Knee Pain Rehabilitation: Exercises and Therapies Recommended by Singaporean Doctors

Knee pain rehabilitation is about restoring the knee to its normal function. To effectively do so, the cause of the pain or problem should be treated. It may be easier said than done, but a visit to a physician or physical therapist can be an educational experience that teaches you much about your knees. The knowledge you gain can help form a rehabilitation program that is tailor-made to your own needs. By understanding how and why an exercise can benefit your knee, you can have a greater willingness and determination to fix it. The levels of pain and rest times required from different injuries or problems can vary; the following rehabilitation is a general guide and may need to be altered to suit individual needs.

When it comes to taking part in knee rehabilitation, the causes of the pain can be disregarded at times. This is not a bad thing if you have not tried to rehabilitate the pain before, but it is never leading by example. By discovering the cause of your knee pain, you can learn how to prevent pain in the future. Knowledge can be a powerful tool. High repetition of activities throughout days and weeks can cause stress to the knee. This is especially the case when your job or lifestyle consists of continually stressing the knee joint, i.e. continually going up and down stairs. An indirect cause of pain can be stiffness of the lower back and/or flat feet. These issues can cause a change in walking pattern and increased stress on the knee joint. Both current and former athletes often develop knee pain that was caused by previous injuries. A gradual onset of pain that is increasingly getting worse with no recollection of a particular injury can be a sign of osteoarthritis. This is a common problem where people aged 45 and older will experience. Other causes include overuse, poorly fitting shoes, and inadequate stretching before exercise.

Regrettably, the structure of the knee is so complicated that injury or disease can harm any part of the knee. It’s why your pain can range from mild to severe and can flare up suddenly, from dull aches to sharp, stabbing pains. The frontal area of the knee, which can be considered the area that comes in front of you when you are sitting on a chair, is known as the anterior region. This area of the knee is a usual victim for pain, although it can be hard to isolate a particular cause.

In the course of your lifetime, you’ve likely encountered some sort of knee pain. Knee pain is a prevalent problem for people of all ages. It tends to stem from an injury to the bony structure of the knee, the kneecap, or the cartilage and ligaments of the knee. Medical conditions — including arthritis, gout, and infections — can also cause knee pain.

Causes of Knee Pain

Infections: Infections of the knee joint are fortunately less common. The knee can become infected through a prior injury or a different infection in the body. However, when it does occur, it can cause severe damage to the cartilage and bone. An infection is usually signaled by pain, swelling, and a fever.

Arthritis: There are various types of arthritis that can cause knee pain. The most common type is osteoarthritis, a degenerative joint disease that is mostly seen in older people but can also occur in younger people. It is usually caused by a prior knee injury and is characterized by swelling, pain, and decreased mobility. Other types of arthritis are rheumatoid arthritis, which is systemic and affects multiple joints. It’s an autoimmune disease, and gout, a condition caused by the deposition of uric acid crystals in the joint. People with gout usually have severe pain, redness, and swelling in the affected joint.

Mechanical problems: Mechanical problems occur when there is an abnormality in the way the knee moves. An example of a mechanical problem is a dislocated kneecap. This can be seen when an individual has pain and restricted movement. It’s very common in younger people, mostly teenagers. Other mechanical problems that can cause knee pain are iliotibial band syndrome, and foot or hip pain.

Injuries: Injuries can create knee problems. An individual may be more likely to develop osteoarthritis if they have injured their knee in the past. Some injuries can cause fragments of the bone or cartilage to break off and float in the joint space. This can cause an issue with the movement of the knee and can be painful. Other injuries may tear the tissue in the knee. Torn cartilage often times is a result from the twisting injury. ACL tears are a highly common sports injury and can cause swelling, instability, and a feeling like the knee gives out.

There are various different reasons why individuals may have knee pain. The most common causes include injuries, mechanical problems, arthritis, gout, and infections in the joint.

Importance of Rehabilitation

This shows that continued education for both the knee rehab patient and the healthcare provider is essential to a successful knee rehab program.

It was noted by a few orthopedic specialists that they tend to not give too much hope to their patients, as they feel that it is difficult to change a knee that is visually or symptomatically unhealthy to a reasonably healthy knee. This outlook has given the perception that knee rehab is futile. However, it was also shown that these same knee pain doctor Singapore have little trouble in changing their views towards knee rehab, learning new information, and giving a more concise program when educated about the success in treatment of knee injuries and the relationship between knowledge and patient’s compliance to treatment.

On the other hand, healthcare professionals tend to give rehab programs for knee injuries less effort than, say, a rehab program for a shoulder injury. A published study in late 1999 shows that general medical practitioners and orthopedic specialists in Australia acknowledge that such efforts are due to the lack of successful outcome from knee injuries and surgeries.

