Conditions & Injuries: Knees

ACL rupture and reconstruction

You may need ACL reconstruction if you rupture your anterior cruciate ligament (ACL), which is the ligament inside your knee that stops your femur (thigh bone) gliding too far forward on your tibia (one of the calf bones). When this injury happens, you normally hear a pop and have sudden pain and swelling in the knee. Your knee will feel unstable when you try to move it.

Common causes

This injury typically happens when your foot is firmly planted on the ground and you either rotate from the knee or a force is applied laterally to your knee.

How we help rehabilitate ACL rupture

An ACL rupture can be treated non-surgically or surgically. The surgeon will weigh up the pros and cons of both with you with. If you decide on surgery, the surgeon will harvest part of your hamstrings or your patella tendon, which is the tendon below your kneecap, and use it to repair your ACL. With an ACL rupture you may also have other soft tissue damage, such as a meniscal tear or a medial or lateral collateral ligament injury. If you have surgery, these will be repaired at the same time.

After surgery you will be fully weight-bearing with elbow crutches for comfort and we will initially work on increasing your knee’s range of movement. At the beginning straightening your knee is really important so that you have a stable leg to weight-bear and walk on. Physiotherapy will include helping you regain full range of movement in the knee, getting you back to walking with a normal gait, and giving you a strengthening and proprioceptive exercise programme leading on to dynamic exercises. The end-stages of the rehabilitation programme will be tailored to your long-term goals.

Average recovery time

Typically, after ACL reconstruction surgery, it will take you a year to fully recover. The earliest you will be able to return to multi-directional sports will be 6 months.

Read our article on Preparing for your surgery

Anterior (front) knee pain

Pain in the front of the knee could be caused by an irritated patella tendon, chondromalacia patellae, osteochondritis dissecans, patellofemoral instability, pes anserine bursitis, prepatellar bursitis, ITB syndrome, and fat pad impingement in adults or Osgood-Schlatter disease in children and adolescents.

If one of these are the cause, you will normally experience pain around your knee cap when you straighten your leg, although it may be painful even when not putting any weight on it. People often complain of difficulties climbing stairs or standing up from a seated position. You may have some localised swelling. The pain may also be caused by tightness in the hamstrings, although this will usually refer pain to the inside or the outside of the knee.

Common causes

Osgood-Schlatter is a condition only seen in children and adolescents. The other conditions mentioned are likely to be caused by tightness in the muscles that attach around the front of the knee. Knee pain is often seen in runners who overload the knee when running, either by increasing the amount of running they’re doing suddenly or by over-striding.

How we treat knee pain

Treatment would include releasing tightness in the muscles around the knee alongside a strengthening programme starting with eccentric loading and then progressively building up the load that you put through the leg to what is required for the activity that you're trying to participate in.

Average recovery time

It should initially take about 6 weeks to reduce the pain, but to ensure the pain doesn't return, it will take 6 months to make a full recovery and return to your chosen activity.

Medial (inside) knee pain

Pain on the inner (medial) side of the knee may be caused by spraining the medialcollateral ligament (MCL) which runs across the knee joint on the inner side of your leg, or by a hamstring strain or tight hamstrings. With an MCL sprain you will usually feel pain on the inside of your knee, but more towards the back of this area. You will have swelling around the area and some laxity on the medial side of the knee when stress tested.

If the pain is caused by tight or injured hamstrings you will feel discomfort when trying to walk. When assessed, you may have tenderness on the medial side of the knee and reduced flexibility in your hamstrings. The painful leg may also be weaker and be harder to control when performing one-leg exercises, especially a one-legged squat. With those conditions, you wouldn't normally have swelling, but a localised ache on the inside of the knee, which can progressively get sharper.

Common causes

Damage to the MCL is usually caused by an external force on the outside of your knee that pushes your knee inwards, causing the ligament to sprain.

A hamstring strain or tightness is typically due to overloading the medial side of the knee, which could be the result of a sudden increase in activity such as running or walking up- or downhill, or sprinting.

How we treat medial knee pain

An MCL sprain could be anywhere between a grade 1 and 3. If you have a grade 3 strain, then you’ll need surgery. At your physio assessment, if we feel there's increased laxity in the knee, we will get you to see a consultant and have an MRI scan to see the level of damage in the ligament. If it's a grade 1 or 2 sprain, surgery is not required and a progressive exercise programme will be sufficient to get you back to your normal activities.

For a grade 3 sprain, you’ll need surgery. Post-surgery we’ll start with gentle range of movement exercises to regain your knee extension and then provide you with a graded strengthening programme. You may require soft tissue release to help regain full range of movement due to muscle shortening to protect the knee initially after surgery.

For the hamstring strain or tightness we will initially provide some soft tissue release, but our main focus will be on gradually strengthening the areas of weakness and improving your movement control. We will also look at your gait in walking and running to see whether this is contributing to you overloading the inside of your knee, and will provide gait re-education if necessary.

Average recovery time

For a grade 1 or 2 MCL sprain you should make a full recovery within 6 months. For a grade 3 MCL sprain it will take 6 months before you can return to sporting activity that is multi-directional, and a year to full recover.

