination by an orthopaedic specialist is required, who uses clinical tests to provide an opinion on the damage to the knee structures.
The choice of conservative rehabilitation treatment or surgical treatment depends on many specifics of the injury that caused the instability, which you can read more about on our website under ‘Knee injuries’.
Jumper’s knee, or patellar tendinopathy, is an overuse injury to the knee joint that is often the cause of a decline in a sports career.
The incidence of jumper’s knee varies greatly between sports, with more than 40% of athletes in volleyball, basketball, and track and field being treated for patellar tendinopathy at least once in their careers.
The overall incidence of jumper’s knee in sports involving jumping is 20%. As many as 55% of athletes who experience patellar tendinopathy report a decline in their sports career.
Although it is a sports injury, it is also common in physically demanding professions. About 35% of the population inactive in sports and experiencing jumper’s knee reports a strong negative impact on work productivity.
Jumper’s knee often occurs in running, basketball, volleyball, football, hiking, tennis, badminton, handball, track and field, American football, and squash. Jumper’s knee has a high rate of recurrence, and symptoms can last for several years if not treated properly.
Symptoms most often include pain on the front of the knee in the subpatellar area (just below the kneecap), which can be elicited by palpation.
The pain is worsened by load, direct pressure on the knee, such as kneeling or blows to the knee.
Patellar tendinopathy is characterised by increased pain a few hours to a few days after putting load on the knee, which may actually decrease during activity.
Advanced phases of patellar tendinopathy are characterised by a decrease in activation in the quadriceps muscle and generally poorer isometric activation compared to a healthy knee.
Patellar tendinopathy has three stages:
The complexity of treating a jumper’s knee escalates depending on the stage of tendinopathy; in all three stages, the basic means of treatment is tailored specialised training, which progressively strengthens the ligament and asymmetrical muscle groups. Only 10% of patients in the third stage of jumper’s knee are suitable for surgical treatment.
The condition is characterised by severe pain symptoms even during basic movements such as walking, sitting down, and standing up, with typical loss of full knee extension and swelling of the joint when overloaded.
The complexity of treating a jumper’s knee escalates depending on the stage of tendinopathy; in all three stages, the basic means of treatment is adapted specialised training, which progressively strengthens the ligament and asymmetrical muscle groups. Only 10% of patients in the third stage of jumper’s knee are suitable for surgical treatment.
It is necessary to apply therapeutic techniques for symptom management, modify loads, and implement a progressive training programme. It is important to emphasise that the second stage of jumper’s knee can progress very quickly if the first stage is not treated, or if it is treated superficially.
Patellofemoral pain syndrome (PFPS) refers to pain in the front of the knee joint, which can have multiple origins that are more difficult to accurately diagnose. It is often an inflammation of the synovial joint membrane, lesions of the subchondral bone of the patella, inflammation of the patellar attachments, or irritation of the infrapatellar fat pads.
The most common cause of patellofemoral pain syndrome (PFPS) is overload of the knee combined with incorrect lower extremity biomechanics and incorrect patellar sliding.
The most common risk factors for developing patellofemoral pain syndrome are:
The risk factors listed above lead to improper sliding of the patella, causing pain symptoms and inflammation in the joint. Patients with PFPS are at higher risk of developing osteoarthrosis of the knee joint.
Because PFPS has different origins, the symptoms also vary. The pain may be present just below or above the patella, or the entire joint may be symptomatic.
Spontaneous, dull pain that an individual feels at rest and is typically worse after exertion is characteristic of chronic overload of the soft structures around the patella.
Sharp, pinpoint pain that occurs with a specific event or movement and is more intense during exertion is often associated with acute joint injury.
The pain that the patient feels at night can be the result of both chronic overload or fresh injuries to the knee joint.
If the pain recurs during minor knee flexions (20–40°, e.g. when landing or running), it indicates an irregular sliding of the patella, which is not in the ideal line in the groove – most often it is a lateral subluxation of the patella.
Treatment begins with a diagnostics and history of knee pain. Clinical tests and magnetic resonance imaging (MRI) are recommended to determine the origin of PFPS. Treatment of PFPS is carried out with rehabilitation training aimed at improving the biomechanics of the knee joint, strengthening the thigh muscles, and stabilising the patella.
Treatment of PFPS is carried out with rehabilitation training aimed at improving the biomechanics of the knee joint, strengthening the thigh muscles, and stabilising the patella. In the case of broken patterns of walking, running or jumping, it is necessary to technically repair the patterns and thereby prevent PFPS recurrence.
In the acute phase, we use instrumental physiotherapy and manual techniques to release tense muscle structures and reduce pain.
Complete rest does alleviate pain, but it does not eliminate the causes of PFPS, specifically poor biomechanical patterns, asymmetric muscles, and improper patellar movement. During specialised rehabilitation training, we focus on optimising the intermuscular coordination of the quadriceps heads and establishing dynamic symmetries between agonists and antagonists in the hips, knees, and feet.
