Patella Dislocation

Patella dislocation is a common injury in adolescents, particularly in those playing sports. Most commonly, the patella dislocates laterally to the outside of the knee. This process often injures tissues on the medial or inside of the knee, such as the medial patellofemoral ligament (MPFL). Dislocation can be divided into two categories: primary (first-time) and secondary (second, third, etc). It may also be categorised as traumatic (involving significant force to dislocate the patella from its resting groove) or atraumatic. The latter scenario can occur in individuals with ligament laxity. After the injury, an MRI is commonly performed to assess injury of bony and soft tissues of the knee cap, in order to guide management. These injuries have also been linked to osteoarthritis many years after the injury, and due to their high prevalence it is important to consider whether surgical or conservative management is best (Sanders et al. 2017).

Surgical vs Conservative Management

The ultimate aim in managing primary dislocations is to prevent another dislocation. A study published in 2017 found surgery to be superior to conservative management in the short-term, thus for professional athletes with return to sport pressure, this may be more suitable. However in the long-term, conservative and surgical management have the same outcomes in knee function when walking, squatting, climbing stairs and squatting (Longo et al. 2017)

Surgical Management

This being said, some injuries associated with patella dislocation may determine surgery necessary, such as osteochondral defect (which is an injury to the bone and cartilage of the knee cap), as it can increase rates of redislocation (Sanders et al. 2017). An orthopaedic specialist is often required to make this decision. The location of injury within the knee cap ligaments also may dictate if surgical management is necessary. (Kang et al. 2013)

Secondary (recurring) dislocations also require a specialist’s opinion, as this may indicate chronic instability of the patella due to injury of the supporting tissues. This does not mean surgery must be performed, as each patient’s individual anatomy affects the decision (Sanders et al. 2017).

Conservative Managament

Conservative management principles have been debated within the literature. Firstly, duration of immobilisation post injury has varied from 2-6 weeks.

The commonly injured MPFL is maximally taught at 20-30 degrees of knee flexion, thus it is recommended to immobilise the leg straight in extension (Mistry et al. 2018). A ROM brace may be used, yet no studies to date have effectively assessed the best immobilisation method when comparing rates of redislocation.

Physiotherapy in the early stages often involves quadriceps activation exercises, weight bearing as tolerated, while the brace is on. VMO activation of the quadriceps is important due to its role in dynamically stabilising the patella and its relationship to the MPFL. (Desio et al. 1998) After a few weeks, the brace can be removed dependent on symptoms, and range of movement is gradually increased. A ROM brace is advantageous at this time to wean the flexion or bending range of movement.

As range improves, exercises may be progressed to incorporate further strength training of the pelvis and lower limb muscles. Proprioceptive training is also important to regain control of the knee, particularly in sports requiring change of direction and impact from external forces e.g. rugby.

Bracing can be helpful with those with symptoms of instability and apprehensiveness completing everyday tasks or even sports but it cannot prevent further dislocations. The brace usually involves a hole for the patella and a lateral buttress that provides support. (Brukner et al., 2017)

If you or someone you know have experienced a patella dislocation and would like physiotherapy rehabilitation, contact us at Xphysio for an assessment and treatment plan.

References

Brukner, P., Khan, K., Clarsen, B., Cook, J., Cools, A., & Crossley, K. et al. (2017). Brukner & Khan's clinical sports medicine (pp. 762-765). North Ryde, N.S.W.: McGraw-Hill Education (Australia).Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998;26(1):59–65.Kang, H. J., Wang, F., Chen, B. C., Zhang, Y. Z., & Ma, L. (2013). Non-surgical treatment for acute patellar dislocation with special emphasis on the MPFL injury patterns. Knee Surgery, Sports Traumatology, Arthroscopy, 21(2), 325-331.Longo, U. G., Berton, A., Salvatore, G., Migliorini, F., Ciuffreda, M., Nazarian, A., & Denaro, V. (2016). Medial patellofemoral ligament reconstruction combined with bony procedures for patellar instability: current indications, outcomes, and complications. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 32(7), 1421-1427.Mistry, J. B., Bonner, K. F., Gwam, C. U., Thomas, M., Etcheson, J. I., & Delanois, R. E. (2018). Management of injuries to the medial patellofemoral ligament: a review. The journal of knee surgery, 31(05), 439-447.Patellar Dislocation: Signs, Symptoms, Treatments | Total Orthopedics and Sports Medicine. (2017). Retrieved from https://www.totalorthosportsmed.com/patellar-dislocation-symptoms-treatments/Sanders, T. L., Pareek, A., Hewett, T. E., Stuart, M. J., Dahm, D. L., & Krych, A. J. (2018). High rate of recurrent patellar dislocation in skeletally immature patients: a long-term population-based study. Knee Surgery, Sports Traumatology, Arthroscopy, 26(4), 1037-1043.

