YOUR GUIDE
TO TREATING
KNEE PAIN
FUNCTIONAL KNEE RANGE
OF MOTION
Normal 0-135°
Walking 0-65°
Climbing up stairs 0-85°
Going down stairs 0-90°
Sitting down and standing up from sitting 0-90/95° more or less
depending on the height of the chairs
Riding a bike 0-115°
Squatting 0-115° minimum
Sitting cross legged 115° knee flexion
Pressure on the knee and kneecap
Walking 2-3x bodyweight (knee joint) 0.5x bodyweight (kneecap)
Climbing up stairs 3-4x bodyweight (knee joint) 2.5x bodyweight
(kneecap)
Going down stairs 3.5x bodyweight (knee joint) 4x bodyweight
(kneecap)
Squatting 2-3x bodyweight (knee joint) 7-8x bodyweight
(kneecap)
FRONT KNEE PAIN
Front knee pain is very common. It could be dull or sharp. Here are
the 5 most common causes of front knee pain that accounts for pretty
much 80% of knee pain that you will see in the clinic.
1. Patellofemoral pain syndrome (runners knee)
This is the most common cause of front knee pain which is a problem
with the patella not gliding properly in the patella groove. Although it
is called runners knee it can happen to non-runners commonly as well.
You may commonly see with this condition:
general ache around the front of the knee and kneecap
accounts for around 25% of all knee problems
Pain in and around the kneecap that happens when you are
active (running, skiing, sports). Or pain after sitting for a long time
with the knees bent.(known as the cinema sign)e.g. sitting at a
cinema, driving long distances, working at a desk) This sometimes
causes weakness or feelings of instability.
can be painful on stairs
Rubbing, grinding, or clicking sound of the kneecap that you hear
when you bend and straighten your knee
usually little to no swelling
can be caused by weak or tight muscles or both (muscle
imbalances) pulling the kneecap to one side or too high
comes on gradually
Strengthening the VMO is essential as it controls the way the
kneecap tracks
avoid bent leg postures for long periods of time.
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FRONT KNEE PAIN
2. Patellar tendonitis (Jumpers knee)
Jumper's knee, also known as patellar tendonitis, is a condition
characterized by inflammation of your patellar tendon classically,
hence the 'itis'. However, studies have shown that there is very little
inflammation in many cases so it is more likely to be degeneration
from wear and tear to the tendon. This is known as tendinosis. This is
why ibuprofen and other anti-inflammatories may have no effect.
You may commonly see with this condition:
Pain and tenderness around your patellar tendon
Pain with jumping, running, or walking
Pain when bending or straightening your leg
Tenderness behind the lower part of your kneecap
usually develops gradually
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FRONT KNEE PAIN
3. Chondromalacia patella
This is a common knee problem caused by a softening and damage
to the cartilage on the back of the patella. The kneecap rubs against
the edge of the patella groove. Abnormal knee cap positioning,
tightness or weakness of the muscles associated with the knee, too
much activity involving the knee, and flat feet may increase the
likelihood of chondromalacia patella. Often affects young healthy
people.
You may commonly see with this condition:
dull aching pain at the front of the knee
A feeling of grinding when the knee is flexed and extended.
pain worse doing knee bends , going down stairs, running down
hill
Standing up after sitting for awhile
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FRONT KNEE PAIN
4. Prepatellar bursitis (housemaids knee)
Caused by inflammation of the bursa generally from frequent or
prolonged kneeling. Bursitis means inflammation within a bursa. A
bursa is a small sac of fluid with a thin lining. There are a number of
bursae in the body. Bursae are normally found around joints and in
places where ligaments and tendons pass over bones. They can also
be found in other places if there has been unusual pressure or friction
placed on that area.
Generally, the function of a bursa is to help reduce friction and allow
maximal range of motion around joints. When there is inflammation
within a bursa (bursitis), the bursa swells due to an increase in the
amount of fluid within the bursa sac.
You may commonly see with this condition:
Swelling on the front of the knee like a sac
Pain when you push with your fingers on the swollen area.
Redness on the swollen area
Increased warmth on the swollen area
Stiffness in the knee joint. Difficulty bending or straightening the
knee
Increased pain with kneeling
Causes
Trauma-direct blow to the knee
Prolonged pressure to the knee (for example kneeling). Common
among carpet layers, tile layers, gardeners and wrestlers
Infection or autoimmune conditions
Repetitive movements of the knee
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FRONT KNEE PAIN
5. Osgood Schlatter Disease
Osgood Schlatter disease is a common but temporary knee pain that
can affect older children and teenagers who play sports. Particularly
sports that include a lot of jumping and knee bending – hockey,
basketball, volleyball, skating, soccer, ballet, and gymnastics are
examples.