Participating in a knee rehab program is crucial for successful recovery. Lack of knowledge and negative attitudes, both from the patient and healthcare professional, can lead to failure of treatment. Patients who expect a full recovery usually are more dedicated to their rehab program. However, this may be unrealistic, especially depending on the injury and/or surgery done.

Usually, rehabilitation is a pretty dry and thankless endeavor. But when it comes to rehabilitating your knee, it’s a whole different ball game. The knee joint is simple in structure, but plays a vital role: it sustains the most weight and is a very complex joint. And when there is damage to the knee, it can severely impact one’s mobility, stability, and subsequently their quality of life.

Exercises for Knee Pain Rehabilitation

Balance and proprioception are often overlooked in knee rehabilitation yet are extremely important for the long term health of the knee. Balance can be defined as the ability to maintain the body’s centre of mass over its base of support. During any activities that involve movement of the knee, forces are transmitted and dissipated through the joint. If the knee lacks stability, these forces may cause increased pressure on the joint and its surrounding structures, which may lead to injury or further damage. Static balance occurs during stillness and can easily be regained with specific static exercises. Dynamic balance is the ability to maintain balance during movement. It is often best improved through exercises that gradually incorporate more knee movement and require stance changes, progressing to exercises that involve high level lower limb function. Static and dynamic balance generally involves maintaining similar exercises to those that improve strength, and ensuring that the exercises are performed on each leg. Proprioception is the body’s ability to sense movement within the joints, and joint position sense is a big component of this for the knee. There are specific receptors within the muscles and the joint itself that feedback information to the brain. Following injury or surgery, these receptors can become less effective and there is often an associated decrease in proprioception. This can lead to an increased risk of re-injury or development of knee osteoarthritis. Exercises to improve proprioception are those of a balance nature, since they also require the lower limb muscles to make continual adjustments to maintain stability. They can also be specifically addressed using wobble or rocker board exercises and other specific proprioception training aids. Ongoing research is continuing into the best methods to improve proprioception.

Stretching exercises are also important to maintain or improve the flexibility of the soft tissues that cross the joint. Good flexibility is important to allow normal movement of the knee and to reduce the forces exerted on the joint. If there are tight structures at the back of the knee this can cause an increase in the forces on the kneecap and lead to knee pain. Static stretching exercises are normally used, often incorporating an aid to help hold the stretch for a specific duration. This may include a towel, band or specific stretching aid. Stretches should be maintained and not forced into painful positions. Each stretch should be felt in the muscle for a 30 second duration with a total of 3-5 repetitions for each muscle group.

Range of motion exercises are important to regain full movement of the knee. This is particularly important after injury or surgery when there may have been a period of immobilisation. Knee movement may also be restricted because of pain or swelling. If the ability to fully straighten the knee is not regained this can lead to a feeling of stiffness and the development of adhesions within the joint that may restrict future movement.

Strengthening exercises are vital for rehabilitation. They help to increase the strength of the muscles around the knee to support it. The quadriceps muscles on the front of the thigh are especially important. If the forces on the kneecap are reduced, less pressure will be transferred through to the underlying knee joint. This will be particularly helpful if the kneecap has been the source of the pain. Strengthening exercises may also be important to regain full function of the knee if it has been weak because of injury, surgery, or illness. The key to successful strengthening is to progress slowly – increasing the weight, resistance or repetitions depending on the type of exercise, whilst being careful not to cause a significant increase in pain or swelling. This can be done using weights, resistance bands or through various other resistance training techniques. It is often best to apply resistance with the leg in a supported position and to progress to functional strengthening exercises that require more balance and coordination at a later stage.

Strengthening Exercises

Step ups are another effective quadriceps exercise. As strength improves, this can be an easy everyday activity to incorporate into your day. Using a staircase, simply step up leading with your injured leg and slowly lower yourself back down. As a progression, step ups can be done in a gym on a stepper machine. Adding resistance with weights will continuously make step ups a more challenging exercise as leg strength increases.

Straight leg raises are an excellent exercise targeting the quadriceps muscles. They are simple and can be performed anywhere. Initially, start lying flat on the floor and later you can progress to doing them off the edge of a step to increase the level of difficulty. To perform this exercise, raise your leg about 12 inches off the ground using your thigh muscles and hold the position for 5 seconds before slowly lowering the leg back down.

Wall slides are an effective exercise to strengthen the quadriceps. It is a low impact exercise ideal for rehabilitation. Stand with your back against a wall, with your feet shoulder width apart and about 12 inches away from the wall. Slowly slide down the wall until your knees are bent at roughly 10 degrees. Hold the position for 5 to 10 seconds and then slowly slide back up the wall.

