Posterior Knee Pain

[ParamedicJim]

I'm a 37 yrs Paramedic who had an active life (outdoor activities for 10+ years) but spent the last year in the office with significantly less exercise. I

6 months ago I suffered an injury whilst playing football. My right leg folded out towards my rear about 6 inches from the normal line. Initially there was no swelling and the RICE approach was utilised overnight. whilst being able to weightbear (and drive) I couldn't do much more than hobble at walking pace. I saw an A&E consultant who dignosed Med Coll Ligament damage. 10 days splinted and then physiotherapy had a good initial response but then ground to a halt. I experienced tremendous pain on flexing my knee and couldn't go more that 140-150 degrees (the left manages full flex) An MRI was inconclusive and I had an arthroscopy 14 days ago. My Ortho Consultant de-brided my kneecap and noted a meniscal tear but thought it sufficiently self healing to do any work on it.

I can now flex my knee to within 5-6 inches of my buttock but only after extension flexing.I still have the pain and feel a tightness on extension behind the knee and above and below. My flex has definately increased but the tightness and pain is still there. Does anyone have any sugestions

[elinwee]

Are you experiencing any:

- knee locking
- knee giving way
- knee effusion (low grade constant "swelling" around knee)

The Med Coll Lig (MCL) is commonly injured in conjunction with the ACL and the Medial Meniscus (known as the Triad) - once that happens the knee often becomes unstable.

You describe in detail your range abilities - what about functionally - ie whats your walking, stepping up and down, running, squatting etc like? What are the activites that you still have trouble with doing?

Most people do worry about getting the bend (flexion) in their knee back, but often, the extension is the one that is harder to return post injury if its not worked on early on. The flexion, with consistent rehab efforts, often does return in time but one can often be left with a full extension deficit due to neglecting to address the extension component.

Your range also sound pretty good 14 days post arthroscope. Given that you have had the injury for 6 months now before getting the arthroscopy, your knee function would be affected just because for the past 6 months it had the injury to deal with while ou were still WBing on it. In the grand scheme of things, 6 weeks is the initial soft tissue healing phase but it takes longer than that with good rehab for any injury to recover to good/ normal function. With bony fractures, it can take up to 12 months, and I imagine with a significant soft tissue injury, anywhere between 6-12 months.

To assist witht he recovery of function, good rehab program is essential. Besides working on pure range and strength, it is also important to address specific functional tasks and the entire lower limb biomechanics to prevent other futher problems from occuring.

[ParamedicJim]

Hi Eliwee, (speaking about prior to the Arthroscope because there's more swelling now) whilst there was some tenderness to the medial collateral area (around the joint point) and I had ongoing effusion (grade1) specifiically medially high up the knee itself was in good order. I managed stairs well and could cycle, walk. Running any more than a slow pace brought on pain and squatting stopped at the critical angle - because ofthe pain. There was some sub patella pain post exercise (though I'm hoping the de-bridement will help that) it was the pain on flexion that was the main problem. I did have some problems with extension but the early physio helped that. My left knee has suffered though as all kneeling activity and weight bearing has been placed on that one. As you can imagine my job has me kneeling and squatting alot and without this ability I'm stumpped. Add to that a new baby daughter who arrived 6 weeks after the accident and you can see my predicament. Thanks

[ParamedicJim]

Sorry Elin Wee, I guess the most important question is why do I have the pain? Is it the damage or swelling in the knee area or just because I haven't fully Flexed my knee in 6 months?

[elinwee]

Hi there

Sorry for delay in reply - I got a 4 month old and as you can guess, my life is consumed with him besides trying to get to work too!

It is really hard to tell without an exam what may be causing your knee pain. Although, posterior knee pain is a lot less common (i think) than anterior knee pain. One of the common causes of posterior knee pain is a BAkers cyst. Other possible causes of post knee pain can be from the hamstring tendons if the pain is not directly central but either medial or lateral. And of course, you can get post knee pain referred from back/ hip/ pelvis.

Re sub patella pain - you mentioned that the debridement was to help this prob. In my experience, most sub patella pain is due to patella femoral pain syndrome (PFPS) - such pain I am not sure is helped much debridement procedures tho I may be wrong. PFPS often responds well to quadriceps strengthening, VMO (Vastus medialis obliqus) retraining and taping during activity.