This is especially true during growth spurts when the bones are
growing rapidly, and the patellar tendon is relatively short. The
growth spurts commonly occur in boys (ages 11-18) and girls (ages 1016). The problem is more common in boys.
The pain occurs where the kneecap tendon attaches to the bony
bump (tibial tuberosity) below the knee.
You may commonly see with this condition:
Pain
Swelling
Redness
Tenderness of the tendon
Tender bony bump at the top of the shin bone, just below the
kneecap.
These symptoms will generally worsen with activities that involve a
lot of jumping and knee bending.
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PAIN BEHIND THE KNEE
1. Bakers Cyst (Popliteal bursitis)
This is the most common pain behind the knee.
A cyst behind the knee is usually the result of a problem inside your
knee joint (arthritis or a cartilage tear). Both conditions can cause
increased inflammation and increased synovial fluid which seeps into
the bursa behind the knee. Unfortunately, it seeps through a one-wayvalve phenomena and cannot seep back. Baker’s Cyst can be
asymptomatic or present with mild discomfort.
You may commonly see with this condition:
Swelling behind your knee, and sometimes in your leg
Knee pain
Stiffness and inability to fully flex the knee
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PAIN BEHIND THE KNEE
Arthritis:
Arthritis can be the result of natural wear and tear of the knee joint
(osteoarthritis), or it can be a more systemic inflammation problem
caused by rheumatoid arthritis. Arthritis is generally worse with weight
bearing, and stiffer in the mornings or after rest.
Muscle or tendon tear or strain:
Hamstring or calf sprain or tear. Indicated by sudden pain in your calf
or hamstring muscles. Followed by swelling and inflammation. You
may be able to feel point tenderness at the spot the tear occurred.
Use of the calf or hamstring muscle generally increases your pain.
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PAIN BEHIND THE KNEE
Deep Vein Thrombosis (DVT):
A DVT is the occurrence of a blood clot in one or more of the deep
veins of your leg. It can occur if you are on a medication affecting
how your blood clots. It can also occur if you are immobile a long
time due to surgery, long distant traveling (plane or car), or being on
bedrest. DVTs can be serious because the clots in your veins can
break loose and travel up and block blood flow in your lungs, heart or
brain.
Common DVT symptoms include:
swelling in your foot, ankle, or leg, usually on one side
cramping pain in your affected leg that usually begins in your calf
severe, unexplained pain in your foot and ankle
an area of skin that feels warmer, swollen and more painful than
the skin on the surrounding areas
skin over the affected area turning pale or a reddish or bluish
color, depending on skin tone
This condition MUST be referred to a Doctor
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INSIDE KNEE PAIN
MCL (medial collateral ligament) tear
The most common cause of medial knee pain in people under 50.
MCL tears are the most common knee ligament injury, and
approximately 40% of all knee injuries involve the MCL.
An MCL tear is damage to the medial collateral ligament, which is a
major ligament that’s located on the inner side of your knee. The tear
can be partial (some fibers in the ligament are torn) or complete (the
ligament is torn into two pieces).
Can you still walk with a torn MCL?
If you have a grade 1 (minor) MCL tear, you'll likely still be able to
walk at the time of the injury, though it might be painful. A grade 2
(moderate) MCL tear could make it difficult to walk at the time of the
injury since your knee won’t be as stable as it normally is. If you have a
grade 3 (severe) MCL tear, it’ll be difficult to walk since your knee will
be unstable, and you probably won’t want to walk since it’ll be very
painful. In most cases, treatment for MCL tears involves using crutches
to limit the amount of weight you put on your affected knee.
If you injure your knee, it’s important to contact your healthcare
provider immediately or go to the nearest hospital, even if you can
still walk on it.
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INSIDE KNEE PAIN
MCL (medial collateral ligament) tear Continued
What causes an MCL tear?
Sudden and forceful turning, twisting and “cutting” can cause MCL
tears. A direct blow to the outer side of your knee can also cause an
MCL tear. MCL tears are most common in people who play certain
sports like skiing, football, basketball and volleyball.
The following situations can cause an MCL tear:
Planting one foot into the ground and forcefully shifting direction
(this is known as “cutting” in sports).
When something or someone hits your knee on its outer side, such
as from a football tackle.
Squatting or lifting heavy objects.
