Posts tagged knee pain
Hip Manipulation Shown To Improve Muscle Strength In Patients With Knee Pain
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Knee pain remains one of the most common reasons patients seek care from a primary care physician and Physical Therapist. The knee is uniquely placed between two long levers in the thigh and leg bones. The levers significantly increase the effect of impairments in the ankle and hip joints on the knee. Commonly, patients present with mobility needs below the knee and stability or strength needs in the hip. A Physical Therapy exercise prescription is provided to each patient on their strength assessment on the initial evaluation, but many patients will demonstrate weakness in the quadriceps and glut musculature. A recent study demonstrates the impact manual Physical Therapy can have as a transition into strength training.

Silva Neto and colleagues examined the impact of a single hip manipulation (high velocity, low amplitude) by a Physical Therapist to determine its’ effect on pre and post strength measurements. 40 patients with knee pathology were enrolled in the study and completed pre and post strength assessment of the quadriceps and glut musculature. Authors noted a significant improvement in strength of the gluteus maximus but not gluteus medius or quadriceps after the hip manipulation. This effect reflects the improved short term ability of the patient to recruit their hip musculature. Although not measured this effect is likely temporary but may allow improved muscle recruitment in a follow up hip strengthening exercise. This research reinforces prior research demonstrating improved hip muscle recruitment following hip mobilizations.

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What Are The Best Treatments For Patellofemoral Pain?
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Patellofemoral pain syndrome or pain under the knee cap is the most common diagnosis in the knee and a frequent reason patients seek out the care of their primary care physician or Physical Therapist. Patient’s with this condition often experience aching or sharp pain under or around the knee cap (patella) during squatting, running, jumping, stair climbing, hiking, and prolonged sitting. Pain results from abnormal contact between the knee cap and thigh (femur). Prior thoughts on this condition believed the knee cap was responsible for the abnormal contact and interventions were designed to target the patella.

Outdated theories including balance between the outer and inner quadriceps muscle have been replaced by better research indicating the hip may play a more significant role in the condition. The hip musculature including the gluts contribute significantly to the alignment of the thigh under the knee cap. As the alignment improves a greater portion of the joint surface area is able to distribute the forces across the knee reducing joint pressure and pain. The quadriceps function to dissipate the forces across the knee and should be targeted along with the hip musculature in this condition.

The Journal of Orthopedic Sports Physical Therapy recently published their clinical practice guidelines including the best available medical evidence and expert opinion on how to effectively diagnosis and treat this condition (Willy et al. 2019). Authors reviewed 4500 scientific articles on this condition between 1960 and present day. They selected 271 articles for the review and broke down their findings into the most supported risk factors, examination tests, diagnosis, treatments, and prognostic factors. Authors found most individuals with this condition improve with Physical Therapy interventions including activity modification and strength training. Patients may also benefit from short term (< 6 weeks) utilization of foot orthotics and taping for pain relief. Authors reported manual therapy and dry needling were not shown to be useful for this condition.

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Which Running Gait Mechanics Predict Knee Injury?
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With access to miles of paths and acres of open space running remains one of the most popular outdoor activities in Boulder. Despite its’ accessibility, low cost of participation, and health benefits running related injuries keep many from training or competing at their preferred levels. One recent area of research has focused on gait retraining by Physical Therapists to reduce forces among runners. Although an “ideal” running gait does not exist some factors including foot strike, impact forces, vertical translation can help us differentiate injured from non injured runners or determine who is at a greater risk of injury. A recent study determined additional factors which can help identify injured runners.

Dingenen and colleagues in the journal Physical Therapy in Sport analyzed the running gait of 42 recreational runners (2019). About half of the participants currently experienced pain on the front or side of their knee. Researchers assessed their lower quarter mechanics to determine how those with knee injuries differed from their non injured peers. Researchers found the injured runners demonstrated greater degrees of opposite sided pelvic drop and knee adduction (inward movement) during their running analysis. We often find these running gait impairments in runners with hip abductor (glut) weakness. Increased inward motion or “wag” of the knee in stance increases forces across the knee joint. Conversely, a level pelvis and stable knee helps dissipate the forces of running over a greater surface area in the joints.