Often, it will be great if a specific dx can be achieved but in the absence of a specific one, knee rehabilitation still can go ahead. You need to work on the range (which you have been), and the strength of the knee muscles. Then also have to work in global lower limb biomechanics - there are many ways to do this my preferred method is to use a progressive series of weigthbearing exercises which will strengthen the knee muscles, but also improve on how the hip-knee-ankle work together in a closed kinematic chain.

You prob will benefit from an assessment of the knee structures - physios can assess the integrity of the ACL/PCL/MCL/LCL, meniscus, patellafemoral joint and overall stability of the knee to determine the extent of deficit in knee function.

Its a bit of a overload in info- hope it helps!

Elin

[ParamedicJim]

Hi Elin, I've been seen by the hospital physios and the Services contract physios now and the general consensus is that there is no underlying damage now (confirmed through the scope) and the pain is from the tighening of all the soft tissues around my knee and the quads because of their lack of use over the last 7 months. Does that sound right? They have both confidently said with a set of rehab including stretching exercises I should regain full flex and be able to go on to exercise fully. If this is the case I'll be over the moon, though I must say I can't guess how long it will take. Many thanks for all your posts. I hope your 4 month old is the light of your life, ours is full of surprises and I admit initially I just wanted to fix myself for me though now I just want to be able to do everything with her.

All the best, ParamedicJim

[elinwee]

Hi back

Babies are amazing arent they - they change lives in ways that you cant imagine. I have a boy - apart from keeping me up at night, he is as perfect as they get

If you are sure through assessment and investigations that there is no underlying structural damage to the knee that can account for the symptoms, then it is fair to assume that the pain is just from soft tissue tightness and disuse - hence rehab should fix it.

It is often hard to answer the question "How long?". I usually say to my patients - that with dedication and hard work in rehab, the first 50-60% of improvements comes fairly quickly within the first 3-6 months, then the next 20% takes another 3 months, then the next 20% another 3 months and the final 10% often takes the longest to return. So in reality to return to 100% function, with any significant injury, the time frame is from 12 months on (more that 12 months with bony injuries). But remember, most of the improvement happens fairly quickly early on. Most people, once they achieve the initial improvement do not pursue to achieve more, hence reinjury.

Have you got a good rehab program going? (4 month olds are often the best rehab ).

Elin

[ParamedicJim]

At the moment the Hospital physios are standing firm saying until I have full ROM they will not allow me to progress to the next stage. On that note I'm just doing lots of strtch exercises; basically extensions and flexion exercises with some single leg dips to work my VMO and quads. The Services' physio is going after the massage and manipulation approach, just taking it to tightness and adding alittle more pressure each time. I would of course, be grateful for any further suggestions you might offer. That would be suggestions other than chasing around after my little girl that is! Thanks for all the help. ParamedicJim.

[elinwee]

Hi again!

Again I'll say its hard to treat a patient without having them in front of you! So take what I say with caution and always refer back to your physios if unsure. They are your primary contact (and know you better than posting in threads!) and therefore I am careful that I dont want to undo what they may be doing with you.

Having said that, I have progressed rehab in my knee patients with less flexion/extn range than you have (you mentioned about 140 flexion and near full extn??).

Please clarify for me your current prog. What I understand is:

- hands on massage and manip
- exercise wise: single leg squats (how much flexion) to strengthen VMO and quads, and flexion/ext ex (what sort - lying down, standing up, weightbearing (WB) or NonWB (NWB) ?

Chasing your little one is great - just dont twist and turn on that knee (ie dont change directions quickly!!) - if posible

Elin

[ParamedicJim]

That's about it. The single leg dips/squats are only to about 40 -50 degree flex at this point. The Flexion/Extension stretches are all lying down (NWB) and just putting alittle pressure on to feel the stretch before adding alittle more to feel the tightness/pain.

I'm toying with the idea of greater exercising, cycling and swimming but I'm going to run that by my physio tomorrow. I realise your advice is merely that (advice)and I'm grateful for your cander - I understand the difficulties associated with such advice giving and accept it all in this vain - I'm just eager to try all (within reason)to get my life back!

