Posts in Knee Injuries
Hip Strength Shown To Have Protective Effect Against Worsening Of Knee Arthritis
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Knee arthritis will affect many older adults limiting their ability to participate in their daily, occupational, and recreational activities. Lost independence and function is one of the most common concerns among patients with knee arthritis who are treated in our Boulder Physical Therapy practice. In addition to manual therapy to the involved joints, exercise remains the gold standard of conservative treatment for this condition. Specifically strength training has been shown to both reduce knee pain and improve function and independence among older adults. New research suggests this form of exercise may also prevent progression of arthritis.

Chang and colleagues examined the association between hip abductor strength on both cartilage injury progression and patient function in patients with knee arthritis (Osteoarthritis and Cartilage. 2019). They enrolled 275 knee in 164 patients with knee arthritis. All patients were given baseline strength and functional assessments, as well as, x rays of their knees. Authors reported patients who had greater hip abduction strength at baseline demonstrated reduced progression of their arthritis at 2 year follow up. In addition, these stronger individuals had a reduced risk of disability and an improved functional level at 5 year follow up. Authors reported these findings provide support for the important role of hip strengthening in modifying the disease progression of arthritis.

Which Muscle's Weakness Predicts Future Knee Pain?
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Patellofemoral Pain Syndrome, pain under the knee cap, is the most common diagnosis of knee pain affecting both sedentary and active individuals. Muscle weakness in the hip and knee are often present in individuals with this diagnosis, but a cause and effect relationship between strength and knee pain has been difficult to established. In short, the research is divided on this relationship especially within the variable of hip weakness. Thus questions remain on which muscle imbalances may predispose an otherwise pain free individual for future patellofemoral pain.

A recent systematic review of the available evidence on the development of patellofemoral pain syndrome reviewed 18 studies of 4818 research participants (Neal et al. Br J Sp Med. 2019). Authors found three common groups of research subjects including military recruits, adolescents, and runners. They reported moderate to strong evidence body mass index, age, and leg alignment were not predictive of future knee pain. Interestingly, although common in clinical patients, moderate evidence reported hip weakness was not predictive of future knee pain. Authors reported quadricep weakness, especially among military recruits, was associated with future onset of knee pain.

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Is Acetaminophen Effective For Hip Or Knee Arthritis?
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Paracetamol, or acetaminophen, was initially introduced in the late 1800s and has become the most commonly prescribed medication for fever and pain in the United States. It is one class of medications recommended by the American College of Rheumatology for patients with arthritis who have not responded favorably to weight loss and Physical Therapy. Although a relatively inexpensive and commonly prescribed medication recent research has demonstrated the harmful effects of acetaminophen when combined with other pain medications which may also contain the same drug. A recent Cochrane Review of the evidence analyzed acetaminophen’s effects on patients with hip or knee arthritis.

Leopoldino and colleagues reviewed 10 randomized placebo controlled trials of 3541 patients with either hip or knee arthritis (Cochrane Review. 2019). Patients within these trials were followed for up to 24 weeks to determine the impact of the medication on pain, activity, and adverse events. Authors reported at 3 and 12 week follow there was high quality evidence that acetaminophen provided no clinically important improvements in pain and physical function. No increased risk of adverse events was found among the medication vs. placebo patients. Patients with knee or hip arthritis should follow up with their physician before making any medication decisions.

Which Muscles Should I Strengthen For Knee Arthritis
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Knee osteoarthritis is a common and increasing diagnosis that is contributing to an rapid rise in total knee arthroplasty surgery in the United States. Knee Osteoarthritis leads to disability in greater than 10% of those over 55 years, however manual therapy and exercise has shown to be twice as successful compared to a home exercise program in short term pain and function. More importantly, research has shown this Physical Therapy approach can postpone or prevent the need for knee replacement. One of most common complaints from patients with knee arthritis is pain with walking or ascending/descending stairs. Weakness of the quadriceps, hip adductors (inner thigh) and abductors (outer hip) are crucial to improving stair climbing and squatting ability.

A recent study (Hislop et al. 2019. Br J Sports Med) aimed to find the benefit of adding hip strengthening exercises to quad strengthening exercises among people with Knee Osteoarthritis. Authors randomized participants with knee arthritis into one of two groups: knee strengthening or knee and hip strengthening. Consistent with clinical practice, the authors found a decrease in patient related pain as well as improvements in patient function in patients who combined hip and knee strengthening exercises compared to knee strengthening exercises alone.

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What Can I Do To Reduce The Progression Of Knee Arthritis
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Knee arthritis is a common condition among older adults and remains one of the greatest causes of disability in our country. Consistent with many musculoskeletal conditions there remains a disconnect between imaging findings and a patient’s clinical presentation. Studies have shown many patients without knee pain can have signs of arthritis on their x rays. In addition, many older adults with knee pain can have negative x rays for arthritis. This lack of association is likely due to many patient factors including activity level, functional demands, strength, flexibility, and overall health. For example, a stronger patient is less likely to experience pain during a given activity compared to their weaker peers. Strength training as part of an individually tailored Physical Therapy program remains the gold standard for conservative treatment of this condition. A new research article highlights other modifiable factors which may influence the progression of knee arthritis.

A longitudinal, observational study was conducted to determine the factors associated with knee arthritis progression in older adults (Halilaj et al. Osteoarthritis and Cartilage. 2018). Authors recruited subjects based on presence (N = 3285) of the condition. Patient history, demongraphic, functional outcomes and x findings were taken upon the first visit. Patient’s were then categorized by risk of progression of arthritis. High risk patients included histories of knee pain, aching or stiffness, previous total knee replacement, family history of arthritis, high body mass index, or previous knee injury. Patient disease progression was based on follow up x rays at 1 and 2 year follow up. In addition, patient’s completed functional outcomes at these time points.

Authors then calculated predictive variables which may have contributed to the radiographic findings. Consistent with previous research, x ray findings of arthritis including joint space narrowing did not predict patient symptoms. Authors prediction models found a slower gait speed, poor sleep, and higher meat intake were associated with knee arthritis disease progression. This supports previous research on the importance of a patient’s overall health in managing their knee arthritis. Smoking history, body mass intake, sleep, diet, and exercise remain some of the most powerful modifiable factors to reduce the progression and symptoms associated with knee arthritis.

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The Benefit Of Physical Therapy Before Knee Replacement Surgery
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Knee arthritis is most effectively treated in its’ early stages with Physical Therapy including manual therapy and exercise interventions. These interventions have been shown to reduce pain and disability, as well as, prevent or post pone the need for future knee surgery. In later stages of disease progression, knee arthritis is most effectively treated with a total knee replacement. This major surgery involving the replacement of joint surfaces in the knee was first performed in the 1960s. Since this time it has become one of the most successful orthopedic surgeries due to its’ ability to improve pain and function among this end stage patient population. In our Boulder physical therapy practice, we often find patients who enter their orthopedic surgery with optimal range of motion, strength, and function have the best outcomes after surgery. A recent review article supports our clinical findings.

Authors in the journal Physical Therapy reviewed the available evidence on the use of pre operate Physical Therapy among patients electing for total knee replacement (Devasenapathy et al. 2019). They were interested in finding the importance of pre operative treatments on post operative function including gait speed, stair climbing, and function. Authors reviewed 12 studies and found an association between pre operative quadricep strength and post operative function. They noted pooling of information was limited in this meta analysis due to the different methodologies used in the available studies. They called for additional studies of higher methodological quality to improve predictor analysis.

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