Landing awkwardly on your knee after a jump.
Hyperextending (overstretching) your knee. This is common in
skiing.
Repeated pressure and stress to your knee, which causes your MCL
to lose its elasticity (like a worn-out rubber band).
The symptoms of an MCL tear can vary based on how severe your
tear is. If your MCL is torn, you may experience the following signs
and symptoms:
Hearing a popping sound at the time of the injury.
Experiencing pain in your knee.
Having tenderness along the inner side of your knee.
Having stiffness and swelling in your knee.
Feeling like your knee is going to “give out” if you put weight on it.
Feeling your knee joint lock or catch when you use it.
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INSIDE KNEE PAIN
Medial Meniscus Tear
The medial meniscus is an important shock absorber on the inside
(medial) aspect of the knee joint. It absorbs about 50% of the shock
of the medial compartment.
A meniscus tear can occur when the knee is suddenly twisted while the
foot is planted on the ground. A tear can also develop slowly as the
meniscus loses resiliency
f you've torn your meniscus, it might take 24 hours or more for pain
and swelling to begin, especially if the tear is small.
You might develop the following signs and symptoms in your knee:
A popping sensation
Swelling or stiffness
Pain, especially when twisting or rotating your knee
Difficulty straightening your knee fully
Feeling as though your knee is locked in place when you try to
move it
Feeling of your knee giving way
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INSIDE KNEE PAIN
Pes Anserine Bursitis
Pes anserine bursitis is an inflammation of the bursa located between
the shinbone (tibia) and three tendons of the hamstring muscle at the
inside of the knee. It occurs when the bursa becomes irritated and
produces too much fluid, which causes it to swell and put pressure on
the adjacent parts of the knee.
Pain and tenderness on the inside of your knee, approximately 2 to 3
inches below the joint, are common symptoms of pes anserine bursitis
of the knee.
Bursitis usually develops as the result of overuse or constant friction
and stress on the bursa. Pes anserine bursitis is common in athletes,
particularly runners and swimmers (in particular breaststroke). People
with osteoarthritis of the knee are also susceptible.
The symptoms of pes anserine bursitis include:
Pain slowly developing on the inside of your knee and/or in the
center of the shinbone, approximately 2 to 3 inches below the
knee joint.
Pain increasing with exercise or climbing stairs
Puffiness or tenderness to the touch in this area
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OUTSIDE KNEE PAIN
Iliotibial Band Syndrome
Pain on the outside of your knee is often Iliotibial band syndrome.
Iliotibial band syndrome (ITBS) is one of the most common knee
injuries. It is caused by friction between the iliotibial band (band on
side of hip) and the lateral epicondyle of the femur (bony bump on
the outside of the knee).
The syndrome often appears with endurance sports such as cycling
and long distant running. Weight training with heavy weights may also
bring on the pain.
Signs and Symptoms:
Pain or a stinging sensation may be felt over the bump on the
outside of the knee. This where the IT band slides over the bone.
The pain may also travel up the side of the knee and slightly
below.
You may also feel swelling or a thickening of the tissue over the
bone.
The pain is most intense when the knee is bent to 30 degrees.
The pain may not be felt immediately with the activity but may
intensify with time such as running
There may be a snapping when the knee is bent
Causes:
Your hip abductor muscles may be weak. You also may be
internally rotating the hip (weak hip external rotators) which is
causing your knee to bend in. Flat feet (pronating) would do the
same.
Training Habits that can contribute to ITBS include:
Sitting in the lotus position for prolonged periods.(Lotus Position)
Running on a surface which is banked or has a camber or running
uphill or downhill.
Excessive heel strike force when running.
Running up and down stairs
Hiking long distances
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OUTSIDE KNEE PAIN
Lateral Collateral Ligament (LCL) Injury
An LCL injury is a sprain or tear to the lateral collateral ligament
(LCL). The LCL is a band of tissue on the outside of your knee. It
connects your thighbone to the bone of your lower leg and helps
keep the knee from bending outward.
You can hurt your LCL during activities that involve bending, twisting,
or a quick change of direction. For example, the LCL can be injured in
football or soccer when the inside of the knee is hit. This type of injury
can also occur during skiing and in other sports with lots of stop-andgo movements, jumping, or weaving.
An injury to your LCL may cause:
Swelling, pain, and tenderness. Several hours after the injury, your
pain may get worse. And it might be harder to move your knee.
There may be swelling or bruising.
An unstable feeling in your knee, like it may lock up, buckle, or give
out.