Building strong quadriceps (thigh muscles) is very important to stabilize your knee joint. These muscles are essential in absorbing shock and protecting the knee. Strong quadriceps help to support your knee cap and prevent it from dislocating, leading to potential further knee damage.

Range of Motion Exercises

Heel slide: Lie on your back, bend the knee to be exercised, and slide the heel along the floor/bed towards your buttocks. Use a plastic bag under the heel if on carpet to minimize friction. Then slide the heel back to the starting position. Repeat ten times.

Flexion and extension: Sit on the floor with both legs out straight. Pull your toes and feet back towards you as far as possible. Pull your knee caps up and tense your quadriceps (thigh muscles) on top of the affected thigh muscle. Keeping this tension in your thigh muscles, bend the knee as far as possible, sliding the heel up along the floor towards your buttocks, then slide the heel back down and straighten the knee. Repeat ten times.

Range of motion exercises are the gentle stretching of your joints to relieve minor pains and also to maintain the health of the joint. These exercises are particularly beneficial if you have been relatively inactive, perhaps because of the discomfort of knee pain. A good range of motion in your legs will help to do the everyday activities and to have balance when standing. Lack of movement in a joint can lead to a reduction in the joint capsule. This means the joint does not have enough space to move and can be very painful. It can also lead to the shortening of the muscles, which can cause an imbalance around the joint. It is very important to apply these exercises gently. You should not feel pain, just a gentle pulling sensation.

Balance and Stability Exercises

Static cycling is also a high-resistance exercise for the knee. By initially setting the seat high, the knee joint can be virtually unloaded, and the seat position is lowered as quadriceps strength improves. This is an alternative to cycling on a wind trainer and far more convenient than going to the local gym.

Step exercises, although functional, may produce large joint forces, particularly for the patellofemoral joint. This can be minimized by stepping up and down onto a level that is less than 20 cm in height and ensuring the quadriceps are doing the work. A simple exercise is to ascend and descend a step with the aim of not letting the knee travel over the toes. This places large joint forces at the hip in order to achieve the correct position at the knee.

Begin with static stance and gait training exercises. These pose minimal muscular and joint loading forces. It is important to achieve the correct alignment and, in turn, postural control. This is then progressed by increasing the base of support and perturbing the center of mass. The aim is to then achieve the same quality of postural control and alignment. An example of a similar exercise is to stand next to a wall or something that may be held to maintain balance. Stand on one leg and hold the contralateral leg in front off the ground. Initially, hold this position for 10 seconds, aiming to achieve 30 seconds. This can be performed in a more difficult position by standing on the flat ground with eyes closed. This decreases the proprioceptive input and is a good test of postural control.

The purpose of balance and stability exercises is to maintain balance and help prevent falls. Fall prevention is especially important as we get older. It discourages mobility and increases the risk of osteoporotic fractures. Good balance ensures the correct response to the disruption of balance and is required to have a normal gait pattern. People with poor balance are more likely to suffer a lower extremity injury from a fall. There is a close relationship between balance and knee OA. Sensorimotor changes associated with knee OA may lead to decreased balance. This, in turn, can lead to diminished proprioceptive input to the central nervous system from the receptors in the surrounding muscles and joints. It is this input that is required to allow the correct adjustments in postural control and thus balance. If the exercises are performed correctly, there is potential to improve balance in people with knee OA by providing an environment in which the body can correct these adjustments. Ideally, in our balance and stability exercise program, we wish to maximize postural alignment and control while minimizing joint forces. We do this through a variety of exercises ranging in difficulty. Often, the inability to perform certain exercises is an indication that the exercise is required. We prescribe the most difficult exercise that can be achieved correctly.

Low Impact Cardiovascular Exercises

The key to successful aerobic conditioning during rehabilitation is the achievement of an appropriate intensity. Aerobic conditioning is only beneficial if the exercise intensity is at a level to improve the body’s fitness. Too easy or too hard does not achieve worthwhile conditioning levels. But how does one achieve the appropriate intensity of exercise? A simplified method is by exercising at a level which allows conversation, but is slightly difficult to do so. This can be monitored by increases in heart rate and breathing. If the intensity is too hard, the patient may feel increased pain and swelling, and thus it is important to monitor knee symptoms during exercise. A safe starting intensity can be achieved by stationary cycling, where the resistance can be increased as fitness improves. Other examples of low-impact aerobic exercise include walking, water exercise, and elliptical cross-training, and the duration can depend on fitness levels and availability.

Many people wonder how they can exercise in order to strengthen their knees, but fail to realize the importance of exercise to improve cardiovascular fitness. Aerobic exercise improves the body’s cardiovascular system. The word “aerobic” means “with oxygen,” and aerobic exercise speeds the body’s consumption of oxygen. It also improves the body’s ability to utilize oxygen to fuel movement. Regular aerobic exercise conditions the heart to pump more blood with each beat, and the heart rate does not increase as much during physical activity or exercise. More blood pumped with each beat means more oxygen.