Management of ACL Injury

Anterior Cruciate Ligament (ACL) rupture is a commonly discussed injury due to its perceived severity and impact on knee function and quality of life. Recently, ACL reconstructive surgery has been on the rise in Australia, particularly within the younger population. Between 2000 and 2015, the annual incidence of reconstructive surgery increased by 43% (from 54.0 to 77.4 per 100 000 people), and by 74% among those under 25 years of age (from 52.6 to 91.4 per 100 000 people). Direct hospital costs of ACL reconstruction surgery in 2014–15 were estimated to be $142 million. The annual incidence of revision of previous ACL reconstructions increased by 5.6% per year, indicating a rise in follow up surgeries.

With this increase in surgical management since early 2000s, it has become worrying for physiotherapists to see a lack of understanding of the importance of exercise and rehabilitation in the management of the injury. Injury to the ACL commonly occurs in sports that require pivoting, change of direction, or sudden deceleration. In Australia, we commonly see these injuries in AFL, football, netball, Rugby among others.

It is important for the injured athlete to understand that if they decide to undergo reconstructive surgery as a form of management, rehabilitation is a lengthy process. Furthermore, if reconstructive surgery is indicated, patients will benefit from a pre-operative strength program which has been shown in literature to optimise postoperative outcomes and ability to return to sport over the long-term.

These exercises should be prescribed by a physiotherapist. This specificity in training is important pre-operatively as different patients will require training and exercises to target different aspects of the rehabilitation program. Areas commonly addressed with pre-operative management include establishing full joint range of movement, early motor control (how your brain coordinates movement) and strength (generally to a level beyond pre-injury level).

In the initial stages, it is important to reduce swelling and restore the bending and straightening range of movement of the knee. It is also important to restore quads strength to approximately 70% of the uninjured side. Once again, 70% is a hurdle, developing further quadricep strength is beneficial.

Once this has been achieved, further strengthening is needed with more complex exercises that do not aggravate knee symptoms. A 5-week program that incorporates strength, balance and plyometric exercises is recommended (see images below). In a study by Failla and colleagues (2016), a group of ACL injured patients went straight for surgery after their injury, whilst the other group commenced an exercise program twice weekly for 5 weeks under supervision prior to their reconstruction.

When they followed up each group at 2 years after the reconstruction, they found that those who did this 5 week program prior to surgery had significantly higher patient-reported knee function and quality of life. Furthermore, they had higher return to pre-injury level of sport rates compared to those that didn't do the program.

Evidently, exercise is key both pre and post-operatively. But there are other aspects of an ACL injury to consider. One of the confounding issues in society is in response to the management of professional athletes. They have the luxuries of infinite resources and access to healthcare both preoperatively and postoperatively, which cannot be deemed, realistically, as the optimal way to address knee injuries across society. Considering that not everyone is a professional athlete, it is important to make a well-judged decision regarding

1. Whether to have surgery or not

2. How quickly to have surgery

3. What level of daily function a person is aiming to return to

4. Return to sport, which nowadays should involve objective criteria as opposed to time-based.

5. Other factors that influence the quality of life of a patient’s knee (ability to exercise, weight, etc)

Ultimately, whether you choose to have an ACL reconstruction or not, early management of symptoms is important for improving your long-term (2 years+) knee function and ability to return to sport. Therefore, there is no need to rush to surgery, and instead you will benefit from physiotherapy intervention which aims to strengthen the knee. Some of the exercises that could be included in your physio-prescribed program are shown below in the images.

If you have suffered an ACL injury and would like to be assessed by one of our physiotherapists, give us a call on 333 55 222 to discuss further.

References

1. Brukner, P., & Khan, K. (2017). Clinical Sports Medicine (5th ed., pp. 715-768). McGraw-Hill Education.

2. Failla, M., Logerstedt, D., Grindem, H., Axe, M., Risberg, M., & Engebretsen, L. et al. (2016). Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction?. The American Journal Of Sports Medicine, 44(10), 2608-2614.

3.Zbrojkiewicz, D., Vertullo, C., & Grayson, J. (2018). Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000-2015. Medical Journal Of Australia, 208(8), 354-358. doi: 10.5694/mja17.00974

What is Osteoarthritis?

Osteoarthritis (OA) is one of the most chronic, debilitating conditions that will affect most of us during our lifetime whether it is in the hip, knee or another joint. It is characterised by inflammation (swelling, redness and heat) in the joint and deterioration of our articular cartilage, which acts as our lubricant to allow smooth movement of our bones in our joints. It can also lead to formation of new bone (subchondral bone), sclerosis of the current bone and fibrocartilage being formed instead of articular cartilage, to resurface the bone, leading to less effective joint mechanics. End stage OA is referred to as "bone on bone" and this is where the joint may ultimately fail. With that comes loss of strength, painful range of motion and a deformity at the joint may occur.