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GENERAL KNEE PAIN
Some knee problems cause more generalized pain all around the knee and
sometimes it even moves around to different areas. Some knee problems
present differently depending on which structures have been damaged e.g.
meniscus tears can present differently depending on the tear and its
location. Also, when there is swelling it can also cause more diffuse
generalized pain.
1. Cartilage/meniscus tear
Tears can often cause general pain and can occur from either a trauma
(acute injury) or from gradual wear and tear.
Classic symptoms of meniscus tears include:
Knee locking : when you try to straighten it it locks
general ache with sharp, catching pain
pain is worse when weight bearing particularily running, squatting and
stairs.
2. Arthritis
Osteoarthritis of the knee is a degenerative condition where the cartilage
is worn down and damaged. Arthritis is the most common cause of knee
pain for people over 50.
Classic symptoms may include:
Knee stiffness which is worse after resting e.g. first thing in the morning
or after sitting for a while and then gradually eases after moving the
joint around.
end range movements can be restricted (extension and flexion)
may be worse in cold weather
may be worse after being on it(i.e standing, walking)
commonly grinding, clicking noises (crepitus) and feel
Swelling that may come and go
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GENERAL KNEE PAIN
3. ACL injuries
Injuries to the ACL can cause generalized pain in the knee also.
The classic symptoms are:
a loud 'pop' is heard/felt in about 50% of injuries
immediate knee swelling from the injury
immediate pain
can be severe instability
knee will often give way
knee movements are often restricted especially knee extension
4. PCL injuries.
These are much less common and are usually caused by a sudden
force through the top of the shin bone from the front which
hyperextends the knee joint. Sometimes it may be from a twisting
injury.
The classic symptoms are :
mild to moderate knee pain when weight bearing on a bent knee
mild to moderate knee swelling
instability but not likely to give way
difficult in certain movements such as the push off movement when
walking, carrying heavy items and taking off shoes
they often say that the knee just doesnt feel right
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KNEE SYMPTOMS
So now that you have heard about possible causes based on location,
not lets try to narrow it down even more by specific symptoms.
Noises-popping, clicking, crunching, snapping, grinding
Many people can hear noises when squatting or standing up from
being on the floor. Some people may bend or straighten the leg to
get a 'releasing pop' and then it feels better.
Popping that causes no pain:
Gas bubbles: These are common causes of knee noises. The formation
of gas bubbles in the joint (CO2) can form when we are resting and
then the person starts moving they pop similar to bubble wrap. This is
the same as cracking your knuckles. It doesnt cause harm and does
not lead to arthritis. These are not harmful
Ligaments/tendons: Sometimes called a tendon snap where as you
move the joint that ligamt or tendon flicks over a bony prominence.
These are not harmful
Popping with an injury
ACL tears: This is a loud pop and happens with about 50% of ACL
tears and is often said to sound like a gunshot.
MCL tears: a popping or tearing sound at the time of injury and then
pain normally on the inside of the knee with pain, swelling and
instability. They will also often have trouble bending the knee.
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KNEE SYMPTOMS
Chronic painful popping without an injury
Knee cartilage tear: a tear of the meniscus can cause pain and
cracking or popping when the flap gets caught in the joint. There may
also be locking and often swelling. These symptoms come and go as
the flap gets caught and releases.
Arthritis: This can produce noises from the wear and tear of the
articular surfaces and maybe formation of bone spurs (osteophytes).
The person may have painful popping, grinding and clicking noises.
These noises tend to be consistent unlike the meniscus tear because
the condition is causing it as opossed to the torn meniscus getting
caught sporadically depending on where it is.
Chondromalacia patella: These can commonly cause a grinding
sensation due to the inflammation and irritation to the back of the
kneecap cartilage. The grinding can often be felt when you put your
hand on their kneecap and have them bend and straingthen the knee
joint. It is most common in healthy, young sporty teenagers.
Runners knee: This is due to a tracking problem of the knee cap in the
the patellafemoral groove and can often create a grinding sensation
on movements of the knee. The grinding noise tends to come and go.
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KNEE SYMPTOMS
Noise coming from doing certain movements
Painless Knee popping on extension: Generally due to gas bubbles
or runners knee
Painful knee popping on extension and flexion: generally cartilage
damage or arthritis. If its painless probably gas bubbles.
Painful popping when bending or squatting: Often due to a
cartilage tear or Chondromalacia patella:
Painful popping with twisting: Sudden knee pain and popping in a
twisting motion is usually due to a ligament injury. Its most likely to be
the ACL or MCL tearing. If the knee swells up and feels unstable they
should see a Doctor.