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PRP Effects On Tendon Injury Attributed To Post Injection Physical Therapy
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Patellar tendinopathy is one of the more common sports medicine conditions seen in our Boulder Physical Therapy clinic. This condition causes increased pain along the front of the knee just beneath the knee cap and leads to pain with jumping, running, and squatting activities. Current medical evidence has described an absence of inflammatory cells and instead we find an increase in cells responsible for tendon repair. These immature cells are initially laid down in a disorganized pattern and require progressive, optimal loading through exercise to reach a mature, healthy state. In addition to exercise some physicians have advocated for PRP injections into the injured tendon in an effort to accelerate the healing process, but well constructed research trials have not been conducted and this treatment is still considered experimental. A recent research trial examined the effectiveness of PRP for patellar tendinopathy.

A well done randomized controlled trial in the American Journal of Sports Medicine examined the effectiveness of PRP vs. placebo (saline) in patients with patellar tendinopathy (> 6 months of symptoms) (Scott et al. 2019). Patients were randomized to one of three injection groups under ultrasound guidance leukocyte rich PRP, leukocyte poor PRP, and saline. Each group then received 6 weeks (3 times per week) of supervised Physical Therapy including heavy slow strength training (concentric and eccentric loading). Patients were folllowed up at 6,12,36, and 52 weeks. Authors found an improvement in all three groups but no difference in pain, function, or recovery between the three groups. If PRP added to the recovery we should have seen a superior effect of PRP and PT vs. saline and PT, but because all groups were similar we can attribute this change in function to the Physical Therapy strengthening program. This evidence supports our current view on the limited benefits of injections for tendon pain. Patients are encouraged to use a Physical Therapy exercise program consisting of progress, loading exercises to accelerate their recovery from tendon injury.

Strengthening Exercises For Patellofemoral Pain
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Patellofemoral pain, or pain around the kneecap, is one of the most common types of knee pain we treat at MEND. It impacts up to 23% of the general population and 40% of those people have persistent symptoms that can last for years! Exercise programs targeting the hip and the knee have been proven effective in managing hip and knee pain.  Most of the exercise programs studied to date have either not provided sufficient exercise progression to improve strength and power or have not been extended long enough to sustain gains in strength or power (which may result in recurrence of symptoms).

 A recent study (Barton et al 2019) reported significant improvements in patellofemoral pain, function and hip muscle capacity with a 12-week progressive strengthening program that can easily be performed at the gym. The key differentiator of this study was that the exercises were progressive – either the challenge of the exercise increased (ie: 2-leg squat to 1-leg squat) or the resistance of the exercise was progressed to ensure participants stayed in a perceived exertion range of 7-9 (which typically means you are only able to perform 1-2 reps in your set).

The exercises included in this study were:

1.     Bridging – 3 sets of 12 repetitions

Double to Single leg

2.     Hip abduction - 3 sets of 12 repetitions

a.     Sidelying to Standing Progression

3.     Plank progressions 3 x 60 sec

a.     Front and Side Planks

4.     Optional quad exercises including squats and single leg squats.

5.     Hamstring Strengthening including body weight and machine.

Authors concluded the 12 week progressive resistance training program was safe and effective for improving pain and function in patients with patellofemoral pain. Stay tuned to our social media for an exercise videos.

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Rupture Of Knee Tendon After PRP Treatment
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Platelet Rich Plasma (PRP) is becoming a popular treatment for muscle strains, arthritis/cartilage injuries, and tendinopathies, but the evidence behind its’ use is limited. Specifically there is a lack of large human trials with randomization to both placebo injections and alternative treatments. Consistent with alternative treatments PRP’s clinical utilization is outpacing the evidence leaving many more questions than answers. To date there is insufficient research to advocate for injections into injured tendons and in some cases (corticosteroid) authors have argued the risks outweigh the benefits. A recent research article highlights a risk of PRP.

A case report published in the Clinical Journal of Sports Medicine highlights a risk on the utilization of PRP for sports injuries (Redler et al. 2018). Authors describe a single patient with a degenerative patellar tendinopathy treated with a series of 4 PRP injections. Upon subsequent surgical examination authors reported a complete rupture in the patellar tendon with significant degeneration is the surrounding tendon. Although the results of this report must be taken in consideration due to its’ methodology, including a single patient, the authors state this report questions both the effectiveness and safety of using this injection in patients with severe tendinopathy.