Presentation

OA can have a rapid onset and most commonly affects 50-60 year old women. The joint will be inflamed, have pain with load bearing activity or after general exercises/activity. They may have muscle wastage around the joint itself (e.g With knee OA we see a marked reduction in our vastus medialis musculature, which is our quad muscle on the inner side of our knee joint), reduced range of motion (particularly flexion and extension both in the hip and knee joint) and there may be Joint Crepitus present (ie. cracking of your joint as you move through range.

OARSI Guidelines

The Osteoarthritis Research Society International has developed guidelines to help practitioners with treatment of OA. Among a comprehensive list of key points that needs to be addressed from their guidelines, specific ones include:

1. Advice and education about OA

2. Referral to Physiotherapy for exercise management

3. Ongoing aerobic/cardiovascular exercise, strengthening and range of motion based exercises.

4. Weight loss will also help improve outcomes if the client is overweight

5. Ask about advice on footwear

The full list of recommendations set out by OARSI can be found at the link below:

https://www.oarsi.org/education/oarsi-resources/oarsi-recommendations-management-hip-and-knee-osteoarthritis-part-ii-oarsi

Physiotherapy Management and Reducing Your Risk!

Based on the OARSI Guidelines, referral to Physiotherapy to receive the correct exercises, advice and education on OA is a fantastic starting point. This allows you to be given exercises, advice and education to improve your quality of life, reduce the progression of disability that OA can cause in your joints, keep you physically active and reduce your risk of other co-morbidities developing as a result of OA progression and limiting your physical activity levels. It must be an individually tailored program to suit your condition based on your presentation and progression through the OA disease process and what you can and cannot do.

Physiotherapy can help by looking at how you are walking, as our gait pattern can usually compensate for our pain, lack of range of motion and joint deformity and help you improve your biomechanics to try to reduce disease progression.

Don't let OA prevent you from living an active lifestyle! Book in for an appointment with one of our Physiotherapists to allow them to help you to manage your condition.

Low Back Pain

What is it?

Low back pain is one of Australia’s most debilitating conditions and can be quite complex when it comes to treating. Low back pain can be split into two main groups; Non Specific or Mechanical Low Back Pain (85-90% of cases) or Specific Low Back Pain (10-15%). Most people who suffer from back pain will fit into this Non-Specific or Mechanical low back pain category and will usually recover within 2-6 weeks, others as long as 3-12 months. There is a recurrence rate of around 50% after having one episode of back pain. Each person who suffers from back pain is different, there is no magic fix or “one approach fits all” when it comes to diagnosing or treating. You can suffer back pain simply by moving wrong, performing repetitive movements that cause strain to your back, poor muscle strength or recruitment and a traumatic event.

So how can we help?

It is important that a thorough assessment is conducted of your back that guides your treatment to provide you with: a graduated return to exercise program, correct advice and education and provide you with suitable manual therapy as befits your specific diagnosis.

Physiotherapy can help you get back to enjoying your daily life without pain. It is about teaching you to exercise smarter, not harder, with a graduated return to exercise and understand what your injury is and how best management of it can lead to good long term outcomes and reduce your recurrence rate.

It is important that you chat to your physiotherapist about ways that you can stay active and how you can get back or stay at work as soon as possible. Simple strategies that you can develop and implement to return to work and stay active have been shown to facilitate good long term outcomes of reducing your back pain and reducing the chance of recurrence.

Important points to remember

Our nervous system is complex and just because we have pain does not mean we necessarily have damage to our bones, muscles, joints or nervous system. Our body can perceive pain as a response to protect an area.

It is essential that you are aware that MRI findings do not correlate with low back pain. If we performed an MRI of most people, we would find a mild disc bulge.

What can you do?

Staying active and incorporating exercises that strengthen our deep core muscles (transverse abdominis, pelvic floor and multifidus), hip stabilisers (glute medius) and legs muscles (glute max, hamstrings, quadriceps) are imperative in helping reduce our risk. A good starting point is aiming for 3 sets of 8-10 repetitions to begin with.

Strength Exercises:

Hip Hinges (on wall)Glute Hamstring BridgeSide laying hip abductionSupine Toe Taps4 point Diagonals “Super-mans”Standing multifidus activators “Growing through your lower back”

Mobility/Stretching Exercises:

Cat-CamelKnee RocksDouble Knee to ChestHamstring stretch

Osteoporosis is a condition that currently affects a large number of people around the world. Approximately 66% of Australians over 50, have osteoporosis or osteopenia. This number is expected to increase over 6 million people by 2022 just in Australia. In addition, it is a costly disease for the Australian Government: 2.75 billion AU$ was spent on osteoporosis or osteopenia in 2012.

However this number of people affected with osteoporosis is not exact, as many people are underdiagnosed and they are not aware of having low bone density. About 75% women and 90% men with an osteoporotic condition are not investigated and around 75% of them are not being treated.