Will the popping ever stop?
The popping depends on what is causing but very often it will just
settle down in time. For example, soft tissue injuries take about 8-12
weeks to heal and the popping sounds generally abate after 2-3
months by doing knee strengthening exercises.
If it is due to gas bubbles they will probably continue because it is not
a structural problem. This is not a problem for the joint itself.
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KNEE SYMPTOMS
Why is it swollen?
Swelling is very common with many knee problems that have pain.
Acute injuries:
when someone injures their knee there can be bleeding in the joint
causing the swelling. It will generally happen quickly after the injury
and depending on the severity, there may be associated bruising as
well. The more severe the injury the more swelling there will be and
the quicker it will accumulate.
Common problems:
ACL tears: This is commonly seen in ACL tears which will be painful,
may have heard a large pop and may be instability.
Meniscus tears: swelling and also may be locking and painful to go
up and down stairs and squatting.
Bone fractures: These will normally be quite obvious and could
involve any of the associated bones including the kneecap.
These conditions should be referred to a Doctor.
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KNEE SYMPTOMS
Why is it swollen?
Effusion:
Excess synovial fluid in the joint due to it being irritated.
Knee swelling that occurs later from an injury
If the swelling wasnt immediate like in the previous examples and
maybe swells after a few hours to a few days after the injury the most
likely cause is from effusion. This is an increase of synovial fluid rather
than from bleeding. The injury tends not severe enough to cause
bleeding but the body produces more synovial fluid to protect itself.
The knee will not feel as tight as from a trauma that causes bleeding
in the joint. Generally, the more swelling the worse the injury.
Most common are:
Meniscus irritation: caused by a compressive injury or a small tear
Sprain: where the knee joint gets overstretched and a few fibers are
torn but the ligament is still intact.
The swelling may be better some days and worse others depending
on the activities.
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KNEE SYMPTOMS
Why is it swollen?
Swelling without an injury that develops slowly
This is generally due to an underlying knee condition that is caused by
constant irritation creating inflammation.
Arthritis: This is the most common cause of knee pain and swelling
that comes on gradually and there is no injury in people over 50. The
person may also complain of stiffness, crepitus and maybe worse in
cold weather.
Bursitis: this normally produces a small area of swelling rather than
the whole knee being swollen caused by excess friction and irritation
to the bursa. e.g. housemaids knee(prepatellar bursitis), bakers cyst
(popliteal bursitis) or swelling on the inside of the knee and 2 inches
down from the joint line (pes anserine)
Tendonitis: the most common tendonitis is patellar tendonitis
producing pain on the patella tendon below the knee at the front.
Rapid swelling without an injury
Infection: These usually occur after surgery or a deep cut or maybe
even from an infection from somewher else in the body that has
spread to the knee. These should be referred to a Doctor as
antibiotics will most likely be need to treat the infection.
Gout: Intense pain, maybe red and hot to the touch with limited
movements. Gout is the most painful form of arthritis and is caused by
needle like crystals which are like shards of glass that are produced
from excess uric acid in the bloodstream. These are most often
caused by a diet that is too high in purine rich foods and excess
alcohol.
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KNEE SYMPTOMS
Why is it swollen?
Others causes
These are rarer but I will add them in.
Dislocated kneecap: This is when the kneecap slides out of its groove
to one side and will cause a large deformity produced by the
kneecap to the side of the knee. This is obvious to see and it can
produce lots of swelling.
Tumor: there are several types of tumors that can afect the knee and
cause swelling. The person may also complain of being fatigued,
feeling unwell and may have also loss of weight.
DVT: deep vein thrombosis is a blood clot in one of the deep veins
most commonly in the calf and usually after prolonged rest such as a
long plane flight. The area will be swollen and will be painful, red and
hot. This is a medical emergency.
Osgood Schlatter: most commonly seen in young teenagers
particularly after a growth spurt which produces a hard lump on the
shin from tension on the tendon.
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KNEE SYMPTOMS
Why is it unstable?
One of the first things you want to ask the client is if it is actually
giving way or it just feels like it will. In other words, it feels unstable
but does not actually give way.
Knee giving way:
this is when the knee actually buckles from underneath them causing
them to stumble or fall.
Ligament tears: The most common reason for this is ligament tears
and the most common is an ACL tear. The ligaments are there to
provide stability for the knee joint so damage to them can cause a
lack of stability especially when challenged such as changing
direction and the structures cannot cope with the stress. The giving
way is not normally painful.
