• Ask The Experts

    Bad Knees asks:

    “I work as a firefighter and have chronic Patellar Tendonitis. I’m a 34 year old weekend warrior as well (basketball mostly, biking, running, etc). My knees hurt from just daily activities. I take NSAIDs and haved applied ice 1 – 2 times each day for about 2 weeks with no relief. I have not played any ball either. Two questions: What can I do for cardio that willnot worsen my knee condition? What type of silf-therapy/rehab can I do to strengthen my knees?”

    David Wales, Clinical Specialist Physiotherapist responds:

    “In answer to your first question, arm ergometry and/or low to moderate resistance upper body weight circuits (between 3 and 5 sets), with a work to rest ratio of 1:1 can give you an aerobic cardiovascular workout. Non impact pool running using a buoyancy belt is also an excellent method of maintaining fitness without putting stress on the Patella Tendon.

    “In answer to your second question, forget self therapy/exercises while you still have knee pain. Have the condition diagnosed by a doctor or physiotherapist. An MRI may be required to ascertain the extent of the tissue damage. If they confirm you have Patella Tendonitis (the medical term is Patella Tendinopathy) you will have to rest from the impact of running and jumping sports for between 6 and 12 weeks depending on the severity of the tissue damage, in order to allow tissue healing to take place. If your diagnosis is confirmed as Patella Tendinopathy then you should undergo rehabilitation with a physiotherapist who will be able to prescribe an ‘eccentric’ strengthening programme. There is good research evidence to suggest that following this type of ‘eccentric’ rehabilitation programme is extremely effective in the treatment of tendon problems.

    “To explain, an eccentric contraction is defined as a contraction where the muscle is lengthening, as opposed to a concentric contraction where the muscle is shortening, or an isometric contraction where there is no change in the muscle length. The exercise for strengthening the Patella Tendon is the squat using a ‘decline’ board (a wooden wedge) with the toes towards the thin end of the wedge. This position maximally works the Patella Tendon. Specifically the eccentric contraction of the Quadriceps and Patella Tendon is the lowering phase of the squat.

    “There is nothing magical about eccentric muscle strengthening in the role of alleviating tendon problems. The key is the controlled progression of specific exercise, which elicits an adaptation in the tendon that produces increased tensile strength. In other words, as you slowly increase the load on the tendon it will get stronger. Research has shown that eccentric muscle contractions generate more tension than isometric or concentric contractions. By using just eccentric work this particular variable can be controlled and gradually progressed.

    “It is important to note that the load and number of repetitions must be carefully recorded and progressively increased under the supervision of a physiotherapist. This ensures that the overload on the tendon is carefully controlled and gradually increased. This gradual progression allows the tendon to adapt and get stronger and healthier, but it can take 3 months in established cases of Patella Tendinopathy.

    “I know this may be difficult for you to follow because of the nature of your work, but without a ‘relative’ rest from sports the condition is unlikely to improve. Also, I recommend that you urgently get some advice from your doctor regarding your medication & long term use of NSAIDs (Non Steroidal Anti Inflammatory Drugs) can cause serious problems with your stomach.”

    Dislocating Knee (Subluxing Patella)

    Sarah in Mirfield, England asks:

    “I have a condition called subluxing patella. I also have a torn meniscus cartilage. My problem is not due to an injury as I have been able to ‘dislocate or sublux’ my knee from an early age. Over the past five years this has got extremely worse (it also comes with a very loud cracking sound, which freaks many a hospital staff out, apparently they have not seen a case as extreme as mine). My knee will dislocate anything from 15-30 times a day. Such as when I’m bending down, pivoting, using stairs or after I walk too far (running is out of the question). I have Hypermobility syndrome although I have no other real problems but the knee. It’s the right knee that’s affected. Occasionally my left knee will dislocate but only once or twice a week.

    My knee is totally unstable, and restricts everything I do. I am currently waiting my second arthroscopy to fix my meniscus, although my consultant said this is unlikely to make much of a difference.

    I have some questions about this and was hoping you could help.”

    David Wales, Clinical Specialist Physiotherapist responds:

    “Will physiotherapy help? “

    “As a physio I am always inclined to say that it is worth doing physiotherapy rather than not, although considering that you have had your problem for quite some time and have seen no improvement then I have to say that physiotherapy treatment will not cure your problem.”

    “If my meniscus is torn due to the subluxing, will this happen again in time? “

    “The menisci and knee joint generally are susceptible to further damage whenever there is knee joint instability. Hyper Mobilty Syndrome represents extreme instability so if you are repeatedly suffering these injuries then you may suffer further damage.”

    “What are my chances when it comes to arthritis?”

    “Arthritis tends to be accelerated secondary to joint damage. Because you are subluxing or dislocating over 15 times each day then the chances of developing arthritis are increased if your situation is not addressed. However, damage to joint surfaces from dislocation and subluxation tends to be less in individuals who have lax joints and Hypermobility Syndrome. In these individuals the joint pops out so easily there may be little or no tissue damage.”

    “What is the best knee support/brace that I could get to help support my knee?”

    “The most appropriate knee brace for Patellofemoral Instabilty is the Donjoy Hinged TRU PULL Advanced Knee Brace. However this brace is designed for people who have suffered one or two subluxations or for those with pain around the knee cap due to Patellofemoral Pain Syndrome. I don’t think that this brace will be effective in your case, due to the very severe symptoms and the way that Hypermobility Syndrome is affecting your knees. Patella subluxations tend to occur when the knee is bent, or when there is rotation of the knee so it is worth asking your orthopaedic doctor if a hinged knee brace that limits the amount of knee bend, such as a good quality Hinged Knee Brace would be suitable for your right knee.”

