KNEE PAIN
Common Knee Pain Generators
Ligaments
There are four main ligaments that hold the knee together during movement. These ligaments are the ACL, PCL, MCL, and LCL. The ACL and PCL are designed to prevent forward and back ward motion in the knee joint. The MCL and LCL prevent the knee from buckling inwards and outwards. Complete rupture of these ligaments requires surgery, but sprains of these can be managed with proper rehabilitation and helped by other therapies such as needling, soft tissue, and Class 4 laser.
Tendons
Many muscular attachments occur at the knee. When muscles attach to bones they come together to form a tendon. Tendons, like the patellar tendon in the knee, can become irritated due to being loaded beyond their capacity. This is why jumpers and sprinters can often develop patellar tendonitis/tendinopathy. It is important to rehabilitate these injuries properly so that load and capacity can be reintroduced without causing further pain and damage.
Menisci
The knee has two menisci that act to increase the shock absorbing capacity of the knee, as well as increase the surface area of contact between the femur and tibia. The menisci are often damaged due to falls or trauma in the knee. Ironically many people without symptoms have been found to have damage in the menisci of the knee, and only certain types of tears have to be managed surgically. In the majority of cases, proper strengthening, and rehabilitation is equally effective to surgical repair.
Knee Arthritis
Previously thought of as a solely structural and “wear and tear” type issue, we now know that many factors go into making an arthritic knee painful. These factors range from overall inflammation, to simple muscle weakness. A large study of over 46,000 people found that weakness in the knee extensors (quads) was a risk factor for the development of knee osteoarthritis (Øiestad et al. 2021). This is definitely one of the cases in which preventative measures for knee arthritis really include resistance training of the knee. In the treatment of knee arthritis itself, contrary to what some may believe, movement can be exceedingly beneficial whether that be walking, squatting, lunging, or running. Long term management with over the counter anti inflammatories and injections are potentially dangerous in that they may decrease what cartilage is left in an unhappy knee (Perry et al. 2021; Singh et al. 2021; Orchard 2020). Some things that may be beneficial include supplementation with collagen peptides and also movement assessments to look for a direction of preference (Zdzieblik et al. 2017; Rosedale et al. 2014).
Patellofemoral Pain syndrome.
This is an interesting pain manifestation behind the kneecap which causes pain while squatting, going up stairs, and can even present after sitting for long periods of time. We used to think that the patella was tracking incorrectly along the condyles of the knee and that these “tracking issues” led to abnormal wear and tear and then pain the back of the kneecap. Unfortunately, tracking the patella is easier said than done, and when we do track it, it seems as though all tracking manners are present even in people without pain in their patella. A few things that were found to be very helpful include some manual therapies along with active exercises. These HAVE to be done together because performing one of these alone is not superior to doing both. The manual therapies that can be helpful to the recovering knee include soft tissue therapies like pin and stretch of the muscles surrounding the knee, as well as acupuncture. The rehabilitation of this injury has also changed significantly in the past 5 years. We once thought that we needed to target the tracking issue of the knee and support it with tape in controlled ranges of motion. However, this has been found to be less effective than a graded loading program to the extensors and stabilizers of the knee. Ironically many of the major stabilizers of the knee are located up in the hip. The muscles in the outside and back of the hips are major players of knee stability, and can be easily strengthened with specific exercises that do not even require a resistance band or tape ((Willy et al. 2019; Winters et al. 2020)
Ligament Injuries
some ligament injuries can (and should) be treated conservatively and without surgery, while some will likely need surgery to repair important structures that provide the knee with some crucial aspects of stability. The four major ligaments of the knee that provide really important stability for skiers are the Anterior cruciate ligament (ACL), Posterior Cruciate ligament (PCL), Medial collateral ligament (MCL) and the Lateral Collateral ligament (LCL). One of the most important things that we do in our office regarding knee pain is a thorough assessment and evaluation if you are a good candidate for our care. Complete tears of one of these ligaments compromises the structural integrity of the knee and leads to significant laxity, which can then lead to damage in other areas and tissues of the knee, which can predispose you to arthritis and joint damage. Luckily, orthopedic tests as well as thorough history taking (both of which can be performed by trained sports chiropractors) can be effective in figuring out if a referral to a surgeon or for imaging is necessary. Complete tears of the ACL and other ligaments are the best candidates for surgery, but minor tears and sprains of ligaments like the MCL and LCL are very effectively managed with non surgical means. The best way to manage these is through a combination of manual techniques and guided rehabilitation which can be performed by sports chiropractors and physical therapists.
Patellar tendonitis
Occurring frequently in athletes that have to jump or accelerate dynamically, Patellar Tendonitis is a condition in which the tendon on the front of the knee becomes inflamed and irritated due to overload. When chronically painful, tendonopathy ensues, which is characterized as both pain and disorganization of the tendon collagen matrix. Tendonitis and tendinopathy are best managed with proper education and rehabilitation. This includes a progressive loading strategy, which will bridge the gap between your current functional capacity back to full capacity without pain.