Meniscus tears: when the cartilage gets jammed in the joint this can
also happen. This will be generally a painful giving way from the
sharp pain.
This is something that the client should see the Doctor for.
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KNEE SYMPTOMS
Why is it unstable?
Knee instability:
So now we are talking about the client saying the knee feels like it is
unstable but actually doesnt collapse under them. They may even say
that they don't trust the knee.
Pain: This can be caused by pain coming from the knee and the
body's response is to want it to move away from the painful position
but it wont let it collapse completely. This is commonly seen after a
knee injury especially if there is swelling.
Muscular weakness: This, as the name suggests, is due to muscle
weakness and may have originally been due to a knee problem. The
knee will feel unsteady or wobbly and is helped greatly by simply
strengthening exercises.
In summary, there may be instability in the short term from a knee
injury as the body tries to protect itself from further damage or
more chronic instability most likely after a knee problem.
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KNEE SYMPTOMS
Why is it locking?
You may have clients that complain about their knee locking and that
they cant move if from its position, it is literally locked in position if
only for a few seconds. There are two types of knee locking that we
most commonly see.
True knee locking:
this is where, as the name would suggest is true knee locking where it
actually physically stuck for a period of time. This is pretty rare to see
though and usually occurs when the client wants to extend the knee.
They may need to move the leg about a bit to free it up. This locking
may or may not be painful and generally is caused by:
Meniscus tear: This is the most common by far that you will see as the
torn cartilage moves around in the joint and sometimes gets jammed
and locks the joint until it moves again.
Loose fragment: This can be caused by bone that is floating within
the knee joint.
Pseudo knee locking:
This is where it feels like its locking but there isnt a physical structure
blocking the joint from moving such as a bony fragment or cartilage.
The cause of this can be due to muscle spasm from pain as the body
tries to protect the joint. It could also be from swelling or both. The
client may also say that it feels more of a 'catching ' feeling .
One difference is that true locking normally happens on knee
extension whereas pseudo locking happens on both flexion or
extension.
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KNEE SYMPTOMS
Why are they having knee pain when they run?
This is a very common problem that you may see and there are
several potential reasons. The knees take such force from jogging or
running-up to 500-600% of body weight!
It could be due to an injury due to a fall, a twist etc which will be
obvious as the client will tell you that they did something to it.i.e.
injured it when running. However, most commonly these are chronic
problems caused by the repetitive nature. The pain generally starts
gradually and gets worse over time.
The most common causes are doing too much too soon at the start,
increasing too much, changing the running e.g. going from different
surfaces, or doing new training drills and biomechanical problems
such as poor foot position and muscular weaknesses and tightness.
Where is the knee pain located?
Outside knee pain: the most common cause is ITBS (iliotibilal band
syndrome).
Inside knee pain: This could be due to meniscus pain. Weak gluteal
muscles cause the arch to drop in the feet and can put excesive load
on the inside of the knee. It will generally sharp and may come and
go as they run.
Front knee pain: The most common cause is patellofemoral syndrome
which is from excess friction on the back of the kneecap due to poor
tracking of the kneecap in the patella groove. This will present as a
general ache normally at the front of the knee and gets worse from
activity and also inactivity such as sitting for extended periods of
time.
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KNEE SYMPTOMS
Why are they having knee pain when they run?
Front knee pain: It can also come from the patellar tendon which is
known as jumpers knee (patellar tendonitis). This will be below the
kneecap and the tendon will generally be tender to touch.
Pain behind the knee: This will most commonly be from the hamstring
tendons often due to hamstring tightness.
Why are they having knee pain on stairs?
Many knee problems make going up and down stairs painful. For
some clients it may be worse going up and others when they go down,
for some it's bad I both directions.
Going upstairs: This tends to be meniscus related most commonly
Going downstairs: this is more commonly seen with kneecap
problems such as runners knee or Chondromalacia patellar.
Sharp pain on stairs: Most commonly meniscus tears, bursitis, arthritis
Why are they having knee pain squatting?
If you remember that squatting produces 7-8 times body weight
through the kneecap its little wonder they can feel pain. Squatting by
the way is not bad for the knees if done correctly. There are ,many
reasons that it could be painful such as kneecap problems (runners
knee, Chondromalacia Patella ), patella tendonitis (jumpers knee),
meniscus tears, arthritis or even ITBS
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ACUTE INJURIES
The R.I.C.E Protocol is a MYTH: A Review and Recommendations
The RICE (Rest, Ice, Compression, Elevation) protocol has been the
preferred method of treatment for acute musculoskeletal injuries
since its origin in a 1978 publication entitled “Sports Medicine Book”
by Dr. Gabe Mirkin.
