Knee Pain - A Different Approach

Inefficiency of muscles around knee lead to altered alignment of patella & above tolerable loads at patellofemoral (kneecap) joint giving pain.

Knee Pain & stiffness in front of the thigh in 55-year-old female
Complaints:
• Progressively increasing knee pain following a jerk while walking 1.5 months back
• Difficulty in getting up from her commode & bed but is comfortable rising from the chair.
• Swelling around ankle &feet on same leg for which she underwent all investigations (which were normal).
Patient’s Worries:
• unable to stand for longer durations for her profession as a teacher & has difficulty in walking.
• she has gone into the shell & become physically inactive to avoid experiencing pain.
Lifestyle Risk Factors: prolonged inactivity, repetitive sit-to-stand (STS), prolonged standing
Muscle Involved: the jerk led to inefficiency in the front of the thigh muscle – Quadriceps (Q). Q plays a key role in STS & maintaining alignment of kneecap (patella). Inefficient Q leads to:
• Increased effort for STS with tendency to underuse the painful knee & overuse the secondary muscles (hip & ankle) of same leg &/or of the opposite leg. Q feels fatigued & overworked thereby becoming stiff. Stiff Q does not allow the knee to become straight, bend completely & exerts more pressure across the kneecap joint.
• change in patella alignment which increases the pressure on the outer aspect of the knee, especially when the knee is flexed at a right angle or more.
• Initially only the STS is challenging but with progressive fatigue & stiffness of various muscles, the quality of the daily tasks gets compromised.

Observations:
• Patient walks or stands with the knee bend to few degrees, has pain while walking, is avoiding putting full pressure on the knee compromising the speed & style
• Swelling at & above the knee
• Knee bending is reduced by 20% compared to opposite knee (stiff Q)
• Hip: Reduced flexion & crossing over to opposite side in comparison to opposite hip (stiff extensors & abductors)
Rehabilitation Goal: Achieve Pain relief & Restore + Enhance Physical Functions. Done by:
• Patella Taping Procedure: Offload the pressure on the outer side of knee
• Reduce the work for the Q & other muscles: Repetitive STS takes away the reserves of the muscle capacity to perform, thereby leaving little strength for dynamic work (walking/standing/stairs). As pain/exhaustion/handicap is experienced in dynamic work, the patient avoids or reduces the same & becomes inactive. Muscle Work is reduced by:
o Raising the height of the sitting surfaces @ 120% of leg length & supporting the feet with a footrest when seated. This will allow the person to get down with gravity rather than against gravity & own weight.
o Do dynamic work in batches interspersed by adequate periods of rest.
o Avoid working into the pain
• Physical activity: Avoid being inactive for more than 25-30 minutes while awake. Take activity breaks for 2-3 minutes.
• Improve flexibility & strength slowly but surely by getting the patient out of her comfort zone.