Posts in Knee Injuries
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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Quad Weakness After ACL Surgery Associated With Decreased Cartilage Health
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ACL injury is one of the most common traumatic sports medicine injuries seen in Boulder Physical Therapy practice. For patients who elect for surgical repair post operative Physical Therapy is key to facilitating a safe return to activity and sports. Common limitations for individuals returning to activity after ACL repair include: a loss of range of motion, balance and agility impairments, as well as, hip and quadricep weakness. The quadriceps are key muscles in maintaining strength and stability of the knee joint and when healthy improve weight bearing across the knee joint surfaces. Abnormal weight bearing in the knee joint leads to a decrease in joint space and increases the likelihood of knee osteoarthritis development. When undergoing surgical procedures of the knee, any effort to decrease progression of post-traumatic osteoarthritis should be taken.

Previous research has shown patients who sustain an ACL tear, treated either with PT or surgery, have an increased risk of knee arthritis. A recent study examined the cartilage and joint health of patients who had undergone ACL surgery (Pietrosimone et al. 2017). Consistent with prior research, authors found a decrease in quadricep strength in individuals 6 months after ACL repair. Concurrently, the authors found a greater T1p relaxation time within the joint which is a key marker of articular cartilage health. Thus, patients with quadricep weakness demonstrated decreased joint health compared to their stronger post operative peers. This emphasizes the importance of restoring quadricep strength after ACL surgery in order to optimize cartilage and joint health.

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Should I Be Concerned About The Noises In My Knee?
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Many healthy joints in the body, most commonly in the knee, present with joint noise called crepitus during range of motion testing. Crepitus can be an auditory cracking or popping sound or a sensation of grating in a joint. More concerning than joint noise is an associated sharp pain in the joint or associated locking, catching, or clicking of the joint. These signs and symptoms should be evaluated for potential injury to the joint surfaces and cartilage. If sharp pain or these mechanical symptoms are not present, joint noise or crepitus likely does not indicate an underlying injury to the joint. We often find crepitus in otherwise healthy knees. A recent research study reinforces our clinical understanding of joint crepitus in the knee joint.

Pazzinatto and colleagues examined 584 participants with crepitus and similar radiographic findings of knee arthritis in both knees (Braz J Phys Ther. 2018). These individuals were matched to peers of similar sex, body mass index, and presence of knee arthritis except these individuals did not have crepitus in either knee. Researchers had both groups, crepitus and absence of crepitus, perform both subjective measurements of pain and function, as well as, objective tests of strength, endurance, gait speed, and function. Authors reported lower subjective reports of pain, function, and quality of life in the group of participants with crepitus. Interestingly, they reported no difference in objective measurements or function. Authors concluded the presence of knee crepitus was not associated with objective function or strength measurements.

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Will Bracing Help My Knee Arthritis?
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Knee arthritis is a painful condition affecting middle age to older adults. Symptoms of stiffness and joint pain lead to decreased mobility, strength, and function within this population of patients. Physical Therapy treatments consisting of manual therapy and exercise remain a first line treatment for this condition. When combined with exercise, weight loss, medication, and injections can further reduce the symptoms of arthritis. We are often asked about the utilization of knee braces for this diagnosis. Bracing has been shown to be helpful within this population, but should be used sparingly due to the negative effects of this treatment on both knee mobility and strength. In particular, one sub group of patients with knee arthritis may benefit the most from this intervention.

The knee joint has two main weight bearing compartments, medial and lateral, which make up the inside and outside regions of the knee respectively. Arthritis contained to the inside compartment, most common among males, has been shown to respond to an unloading brace designed to transfer forces to the lateral or outside compartment. Gohal and colleagues reviewed the available evidence on the utilization of lateral unloading braces for patients with medial compartment arthritis (Sports Health. 2018). Authors reviewed 31 studies of 619 patients to determine the effectiveness of this intervention for patients with medial knee arthritis. They found knee unloader braces were significantly more effective than neoprene sleeves and neutral braces for relieving pain. Conversely, the effects of these braces on function was less clear and the authors called for additional larger randomized controlled trials to support their use.

Hip Strengthening Improves Outcomes In Patients With Knee Arthritis
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Knee Osteoarthritis is one of the leading causes of disability today. This painful condition limits an individual’s ability to walk, climb stairs, stand, and participate in recreational activities. Patient’s often demonstrate significant impairments in mobility and strength in both the knee, but also the ankle and hip. When evaluating patients with knee arthritis, Physical Therapists aim to examine and treat regions which either precipitate or perpetuate arthritic symptoms. Hip strength and coordination is a key area of our focus due to its’ influence on knee joint loading during gait and functional movements. Abnormal gait and movement may perpetuate the intra-articular joint inflammation and pain.

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As highlighted in a previous blog, patients with knee osteoarthritis display weakness and atrophy in their hip muscles. A review of the available evidence in the Journal of Geriatric Physical Therapy (Y.V. Raghava Neelapal et al. 2018) reported on the effect of hip strengthening on knee pain and physical function in those who have knee osteoarthritis. The review article included 5 randomized controlled trails and a total of 331 patients. Consistent with our clinical practice, authors reported improvements in knee pain and function after their Physical Therapists implemented hip strengthening exercises into their exercise programs. Interestingly, despite improvements in hip strength and knee function, knee mechanics did not improve as consistently with the exercise interventions. Impairments in knee biomechanics require motor control or coordination interventions in addition to strengthening.

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