These guidelines have been used by coaches and healthcare
providers for over four decades with the intent of expediting the
recovery process and reducing inflammation. Although popular, the
implementation of this protocol to attenuate the recovery process is
unsubstantiated.
There is, however, an abundance of research that collectively
supports the notion that ice and rest does not enhance the recovery
process, but instead delays recovery, and may result in further
damage to the tissue. Research in regard to compression and
elevation is inconclusive, diluted and largely anecdotal. Definitive
guidelines for their application have yet to be purported.
As a result of the subsequent research that examined the validity of
the protocol, Dr. Mirkin recanted his original position on the protocol
in 2015. The objective of this article is to analyze the available
evidence within the research literature to elucidate why the RICE
protocol is not a credible method for enhancing the recovery process
of acute musculoskeletal injuries. In addition, evidence- based
alternatives to the protocol will be examined. These findings are
important to consider and should be utilized by any healthcare
professional; specifically, those who specialize in the facilitation of
optimal recovery, as well as those who teach in health-related
disciplines in higher education.
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ACUTE INJURIES
In 1978, Dr. Gabe Mirkin released “Sportsmedicine Book” and coined
the acronym “RICE” (Rest, Ice, Compression, and Elevation) to
represent the four activities for treating acute athletic injuries. The
RICE protocol has been ingrained in academic curriculum as well as
in public perception for over four decades.
In 2013, however, RICE was challenged by Gary Reinl in his book
“Iced! The Illusionary Treatment Option.” Reinl cited numerous studies
and anatomical resources in support of the notion that resting an
injury, while wrapping it tightly (compression) with ice, is ineffective in
accelerating the recovery process and could also result in further
damage to the affected tissues.
Following the release of Reinl’s book, Mirkin publicly recanted his
original position on the RICE protocol in a 2015 publication on his
personal website (31). Mirkin even wrote the foreword to Reinl’s
second edition of “Iced! The Illusionary Treatment Option”, and
offered his revised opinion on the protocol he created;
Subsequent research shows that rest and ice can actually delay
recovery. Mild movement helps tissue to heal faster, and the
application of cold suppresses the immune responses that start and
hasten recovery. Icing does help suppress pain, but athletes are
usually far more interested in returning as quickly as possible to the
playing field. So, today, RICE is not the preferred treatment for an
acute athletic injury (36).
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ACUTE INJURIES
Inflammation is commonly misunderstood and generally believed to
be synonymous with swelling. However, the two are entirely different.
Inflammation is the first phase of a three-phase sequence of tissue
repair, while swelling is “the accumulation of waste at the end of the
inflammatory process that is not yet evacuated” (36).
Inflammation is not an undesired outcome that needs to be reduced
or delayed, but rather an instantaneous defense mechanism with the
primary objective of controlling the extent of cell injury and
preparing the tissue for the process of repair (24). As noted by
Leadbetter (23), “inflammation can occur without healing, but healing
cannot occur without inflammation.”
As the waste products produced by macrophages and neutrophils
begin to accumulate around the damaged site in the form of fluid, the
body relies on the lymphatic system to drain the area (36).
The lymphatic system is a passive, one-way mode of transportation
for excess fluid that relies on the voluntary contraction of the body’s
tissues as a method of propulsion. “When fluid enters the terminal
lymphatic capillaries, any motion in the tissues that intermittently
compresses the lymphatic capillaries propels the lymph forward
through the lymphatic system” (12).
Therefore, to ensure the lymphatic’s system functionality, the muscles
must be actively contracted to facilitate the efficient flow of lymph
throughout the body. The inadequate functioning of the lymphatic
system is the primary contributor to the accumulation of waste
products, excess swelling, and the inability to allow for the optimal
recovery of damaged tissues (36).
As noted by Reinl (37), “there’s not too much inflammation, there’s too
little evacuation.”
When the body is able to successfully clear the damaged site of
excess fluid via the lymphatic system, the process of repair is enabled
(phase two of the recovery process).