It is a common disease affecting predominantly on the ageing population and the most serious complication is having an osteoporotic fracture. This type of fracture increases as we get older, osteoporosis is the commonest cause of fractures in this population, especially fractures of the wrist, hip, humerus and vertebras. Some fractures may be related to a minimal trauma or no trauma, or it can be related to a fall. For instance, some vertebral fractures can be caused by simple movements like forward bending with the trunk or lifting. Spinal compression fractures can take place suddenly (with or without pain), and it is characterized of height loss (can be up to 4-8 inches) and a significant stooped posture.

Osteoporosis is a disease which affects the quality of the bone tissue. It is characterised by a decrease in bone mass, increased fragility and consequently increasing the risk of fracture.

Bone is a living tissue that reacts to load, mechanical stresses and stimulus (different to the normal habitual load), enhancing bone remodelling and creating new bone formation. Specific exercises can create this mechanical stimulus and promote beneficial effects on bone density.

It is important that you always consult with your doctor for specific osteoporosis medical treatment and preventative treatment to minimize the risk of bone loss and fracture. Vitamin D, calcium and pharmacologic treatment are beneficial and effective treating osteoporosis, but your GP will be involved prescribing the adequate treatment for you.

Different factors may increase the risk of having osteoporosis:

AGEGENES (eg: Family history of fracture)MEDICATIONS (eg: diuretic, corticosteroids, anti-convulstants)HORMONAL IMBALANCE ( eg: low testosterone, menopause )DIET (eg: vitamin D or calcium deficiency, anorexia, alcohol consumption)SECONDARY TO OTHER DISEASES ( eg: thyroid, liver, bowel diseases)LIFESTYLE ( eg: smoking, sedentary lifestyle)

One of the most common risks for osteoporosis is menopause. It is believed that oestrogen levels alter through menopause, influencing bone tissue demineralization, in fact, since the commencement of menopause there can be an increase of bone loss up to 2- 4% per year.

Physiotherapy and exercise assist in the treatment for osteoporosis. Known benefits include improved quality of life and decreased the risk of falling, consequently reducing the risk of fractures. Even though the evidence about the effects of exercise on the Bone Density Mass seems to provide little improvement (between 2% and 4% increase of BDM depending on studies), specific exercises can prevent further bone loss and can decrease the risk of falling.

At XPhysiotherapy, we are aware that not all kinds of exercises are beneficial for treating osteoporosis. It appears that weight bearing exercises; progressive resistance training and impact exercises have a positive effect on the bone density. On the contrary, exercises that does not include gravitational load (for example swimming) have no significant effects on the bone density. Aerobic exercise alone has been shown not prevent of falling or fracture, so it is necessary to add to your exercise routine balance retraining daily in a safe environment (15 -20 min daily), so you can train your body to react if you lose the balance and therefore prevent a fall.

Expert Panel Board consensus recommendation:

Furthermore, it is important to bear in mind that some type of exercises can be harmful. For example exercises which include excessive spinal flexion movements (eg: sit ups) can increase the risk of damaging the spine. For this reason, having a correct posture during exercise is crucial, maintaining appropriate body alignment throughout exercises and daily activities. It is recommended to consult your physiotherapist or exercise physiologist to prescribe an adequate exercise program and postural advice, according to your past injuries and other medical conditions.

To sum up, osteoporosis is a complex disease influenced by multiple factors and treatment requires a combination pharmacological therapy, adequate diet program and physical activity to provide the best outcomes. Being fitter, stronger, improving balance and reflexes will help you to prevent the consequences of having low bone density and improve your quality of life. We are pleased to now offer a targeted osteoporosis exercise class at XPhysiotherapy. Times will be posted soon.

REFERENCES

Kelley GA, Kelley KS, Kohrt WM. Exercise and bone mineral density in premenopausal women: a meta-analysis of randomized controlled trials. Int J Endocrinol. 2013;2013:741639.

Nguyen TV , Jacqueline R Center and John A Eisman (2004) Osteoporosis: underrated, underdiagnosed and undertreated., Medical Journal Australia Med J Aust 180:S18–S22

Osteoporosis Australia. 2014. www.osteoporosis.org.au. [ONLINE] Available at: http://www.osteoporosis.org.au/sites/default/files/files/oa_consumer_ed2_Aug2014.pdf. [Accessed 3 November 2016].

Osteoporosis Australia. 2012. www.osteoporosis.org.au. [ONLINE] Available at: http://osteoporosis.org.au/sites/default/files/files/Burden%20of%20Disease%20Analysis%202012-2022.pdf. [Accessed 3 November 2016].

World Health Organization (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. WHO Technical Report Series 843. WHO, Geneva

Sinaki, M., & Mikkelsen, B.A. 1984. Postmenopausal spinal osteoporosis: Flexion versus extension exercises. Archives of Physical Medicine and Rehabilitation, 65 (10), 593-96

Nikander R, Sievanen H, Heinonen A, et al. Targeted exercise against osteoporosis: a systematic review and metaanalysis for optimising bone strength throughout life. BMC Med 2010; 8: 47

Howe TE, Shea B, Dawson LJ, Downie F, Murray A, Ross C, Harbour RT, Caldwell LM, Creed G.Exercise for preventing and treating osteoporosis in postmenopausal women.Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD000333.DOI: 10.1002/14651858.CD000333.pub2.