Patellar instability is a frequent cause of patellofemoral pain syndrome. This means that the patella moves outside the femoral groove and causes pain symptoms during knee movements.
This condition may be the result of a congenital abnormal femoral groove (an uneven, shallow groove) and/or a congenital malpositioning of the patella, which may be too high or too low in the femoral groove. It can also be the result of an acute dislocation of the patella from a blow to the knee, a fall, or quick rotation of the knee, and can also be caused by asymmetries in muscle tension and activation.
Patellar instability is categorised into several types, which also present different symptoms.
The patella may simply be malpositioned in the knee joint, and chronic dislocation of the patella is also possible.
Symptoms of patellar instability include swelling of the knee, snapping and catching during movement, pain when sitting, stiffness of the knee with loss of mobility, outwardly visible deformity of the knee, and complete loss of strength. Only one of the symptoms may appear, or there may be a combination and progression of symptoms.
The most common symptom of patellar instability is pain under the patella when the knee is flexed beyond 120° and mild dislocation of the patella when the knee is bent.
To make a diagnosis, it is necessary to perform a clinical examination of the knee, do an X-ray scan that shows the location of the patella in the joint, and magnetic resonance imaging (MRI) to assess the extent of damage to the knee structures.
If we are treating a complete dislocation of the patella, it is necessary to reposition it back into the femoral groove, which often happens spontaneously.
If we are treating a complete dislocation of the patella, it is necessary to reposition it back into the femoral groove, which often happens spontaneously. A patellar dislocation often results in damage to the cartilage surface under the patella and a rupture of the medial patellofemoral ligament, which stabilises the patella.
In most cases of patellar instability, when the patella lies incorrectly in the femoral groove, the greatest success is achieved with conservative individualised therapy and rehabilitation training.
Conservative treatment is carried out in two phases:
Runner’s knee, or iliotibial band syndrome (ITBS), is a common overuse injury in runners and cyclists. This conditions is characterised by pain on the outside of the knee during movement. Pain symptoms occur due to the friction of the iliotibial band (ITB) against the lateral condyle of the femur, which causes inflammation and damage to local tissue, and is often described as friction syndrome.
Recent research shows that in addition to friction, there is compression of the innervated adipose (fatty) tissue located between the lateral condyle of the femur and the ITB. At a 30° knee flexion angle, the greatest compression of adipose tissue occurs between the femur and the ITB – these are primarily the angles involved in running and cycling.
Runner’s knee is most often caused by excessive amounts of monotonous load, changes in the running surface, muscle imbalances in the thighs, valgus knee and hip, and poor footwear. Iliotibial band syndrome (ITBS) is an injury of the young, as it most often develops before the age of 35, and it affects women more often.
Runner’s knee is an overuse injury that is common in runners and cyclists. The causes of ITBP are most often related to muscles and training. Weak hip abductors and pelvic stabilisers (especially the gluteus medius) cause forces to be transferred to a greater extent to the ITB, which becomes overloaded.
With weak active stabilisers (muscles), force is always transferred to the passive stabilisers – the iliotibial band (ITB), which becomes excessively tense, consequently irritating the adipose fat pad on the outside of the knee during movement, and causing sharp and burning pain.
The most severe pain often occurs when the heel contacts the ground (running, walking). Pain often occurs after just a few minutes of walking or running. After the activity is over, the pain usually subsides and reappears with increased load.
The diagnosis is made based on a clinical examination. A patient with ITBS shows tenderness upon palpation over the lateral projection of the femur.
Magnetic resonance imaging (MRI) is recommended, which shows swelling in the area of adipose (fatty) tissue. In the chronic state of ITBS, MRI scans show structural changes in adipose (fatty) tissue and changes in bone.
With the rehabilitation training programme, we strengthen the hip abductors, improve dynamic muscle imbalances, and proprioceptive mechanisms of the hip and knee joints. It is important to perform a biomechanical analysis of walking and running, and to correct abnormalities that could lead to the recurrence of ITBS.
Osgood-Schlatter disease is classified as an osteochondrosis, characterised by a disruption of the normal bone growth process. It most often occurs during the period of accelerated skeletal growth during puberty. When overloaded, repeated mechanical pulling of the patellar ligament attachment point on the tibia causes avascular necrosis and inflammation, which, with continued load, leads to microinjuries and weakening of the growth plate.
An Osgood-Schlatter lesion is only a superficial defect of the attachment of the patellar ligament or apophysis. At the pathophysiological level, it is a locally disrupted blood supply due to microtrauma to the growth plate caused by excessive forces. The disease can also occur as a result of acute injury to the knee joint ligaments or dislocations and fractures of the knee. It most frequently affects are male adolescents between the ages of 7 and 18 and children who rapidly gain body weight and/or grow in height.
The pain occurs in the area of the tibial tuberosity and typically worsens after sports activity or load.
Young athletes who perform a lot of jumps, changes of direction, and stops are most commonly affected. The pain can be unilateral or bilateral, increases with higher loads, and improves with rest.