Therapies for Knee Pain Rehabilitation

It’s not just about the injury. When a knee is injured, it’s often the start of a lifetime of knee problems. Evidence of this is seen repeatedly with the high incidence of knee osteoarthritis following a significant knee injury. This is particularly true with a cruciate ligament injury, meniscal tear, or a combination of these injuries. People with a knee injury face six times the risk of developing osteoarthritis compared to the general population. When it comes to knee injuries, the best therapy is to address the injury rather than the symptoms. This is particularly true with a significant knee injury, post-knee surgery, or for people with arthritis and a torn cartilage. Therapy consists of multiple stages and focuses on a number of different features. These include maintenance/increase of muscle control, strength, and proprioception, healing the injury site, increasing range of motion and day-to-day level of activity, and prevention of further injury or disease progression. Often an injury will have caused a limiting effect on these features. By treating the specific problem, each patient will have different forms of therapy but should all be aiming towards the same goals.

Physical Therapy

The second common practice conducted by physical therapists is muscle strengthening, often focusing on the quadriceps and hamstrings, which have been shown to have a significant effect on the rate of knee pain degeneration, in turn, affecting the patient’s quality of life. This can be achieved in a number of ways, but most commonly through exercises using resistive bands, weight cuffs, and general weight training. The therapist will decide on the method based on the severity of the patient’s condition. A recent randomized trial provided evidence to the fact that high-load exercise therapy is more effective in patients with knee osteoarthritis than low-load therapy.

Firstly, a physical therapist will conduct gait training, which is an analytical process using the human eye to assess and help improve a patient’s walking or running patterns. This is important because abnormal gait is often the root cause for overuse of certain muscles, hence resulting in pain. Gait training includes speed and stride length training, intensified concentric and eccentric muscle contraction, and motion analysis, which may even include videotaping.

The primary objective of physical therapy is to return the patient to a functional state when further treatment is minimal or unnecessary. The process of physical therapy ideally begins immediately after the initial onset of pain.

Occupational Therapy

Occupational therapy is also a basic treatment process, but the primary goal is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do. In the case of knee pain rehabilitation, an occupational therapist might suggest alternative methods for a person to continue their work or hobbies that have been hindered by their injury. They might also suggest ways to alter the environment to prevent re-injury of the knee. Although an OT can do other things such as provide acute care or work in a mental health setting, their focus on teaching or enabling a person to do an occupation while considering their health condition makes them unique from the other health professions.

Physical therapy is a basic treatment process that involves the use of physical methods and modalities (i.e., exercise, manipulation, other treatments involving physical agents) to help rehabilitate the patient back to their prior level of physical function. A physical therapist is the only professional able to administer physical therapy, and they most often practice in a private clinic, rehabilitation facility, or hospital.

Techniques and exercises that help rehabilitate the knee are most often prescribed by a physical therapist or an occupational therapist. Both professions are valuable to a patient’s recovery; however, there are a few differences.

Pain Management Techniques

Recently, the use of visco-supplementation has been developed, whereby hyaluronic acid is injected to supplement the viscosity of the synovial fluid and act as a lubricant and shock absorber. This provides pain relief for patients with mild symptoms of osteoarthritis. This approach has shown to be moderately effective but is a costly treatment, and its long-term benefits are still in question.

Analgesic medications are often prescribed to individuals with knee pain to provide pain relief. Medications widely used for knee pain are simple painkillers (e.g., paracetamol) and non-steroidal anti-inflammatory drugs. To achieve greater pain relief, more potent opioid-based medications and sometimes antidepressants are used. However, these are usually for patients with severe pain and are closely monitored due to potential dependency problems.

It is acknowledged that the sensation of pain associated with knee injuries is the primary reason many people seek medical help. There are several modes of pain management available to the clinician, which include medical, physical, and psychological strategies. These go some way to breaking the pain cycle commonly associated with chronic injuries.

Assistive Devices and Bracing

An assistive device or an orthosis can help to reduce the pain and keep the knee stable. The patient should select an assistive device on the basis of the site and the nature of the knee pain. An elasticized knee brace often helps in stable minor pain and exercise-related pain. Unloader braces for osteoarthritic knees can effectively reduce pain. A cane of the appropriate height will reduce the load at the knee by 10-15 lbs. A single crutch will reduce the load at the knee by 65% and two crutches by 75%. A de-rotation brace will be required for patients with patellar subluxation or dislocation. Bracing may help in the post-surgical rehabilitation phase but in general, reliance on a brace is undesirable and the residual strength deficit may prevent return to the pre-injury activities. At this stage, increased dependence on the brace will become appropriate.

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