    “Will my left knee eventually do the same in time?”

    “Due to the fact that you have Hypermobility Syndrome then your left knee may also become more affected, but it is impossible to predict with certainty.”

    “What other damage could be caused in the future?”

    “As you’ve alluded to earlier, meniscal damage and general joint damage may precede osteoarthritis of the affected joints. However, damage to joint surfaces tends to be less in individuals who have lax joints and Hypermobility Syndrome, where the subluxations are relatively less painful and the joint goes back in place easily.”

    “Is there anything I should avoid that might make this worse?”

    “Try and avoid all the specific movements which you know tend to cause a subluxation. However I understand that this may be very difficult in your case, due to the subluxations occurring during such trivial, everyday activities.”

    “Overall I would recommend that you consult an orthopaedic consultant who specialises in knee problems, particularly Patellofemoral problems. They will be able to give you specific advice following a thorough history and physical examination of your knees. There are many factors to consider related to Patellofemoral Instability and the orthopaedic consultant will be able to explain these to you following his assessment of your knees. The orthopaedic consultant will also be able to let you know if a non surgical or surgical approach is indicated. There are several surgical approaches to Patella Instability, with the more modern techniques having a particularly good degree of success.”

    Ankle Strengthening Following Broken Ankle

    Ashley in England asks:

    “I recently had an operation after breaking part of my Tibia in the ankle. I have had two pins placed into the bone. The injury was to the inside of my ankle and I have now had a cast on for 3 weeks. I am due to have another cast put on next week. I understand it is normal for a cast to stay on for about 8 weeks depending on how well the bone fuses. The doctor said the best physio would be to move my foot around myself and get the joint functional again. As a keen footballer I just wanted to know whether you have dealt with cases like this before and the time scale involved in building my ankle back to full strength and the best techniques for that.”

    David Wales, Clinical Specialist Physiotherapist responds:

    “Obviously we can’t give a specific reply to your injury and we recommend that you follow the advice of your orthopaedic consultant and Chartered Physiotherapist. The good news is that you should make a full recovery following this type of injury, provided you follow the advice of your treating doctor. In high level soccer players the average time out is about six months.

    “Generally it takes about 3 months of immobilisation in a cast for the bone to heal adequately to do full weight bearing activities. You should wait for the go ahead to do this from your orthopaedic doctor. During the immobilisation period your ankle will get stiff and your Calf and Thigh muscles will waste. These problems can be addressed by physiotherapy treatment. To give a rough guide of the rehabilitation:

    • 8 – 12 weeks in plaster and using crutches until the orthopaedic doctor is satisfied there is sufficient healing. Once your doctor is satisfied that there is a sufficient degree of bone healing he may allow you to wear a removable plastic cast , instead of a plaster cast. Once out of the plaster cast hydrotherapy (exercises in the swimming pool) will help to restore ankle range of motion and general fitness. Pool running using a bouyancy belt is an excellent non impact form of exercise. Once you have been given permission to put partial weight through the injured leg then an exercise bike can also be used for fitness work.
    • 3 – 4 months. So long as there is evidence of fracture healing on x-ray, your doctor will give you permission to begin full weight bearing activities such as walking without a removable plastic cast or crutches. It is usually possible to begin strengthening and proprioception exercises.
      Exercise 1This exercise strengthens the muscles at the front of the shin that pull the foot back towards the knee.

    Sitting on the floor, a low resistance band is tied around the foot, with the other end attached to a fixed object that is out in front of the foot.Slowly the foot is pulled back towards the knee. 20 repetitions, 5 times daily.

    As this becomes easier, the resistance band is changed to one that provides more resistance.Tip: doubling up the elastic is an easy way to achieve more resistance.Exercise 2Sitting on the floor, with the legs out straight, a resistance band tied around the foot, and the other end held in the hand. Slowly, the foot is pushed forward and then relaxed.20 repetitions, 5 times daily.

    As this becomes easier, the resistance band is changed to one that provides more resistance.Exercise 3This exercise is a progression of the previous Calf strengthening exercises.

    The patient stands with their hands resting against a wall so that it is taking some of their body weight. With both feet, the patient pushes up on the toes so the heels rise up off the floor. This position is held for 2 seconds and then the heels are slowly lowered.20 repetitions, 5 times daily.

    Once this becomes easier, the same exercise is done but without any hands against the wall. Once this has been mastered, the patient progresses to doing the exercise with the toes positioned on a block, so that the heels have to come down lower before pushing up.

    The final progression to this exercise is to do it on the affected ankle alone.

    “Strength can be progressed using a Calf press resistance machine and Thigh strengthening should be progressed under the supervision of your physiotherapist. Muscle strength should be equal to the unaffected side before plyometric exercises (jump training) and running are resumed.

    “Proprioception exercises enhance neuromuscular control around a joint and are very important if you would like to return to sporting activities.

    A Guide to Proprioception

    “5 – 6 months. If range of motion, strength and proprioception are returned to pre injury levels, then functional activities can be resumed with a gradual return to sport.

    “You should be guided at every stage by the orthopaedic doctor and all rehab should be done under the supervision of a Chartered Physiotherapist. Good luck with your recovery.”

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