Osgood-Schlatter disease is also characterised by redness and a change in the temperature of the skin below the knee, an externally visible bulge may also appear, and an X-ray scan shows changes in the bones and swelling of the soft tissues. Symptoms often subside once the growth period ends. The bump under the knee is often hard to the touch, and loss of full knee mobility is also characteristic in advanced stages of the disease.
To rule out fractures, an X-ray scan should be performed, followed by clinical testing by an orthopaedic specialist.
Treatment is conservative with physical therapy and rehabilitation training after a diagnosis or confirmed suspicion of Osgood-Schlatter disease.
In the second phase of treatment, a progressive training programme is implemented, which gradually prepares the athlete to return to their regular training process. Treatment of Osgood-Schlatter disease is long and lasts from four months to several years, but the athlete can gradually return to activities when the acute symptoms subside and a progressive training programme strengthens the knee muscle tissues.
The medial and lateral collateral ligaments are important lateral stabilisers of the knee joint.
A medial collateral ligament (MCL) injury is often isolated, while a lateral collateral ligament (LCL) injury is often accompanied by injuries to other knee structures. Approximately 40% of all serious knee injuries involve an MCL injury (medial collateral ligament), which is the second most commonly injured anatomical structure of the knee after the ACL (anterior cruciate ligament).
Collateral ligament injuries are characterised by severe pain medially and/or laterally in the knee joint. Collateral ligament injuries do not cause joint swelling, unless there are associated injuries to other knee structures that cause joint inflammation. After an LCL injury, there is often bleeding in the joint. A particular characteristic of an LCL injury is that a sprain causes more pain than a complete rupture.
Before starting treatment, it is necessary to perform an X-ray scan to exclude skeletal injuries and a diagnostic magnetic resonance imaging (MRI) scan to confirm the suspicion of a rupture of the collateral ligaments of the knee. The valgus stress test is positive in most MCL injuries (mostly grade 1), while the varus stress test is positive mostly in more severe injuries to the lateral side of the knee.
Conservative treatment of the medial collateral ligament (MCL) is usually successful, while damage to the lateral collateral ligament (LCL) requires surgical treatment in most cases.
Arthrosis or osteoarthrosis is a degenerative process that begins in the articular cartilage in the initial stages and continues in the bone in the late stages of joint wear.
Arthrosis refers to the general progressive loss of articular cartilage. The cartilage in the knee is the most commonly damaged cartilage amongst all joints.
Articular cartilage is a dense connective tissue that, by reducing friction, allows smooth movement of joint structures and protects the bone. A characteristic of cartilage is that it does not have a blood supply; therefore, it has a low healing potential, it regenerates or nourishes itself exclusively by diffusion or spreading of nutrients and oxygen through the synovial fluid, which means that movement of the joint enables its regeneration.
Knee arthrosis is a chronic degenerative disease that causes ossification of articular cartilage. In the initial stage of cartilage degeneration or joint wear, changes occur only on the surface of cartilage as disruptions of the upper layers – such cartilage loses its natural shape and is no longer smooth or flat.
As osteoarthritis progresses, the degeneration process spreads into deeper cartilage structures, reaching the subchondral bone. Defective cartilage has a low healing potential, but is repaired to a certain extent at the edges with softer tissue that is less able to withstand large forces, which inevitably leads to wear spreading.
Before starting treatment for knee arthrosis, it is necessary to perform magnetic resonance imaging (MRI) diagnostics to accurately assess the extent of joint damage.
Effective measures to improve symptoms of knee arthrosis include:
Knee endoprosthesis is the technical term for the surgical insertion of an artificial knee joint into the lower extremity.
The goal of inserting a total knee endoprosthesis is to eliminate pain, improve quality of life, and correct knee mechanics. Total endoprosthesis of the knee joint is performed when there is advanced wear or damage to the cartilage in one or more areas of the cartilage surfaces of the knee due to various causes, most often as a result of osteoarthrosis or inflammatory arthritis. In Slovenia, 4,000 knee joint endoprostheses are performed annually.
Symptoms of late-stage cartilage wear cause chronic pain:
Before surgical insertion of a total knee endoprosthesis, it is recommended to undergo conservative preparation for surgical procedure; specifically, the patient should undergo a three-month regimen of specialised training to improve the proprioceptive mechanisms of the knee, exercises to strengthen the thigh muscles in a predominantly isometric regimen at angles that do not provoke symptoms, and a regimen to improve general physical fitness.
Preoperative rehabilitation should be carried out comprehensively, as improving general physical fitness and local muscle capacity accelerates the mechanisms of soft tissue regeneration. Between six and nine months after the surgical insertion of a total knee endoprosthesis, most patients can return to normal physical activity.
Postoperative rehabilitation is finally completed in a period between nine and twelve months. It should be carried out in a progressive regimen of specialised training with physical therapy in the first postoperative months and continued with professionally guided individualised training in the second phase of rehabilitation.