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ACUTE INJURIES
A More Optimal Approach: Active Recovery
There is an abundance of available information that suggests moving
early in the recovery process is more beneficial than extended
periods of stillness (5, 6, 36, 37, 38). Reinl (36) proposed his own
acronym for recovery, ARITA, which stands for “active recovery is the
answer.” Active recovery is a broad term that can include any activity
that involves the contraction of skeletal muscle tissue that was
previously subjected to trauma (30). Active recovery can include
activation/mobility exercises or low intensity physical activity that
utilizes pain free movements through a full range of motion. If an injury
is minor, rehabilitation can begin as early as the next day, assuming
there is no pain associated with the desired movements. However, if
the injury is severe, it is best to follow a physician’s advice on
rehabilitation (31).
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ACUTE INJURIES
MEAT (movement, exercise, analgesia, treatment) has been
proposed as a more optimal alternative and effectively addresses
the discrepancies surrounding the RICE protocol.
Instead of resting an injury, this acronym suggests moving the
damaged area through a range of motion that is pain free in an
effort to provide the propulsive force required to adequately move
lymph throughout the body. Exercise with resistance should be the
next step beyond simple movements. Campbell (6) suggests that
eccentric loading should be prioritized when rehabilitating a tendon
injury.
Analgesia, the inability to feel pain, is the third aspect of the MEAT
protocol. Pain limits one’s ability to efficiently move the injured area
through a full range of motion. It is quite common for people to rely
on the use of NSAIDs (nonsteroidal anti-inflammatory drugs) for pain
management. Common brand names of NSAIDs include Ibuprofen,
Motrin, Aleve, or Advil. However, it is important to note that the use of
NSAIDs will not accelerate, and may actually delay, the recovery
process (44). NSAIDs inhibit the synthesis of prostaglandins, which
initiate inflammation (44). Campbell (6) suggests Tylenol as an
alternative, as it is not an NSAID and will not disrupt the inflammatory
process. However, Tylenol can damage the liver and
recommendations on a proper dosage should be followed.
The final aspect of the MEAT protocol is treatment. This is a broad
category that consists of treating the individual injury using a variety
of therapeutic approaches that are utilized on a patient to patient
basis. Campbell (6) suggests the consumption of certain
supplements/nutrients that reduce inflammation, as well as the
application of rehabilitation modalities such as kinesiology taping or
acupuncture.
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ACUTE INJURIES
CONCLUSIONS
The theory of resting an injury while wrapping it tightly with ice to
accelerate the recovery of damaged tissues seems to be completely
predicated upon unsubstantiated reports dating back over four
decades. The original support for the argument to ice
musculoskeletal injuries was recanted in 2015 by the founding father
of the RICE protocol (31).
In otherwise healthy individuals, the body is well equipped with the
means to adequately remove any accumulation of fluid from the
damaged site, as it contains the lymphatic system that primarily
functions to perform such duties.
However, it is important to note that the success of the lymphatic
system depends on the body’s ability to provide a propulsive force
that facilitates the movement of lymph through active skeletal muscle
contraction.
In other words, movement of the body’s voluntary tissues is vital to the
adequate functioning of this system. Therefore, an extended period
of rest following an injury to a tendon, ligament, or muscle is not the
most optimal way to accelerate the process of tissue regeneration.
The notion of moving as much as possible following an injury is
supported by the literature (5, 6, 30, 35, 38).
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ACUTE INJURIES
CONCLUSIONS (continued)
In addition, the application of ice, or cryotherapy, has been found to
not only delay recovery, but to also damage tissue in the process (9,
20, 27, 49).
The evidence suggests that the application of ice is only necessary if
pain reduction is the desired outcome (3, 8, 16, 19, 26).
Evidence in support of compression and elevation is lacking, as most
studies are inconclusive (4, 35, 51) and fail to establish definitive
application guidelines that are supported by research. These
findings, along with the public recant from Dr. Gabe Mirkin in 2015
(31), support the premise that the RICE protocol, which is a generally
preferred method of immediate treatment for acute musculoskeletal
injuries, is a myth.
Based on the available literature, a rehabilitation protocol for an
acute athletic injury should prioritize pain free movement through a
full range of motion as early as possible and gradually progress to
higher intensities and more complex movements.
In addition, the healthcare professional should evaluate the
individual injury and work with the patient or athlete to decide which
therapeutic modalities are most appropriate.
If a patient or athlete believes that compression or elevation is
beneficial to their recovery process then the two modalities can be
used, as it has been purported that there are no adverse side effects
associated with their application. The method and duration of the
compression should be at the discretion of the healthcare
professional, as no definitive guidelines have been purported.
However, there should be little to no utilization of ice or NSAIDs,
unless the only desired outcome is pain reduction.
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PN
A MASSAGE
THERAPIST'S
GUIDE TO
TREATING KNEE
PAIN
The End