Watson SL, Weeks BK, Weis LJ, Horan SA, Beck BR (2015) Heavy resistance training is safe and improves bone, function, and stature in postmenopausal women with low to very low bone mass: novel early findings from the LIFTMOR trial. Osteoporos Int 26(12):2889–94. doi:10.1007/s00198-015-3263-2

Giangregorio LM, Papaioannou A, Macintyre NJ, Ashe MC,Heinonen A, Shipp K, Wark J, McGill S, Keller H, Jain R,Laprade J, Cheung AM (2014) Too Fit to fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporosis Int 25(3):821–835Image http://medical-dictionary.thefreedictionary.com/osteoporosisImage http://www.healthelective.ca/wp-content/uploads/2013/04/172853.jpg

Ankles injuries are the more common in indoor and court sports with higher incidence recorded in males 12 to 24 years and females above 30 years. lateral ankle injuries are more common than syndesmosis and medial ankle injuries.

Lateral Ankle Sprains

Lateral ligament sprains make up about 80% of all ankle sprains and are a very common presentation to physiotherapy clinics. Most of these injuries happen from a “rolled ankle” or inversion mechanism whereby the ankle is overstretched in a downward and inward direction. Factors such as the playing surface, awkward landing positions, opponent’s feet and sporting equipment can influence this injury.

Rehabilitation of lateral ankle sprains in the acute stages involves oedema (swelling) management, pain relief and to do no further harm to the injured area. The POLICE (Prevention of further injury, Optimal Load, Ice, Compression and Elevation) protocol is used usually used in the first 24-72hrs following ligament sprains.

Thereafter, more intensive physiotherapy may involve specific muscle strengthening exercises gentle range of motion to help promote healing and cellular repair and mobilization of painful or stiff joints.

Grades of ligament damage go from grade 1 (<10% fibres affected), Grade 2 (10-99% fibres affected) and grade 3 (complete rupture). Furthermore, the more severe the ankle injury may require immobilisation for a period of time before commencement of rehabilitation. Typically grade 1 injuries take 4 weeks to return to full sporting activities, grade 2 6 weeks and grade 3 10-12 weeks although each injury is different and the prognosis will vary.

Syndesmosis Injury

A syndesmosis injury or high ankle injury usually happens from an external rotation injury commonly from snowboarding accidents or contact sports such as rugby. It involves injury to the AITFL/ PITFL and/ or the “syndesmosis” or connection of the inferior (or distal) aspect of tibia and fibula. The syndesmosis is articulation where there is an interosseous membrane (a leather strap-like tissue) and interosseous ligament holding these bones in place. Rupture or separation of the syndesmosis rarely occurs by itself and more commonly occurs with other injuries such as fractures or other ligament sprains.

Taping or bracing high ankle sprains may be required to return to sport. Taping and/ or bracing allows the tape to tug on the skin firing certain receptors in your ankle to move it in a more preferable position and preventing excessive stretch on the vulnerable ligaments. Some individuals need taping or bracing 6 months after injury and some others feel they need it on all the time. Although the taping will help with function and returning to sporting performance even the best taping technique is no good without appropriate and diligent exercise rehabilitation which includes similar protocols to lateral ankle sprain.

Cuboid Syndrome

Cuboid Syndrome is defined as minor disruption or subluxation of the structural congruity of the calcaneocuboid portion of the mid-tarsal joint. Simply put, it is where the cuboid is out of place or losses its correct joint position. It is usually caused by plantarflexion/ inversion injuries or from overuse.

The plantarflexion/ inversion injuries are from forceful stretch or contraction on the lateral side of the ankle more specifically on the peroneus longus muscle. This powerful contraction causes a tug on the peroneal tendon which has attachments on the cuboid; hence the cuboid gets pulled out of its correct position. The other proposed mechanism occurs when repeated and chronic micro trauma causes an in directed effect on the cuboid causing subluxation. Although, previously thought to effect more individuals with flat feet (pes planus) a study by Marshall & Hamilton (1992) concluded that 17% of ballet dancers (who classically have high arches – pes cavus) had cuboid syndrome.

Treatments for cuboid syndrome are aimed at:

Decreasing overactive muscles and spasm through massageIncreased joint movement and decrease pain with joint mobilisationImproved biomechanics through strengthening foot intrinsic musclesAddressing imbalances and increasing proprioception with exercises and taping.

References

Bruckner, P & Khan, K. (2013). Clinical Sports Medicine. Elsevier Health.

Williams, D. S. Blaise; Taunton, Jack (2007). Foot and Lower Leg; Physical Therapies in Sport and Exercise. Elsevier Health Sciences.

Marshall, P. and Hamilton, W.G. (1992) Cuboid subluxation in ballet dancers. American Journal of Sports Medicine 20(2), 169-175.