Many thanks, Jim

[elinwee]

6 months ago initial injury, 14 days ago arthroscope - m I right?

Post arthroscope I usually put my pats on an icing regime, with using a tubigrip to control swelling. This continues until swelling settles. Plus-minus anti-inflammatories for pain relief and swelling control. I usually prescribe this in the first 7-14 days post arthroscope. If your knee is still puffy, I strongly suggest ice EOD and to use a tubigrip around knee during the day while walking around or at work.

Following that - depending on what has been done at athroscope. If there has been any meniscal or ligament repair, then more care to be taken to ensure that stitching and graft holds. If not (as in your case), then rehab can progress according to patient tolerance (and any Wbing restrictions, which is uncommon post arthroscope if there hasn’t been a repair or graft).

WIth the rehab prog - I will usually try and challenge my pats as far as possible. I tell them that as long as what they are doing does not (1) increase their pain; (2) increase knee swelling; (3) affect their function, they should be right.

Immediately post-arthroscope, they;ll be doing isometric quads tightening n ankle pummping in bed.

Week 1: test for quads lag (physios can do that, basically to determine if there is a deficit in end range quads control which determines the ability of quads to hold the knee straight). If there is no quads lag, commence the following bed exercises (provided that there are no contraindications (CIs) for open-kinetic-chain (OKC) exercises:

- isometric quads (in full extn focus on VMO)
- straight leg raising (SLR) : basically lying in bed propped up on elbows if desired, keep leg straight with kneecap and toes pointed directly to ceiling, tighten quads first to keep leg straight then slowly lifting leg off bed. Keep opp leg bent with feet on bed
- S/L hip abduction: lying on side with exercising leg uppermost, bend up bottom leg for stability. Keep kneecap and toes pointed directly forwards (therefore controlling hip rotation). Tighten quads first to keep leg straight then slowly lift leg up in air.
- Bridging: lying on back with both knees bent up and feet on bed. Lift bottom up in air

If pat hasn’t got WB restrictions and is ambulating without aids, commence gentle WB exercises as tolerated:

- short range squats with both legs, back on SB at wall
- double leg calf raises at wall

Week 2: continue with bed exercises and WBing exercises as above. If Wbing ex not commenced in week 1, then start here. New bed ex:

- In prone lying, hamstring flicks. Simply bending and straigtening knee slowly controlling movement. Practice slowly through range movements and quick short range flicks.

- In prone lying, glutes. Bend knee up to 90deg. Maintain 90 deg and lift leg up toward ceiling by squeezing glutes.

WB regime – continue as above, maybe increasing depth of squats and adding isometric holding. I will still keep exercises to bilateral only and not single leg at this stage.

If pat is comfortable at this stage with exercises, ie no problems with flareups and with good control of movement, start gentle cycling – low resitance thru available knee range.

Week 3: continue bed ex as desired.

WB regime:

• Inc knee squatting range
• Hip ER against ball @wall (sorry I cant really describe this!) – this is an isometric single leg ex
• Double calf raises, trial single leg raises if able
• Continue cycling – inc resistance

Week 4:

WB regime:

As Week 3, adding on

• Static lunges
• Low step ups
• Cycling – inc resistance

Week 5 and on:

Rehab Progression to work toward:

• High step ups
• Step downs
• Step lunges
• Full squats
• Impact tasks – jumping, running, changing directions
• Specific funtional tasks

Its harder to detail a timeline for Wk 4 on as it is dependent on how one porgresses and on one’s ability. Having said that even the first 4 weeks r also guides only, still dependent on each ind case. As long as exs r not flaring up knee condition, ie the 3 things stated above, its usually ok.

Being a pilates instructor, I also utilise a lot of pilates based ex to improve on core stability as a lot of probs arise in the first place due to poor core control. A lot of daily tasks can also be improved with improving core stability.

Hope this helps!!

Elin

PS: u noticed i havent included swimming. Its a funny one cos its highly dependent on what u intend 2do in the pool. I usually advise no breaststroke kicks for knees.