Van Rijn, R. M., Van, A. G., Bernsen, R. M., Luijsterburg, P.A., Koes, B. W., Bierma-Zeinstra S. M. (2008) What is the clinical course of acute ankle sprains? A systematic literature review. American Journal of Medicine.

Neumann, D.A. (2002). Kinesiology of the musculoskeletal system. Foundation for physical rehabilitation.

Sman, A. D., Hiller, C. E., Refshauge, K. M. (2013). "Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review". British Journal of Sports Medicine.

Anterior knee pain is the most common presenting symptom to physiotherapy practices across Australia (Brukner & Khan, 2014).

In this blog:

A basic anatomy of the knee is outlinedCommon causes of anterior knee pain are presentedThe evidenced based treatment of more common conditions are highlighted

Anatomy of the Knee

The knee joint comprises of bones, ligaments and cartilage.

Medial = inner, Lateral = outer

Bones: the thigh (femur), inside shin (tibia), outside shin (fibula) and knee cap (patella)Ligaments: anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL)Cartilage: medial and lateral meniscus

Surrounding muscles can attach directly to the bones, ligaments or cartilage or indirectly via muscle fascia (connective tissue).

Known technically as a synovial hinge (likened to a door hinge) joint, the knee is a complex weight-bearing joint that is subject to high forces. This predisposes the knee and surrounding soft tissue to injury. Estimated forces through the knee are:

Walking = 1.5 times body weightSingle leg land in netball = 4 times body weight1 metre jump = 25 times body weight

Different Conditions for Anterior Knee Pain

Many factors from the history of the complaint assist in a correct diagnosis. These include (among others) onset characteristics, specific location, and aggravating activity. See the table below for a comparison of these aforementioned features across more common conditions resulting in anterior knee pain:

Physiotherapy Management

Patellofemoral Joint Pain

Physiotherapy will involve exercise therapy and patient education in combination with foot orthoses, or patella taping. Exercise therapy, as concluded in high quality evidence (Cochrane), has been shown to be more effective than wait-and-see or placebo treatment (van der Heijden et al. 2015). Exercise therapy will result in reductions in pain and improve the functional level of the patient. Further, it may enhance long-term recovery, preventing the injury from arising again.

Infrapatella Fat Pad Irritation

An effective physiotherapy program targets the neuromuscular system in a weight bearing position - simply put, optimizing the way a patient moves. The program will not require any equipment, take no longer than 5 minutes, and be completed twice daily (McConnell, J. 2014). Pain reduction will be achieved with de-loaded taping of the fat pad (see picture below), with an initial aim to reduce pain when walking downstairs by 50%. The evidence proposes that, on average, 6 physiotherapy sessions over a 3-month period are required to overcome this condition (McConnell, J. 2014).

Infrapatella Fat Pad Deload Taping

Patella Tendinopathy

Exercise is the most investigated intervention for patellar tendinopathy. Previously, eccentric exercise in the form of an incline board squat (figure x) was suggested as gold standard for recovery. More recent research highlights the need for initial isometric exercise, as eccentric based exercises may be too aggressive. Below shows a continuum of specific exercises used throughout the rehabilitation.

Modified from Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015).

Pes Anserinus Tendinopathy

Current evidence concludes that physiotherapy is the mainstay in the treatment of pes anserinus syndrome (Rennie & Saifuddin, 2005). Initially this involves pain management strategies (ice), patient education and activity modification (Helfenstein Jr, M., & Kuromoto, J. 2010). After the pain and aggravating activities are controlled, specific exercises to activate, lengthen and/or strengthen muscle will be prescribed. Further research, however, is required to clearly define specific physiotherapy techniques beneficial in treating this pathology.

References:

Brukner, P. (2012). Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill.

Helfenstein Jr, M., & Kuromoto, J. (2010). Anserine syndrome. Revista brasileira de reumatologia, 50(3), 313-327.

Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015). Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. The Journal of orthopaedic and sports physical therapy, 1-33.

McConnell, J. 2014. Rescuing the Older Knee

Rennie, W. J., & Saifuddin, A. (2005). Pes anserine bursitis: incidence in symptomatic knees and clinical presentation. Skeletal radiology, 34(7), 395-398.

van der Heijden, R. A., Lankhorst, N. E., van Linschoten, R., Bierma-Zeinstra, S. M., & van Middelkoop, M. (2015). Exercise for treating patellofemoral pain syndrome. Cochrane Database Syst Rev, 1.

Across the entire Australian population, there is limited research illustrating specifically the prevalence of hip pain. In 2003, however, Chen and colleagues (2003) concluded that general hip pain was reported in 39% of women from a 24’800 cohort.

From an anatomy point of view, the hip joint is a ball and socket joint. Due to the precise structure of the joint (large ball with a deep socket), the hip is able to withstand large repeated motions and the forces from weight bearing and movement. The demand on the hip joint from these large forces and movements place the joint at risk of developing various injuries.

Disorders of the hip are generally categorised as intra-articular or extra-articular:

Intra-articular: Driven by pathology, general wear and tear, or congenital reasonsExtra-articular: Muscular/tendon origins of pain from strains, tears and overuse injuries

Imaging can assist in establishing a diagnosis, however, false positives (findings that may not be the precise source of symptoms) are common. Therefore, an accurate, comprehensive and efficient physical examination is important to determine the distinct pathology.

Different Conditions for Hip Pain

There are many different and broad diagnoses that can result in symptoms at, near or away from the hip joint. The following table illustrates the plethora of different diagnoses

The cause, symptoms, prognosis and treatment will differ based on the diagnoses above. The following sections will focus primarily on the more common diagnoses of hip-pain:

Intra-articular: osteoarthritis and labral tearExtra-articular: gluteus medius tendinopathy and trochanteric bursitis

Osteoarthritis

Causes

Osteoarthritis, a condition that affects the bone, cartilage and ligaments of the whole joint is not caused by one sole factor, but by a combination of many risk factors such as previous hip injuries, jobs that have required climbing, squatting and heavy lifting, being overweigh and a family history of OA

Treatment

Exercise is one of the most important treatments as it reduces pain and maintains level of function. Low-impact activities are ideal and these can include cycling, walking and pool-based exercise. Specifically to pool-based exercise, the buoyancy of the water takes pressure off the hips allowing you to move more freely than on land.

Physiotherapy may include:

Specific strengthening exercises for muscles around the hipEducation and development of a self-management planGait and posture adviceTaping

Labral Tear

Causes

The hip labrum has many functions including shock absorption, joint lubrication, pressure distribution and aiding in stability. In many cases, damage to the labrum has coincided with osteoarthritis. Other causes include trauma and sports injuries, having joint hypermobility and impingement pathologies.

Treatment

Physiotherapy may include:

Improving neuromotor control via deep stabilisation muscle activationGait and, if applicable, running retrainingReturn to sport plan, if applicable

Gluteus Medius Tendinopathy

Causes

Gluteal Tendinopathy (GT) is thought to be the primary cause of lateral hip pain. Many risk factors have been proposed for GT but few have been validated (Grimaldi, et al. 2015).

Risk factors include:

Over 40 years of ageFemaleLower back pain

Symptoms generally arise from structural change at the gluteal tendons (connects muscle to bone) and bursae (fluid filled sacks that overly tendons and muscles). This process is thought to catalyse from a combination of:

Recent increases in load- training for marathon, beginning gym again, or considerably increasing walking distanceProlonged period of insufficient load - poor muscle activation, low back pain may inhibit (turn off) this muscles ability to activateCompression forces – from surrounding muscles, certain postures and stretches

Treatment

Physiotherapy can include (Grimaldi, et al. 2015):

Education regarding posture and gait retrainingLoad management – reducing the catalytic process mentioned aboveExercise therapy – Isometric, gentle loading exercise, and movement retraining

References

http://www.arthritisaustralia.com.au/images/stories/documents/info_sheets/2015/Condition%20specific/Osteoarthritis.pdf

Brukner, P. (2012). Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill.

Chen, J., Devine, A., Dick, I. M., Dhaliwal, S. S., & Prince, R. L. (2003). Prevalence of lower extremity pain and its association with functionality and quality of life in elderly women in Australia. The Journal of Rheumatology, 30(12), 2689-2693.

Grimaldi, A., & Fearon, A. (2015). Gluteal Tendinopathy: integrating pathomechanics and clinical features in its management. journal of orthopaedic & sports physical therapy, 45(11), 910-922.

Groh, M. M., & Herrera, J. (2009). A comprehensive review of hip labral tears. Current reviews in musculoskeletal medicine, 2(2), 105-117.

Magee, D. J. (2014). Orthopedic physical assessment. Elsevier Health Sciences.

Tibor, L. M., & Sekiya, J. K. (2008). Differential diagnosis of pain around the hip joint. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 24(12), 1407-1421.

Pilates was founded by Joseph Pilates (1880-1967) as a system of fitness exercises that is still practiced in more or less modified forms. In the last two decades, there has been a significant increase in the popularity of Pilates-inspired exercises.

What is Pilates?

Pilates is a form of exercise where emphasis is placed on control of body position and movement. Generally exercises use a reformer (see picture below), an adjustable spring based resistance piece of equipment. Exercises can also be floor based. Traditional principles of Pilates exercise include centering, concentration, control, precision, flow, and breathing.

A reformer being used

Image taken from: http://www.highlightfitness.com.au/wp-content/uploads/2014/04/pilates-reformer-image.jpg

Previously exclusively used by dancers, Pilates is becoming popular in the mainstream exercise arena and in injury rehabilitation for both females and males. Pilates has been well researched and as a result is frequently prescribed to people who suffer, but not restricted to:

Balance difficulties

Pilates is effective in improving static (when still) and dynamic (when moving) balance and balance confidence in older adults. Josephs

Cardiovascular conditions

Pilates training provides a functional capacity grain in cardiovascular disease (such as heart failure) compared to conventional exercises (walking), importantly, with no additional adverse event risk.

Cross-training for other sports

Professional athletes from such sports as Rowing, AFL, Rugby League and Union, and Soccer utilise Pilates to prevent injuries. (rumball, moirera, brukner, bridgens)

Overall Healthy:

Pilates is a form of exercises which can proactively reduce the incidence of musculoskeletal-related pathologies (Wells)

Lower back pain:

A Pilates exercise program yields improvements in the level of pain and postures of sufferers of non-specific low back pain (Patti)Pilates has been reported to reduce pain and disability in people with chronic low back pain (Wells)

Mental Health

Pilates, as a form of physical activity has been shown to maintain, enhance and ameliorate mental health in sufferers of severe mental illness such as depression, and anxiety. (Pernham)

Neurological conditions

Pilates is beneficial to sufferers of Parkinson’s Disease (PD) or Multiple Sclerosis who are prone to falls, with significant improvements to balance, mobility and greater confidence in activities of daily living (Johnson, Freeman)

Painful joints

Pilates has been shown to improve the level of function of sufferers of patients with knee and hip osteoarthritis (Baltaci).Following total hip or knee replacements, Pilates can be incorporated without early complications to improve level of function. (Levine)

Recurring Injuries

Pilates has been implemented by professional sporting teams to reduce the incidence and reccurence of low back, hip-related (hamstring and groin) injuries. (Brukner)

Pilates is offered at xPhysiotherapy 6 days a week, across various times of the day (see timetable). An initial assessment with a physiotherapist is compulsory to gather information pertinent to your history, evaluate baseline postures and movement patterns, and to ensure your safety before beginning. Well-trained Pilates instructors and physiotherapists will prescribe personalised exercisesin an hourly class based on the information from the assessment. All of this intends to positively influence your health and wellbeing. Pilates at Xphysiotherapy may also be private health rebateable. It is advisable to check with your private health insurer, as they may offer a living well benefit or similar for Pilates-based exercise.

References

Baltaci, G. (2006). Comparison of strength, functional outcome and proprioceptive ability after pilates-based exercise program in women patients with knee osteoarthritis. Faculty of Health Sciences, Dept of Physiotherapy and Rehabilitation.

Bridgens, S. (2013). The role of Pilates in preventing injuries in soccer players.

Brukner, P., Nealon, A., Morgan, C., Burgess, D., & Dunn, A. (2013). Recurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme. British journal of sports medicine, bjsports-2012.

Freeman, J. A., Gear, M., Pauli, A., Cowan, P., Finnigan, C., Hunter, H., ... & Thain, J. (2010). The effect of core stability training on balance and mobility in ambulant individuals with multiple sclerosis: a multi-centre series of single case studies. Multiple sclerosis.

Guimarães, G. V., Carvalho, V. O., Bocchi, E. A., & d’Avila, V. M. (2012). Pilates in heart failure patients: a randomized controlled pilot trial. Cardiovascular therapeutics, 30(6), 351-356.

Johnson, L., Putrino, D., James, I., Rodrigues, J., Stell, R., Thickbroom, G., & Mastaglia, F. L. (2013). The effects of a supervised Pilates training program on balance in Parkinson’s disease.

Josephs, S., Pratt, M. L., Meadows, E. C., Thurmond, S., & Wagner, A. (2016). The effectiveness of Pilates on balance and falls in community dwelling older adults: a randomized controlled trial. Journal of Bodywork and Movement Therapies.

Patti, A., Bianco, A., Paoli, A., Messina, G., Montalto, M. A., Bellafiore, M., ... & Palma, A. (2016). Pain Perception and Stabilometric Parameters in People With Chronic Low Back Pain After a Pilates Exercise Program: A Randomized Controlled Trial. Medicine, 95(2), e2414.

Levine, B., Kaplanek, B., & Jaffe, W. L. (2009). Pilates training for use in rehabilitation after total hip and knee arthroplasty: a preliminary report. Clinical Orthopaedics and Related Research®, 467(6), 1468-1475.

Moreira, A., Bilsborough, J. C., Sullivan, C. J., Cianciosi, M., Aoki, M. S., & Coutts, A. J. (2015). Training periodization of professional australian football players during an entire Australian Football League season. International Journal of Sports Physiology & Performance, 10(5).

Perham, A. S., & Accordino, M. P. (2007). Exercise and functioning level of individuals with severe mental illness: a comparison of two groups. Journal of Mental Health Counseling, 29(4), 350.

Rumball, J. S., Lebrun, C. M., Di Ciacca, S. R., & Orlando, K. (2005). Rowing injuries. Sports medicine, 35(6), 537-555.

Wells, C., Kolt, G. S., & Bialocerkowski, A. (2012). Defining Pilates exercise: a systematic review. Complementary therapies in medicine, 20(4), 253-262.