For hamstring strain or weakness, you’ll*t*ypically notice a significant reduction in pain within 6 weeks, but it can take up to 3 to 6 months to make a full recovery, depending on your level of weakness and also the activity that you want to return to.

Read our article on Preparing for your knee surgery

Meniscal surgery

Meniscal surgery is an arthroscopic (keyhole) surgery to either remove or repair a torn meniscus. The meniscus is a thickening of cartilage in your knee that increases the stability and surface area of your knee joint.

Common causes

Your meniscus may be damaged by any injury to the knee, including twisting it. The meniscus may also deteriorate naturally over time.

Rehabilitation after meniscal surgery

If the surgery is to remove your meniscus, you'll be able to fully weight-bear as soon as comfort allows after the surgery.

If you undergo surgery to repair your meniscus, you will initially be non-weight bearing and will slowly increase your weight-bearing every 2 weeks until you're able to take your full weight at 6 weeks. This may vary depending on your surgeon and the extent of the repair. You may also be restricted in the range of movement of your knee, and may be given a brace to restrict excessive movement over the repaired meniscus to allow it to heal.

With either type of meniscal surgery, you’ll need physiotherapy to help you regain full range of movement, reduce excessive swelling and regain normal control around the knee. This will initially include manual therapies such as lymphatic drainage, soft tissue release and taking your knee through a passive range of movement.

We also provide you with an exercise programme consisting of strengthening and range of movement exercises. Depending on your weight-bearing status initial exercises may only include gentle resistance and the use of a hydrotherapy pool as we can use the water to vary the amount that you’re weight bearing through your leg. You then progress on to heavier loading, movement-control exercises and sport-specific exercises so that you can return to your sporting endeavours. We may also look at your gait for walking and running to make sure that you're not compensating and overloading other muscles or joints in your body.

Average recovery time

Depending on whether your meniscus is removed or repaired, you could start returning to some sporting activities at 6 weeks or at 3 months post-op. Typically you won't return to full sporting activity until 6 to 9 months after your surgery. This will depend on what sports you want to participate in, and it can take a year to make a full recovery.

Read our article on Preparing for your knee surgery

Patellofemoral joint replacement

The patellofemoral joint is where your kneecap and your femur (thighbone) meet. With a patellofemoral joint replacement, the back of your kneecap and the groove in your femur known as the trochlea are replaced with a prosthesis made of metal and plastic.

Common causes

A patellofemoral joint replacement is usually performed when arthritic changes on the joint surfaces irritate the soft tissues around the joint and cause your kneecap to maltrack when you bend or straighten your knee.

Rehabilitation after a patellofemoral joint replacement

After the surgery you will stay in hospital for 2 or 3 days whilst your pain is managed. During this time a physiotherapist will teach you how to use elbow crutches to walk on the flat and up and down stairs. They will also provide you with initial exercises to continue with post-surgery. On discharge, you will need to organise physiotherapy at home or in a clinic to ensure you regain full range of movement in the knee and improve your muscle strength and proprioception of the operated leg to also assist with patella tracking – the smooth movement of the kneecap. Physiotherapy will ensure that you return to walking with a normal gait pattern. Our physio will then devise an exercise programme to ensure you can return to all your physical and sporting activity at appropriate stage of your recovery. This will include exercises on land and in the pool. Hydrotherapy is especially useful for completing standing-based exercises before you can bear your full body weight on the operated leg.

Average recovery time

Typically it takes a year to fully recover, but you should be able to return to most activities at 80 percent of your capacity by 6 months.

Read our article on Preparing for your knee surgery

Total knee replacement

A total knee replacement involves having the knee-end surfaces of your femur and tibia – and sometimes the back of your kneecap – replaced with a combination of metal and plastic parts.

Common causes

A full knee replacement is typically done because arthritic changes in the knee have caused the joint surfaces to become uneven. This unevenness in turn irritates the soft tissues around your knee.

How we help rehabilitate after a total knee replacement

After the knee replacement surgery you will spend 3 to 5 days in hospital. During this time a physio will perform muscle activation and range-of-movement exercises to increase your confidence in walking on your operated leg with the aid of elbow crutches. They’ll make sure you're safe to walk on the flat and up and down stairs. At some hospitals, you may have the option of hydrotherapy too.

On discharge you will need to continue physiotherapy either at home or at a clinic where the physiotherapist will help you to regain full knee extension, and typically up to 120 degrees of knee flexion. (The amount you can bend your knee will be restricted by the prosthesis.) Physiotherapy will be aimed at getting you to walk unaided and building up the muscle strength in the legs, which will have deteriorated during the surgery or prior to the surgery due to reduced physical activity caused by your knee pain.

Physio treatment is likely to include manual therapy to help with soft tissue release and manage swelling; an exercise programme consisting of strengthening, stretching and proprioceptive exercises; gait re-education from walking with crutches to unaided.

Hydrotherapy may be used to aid with your recovery, especially if it’s uncomfortable to fully weight-bear through the leg. Water-based exercise will include range-of-movement exercises and gait re-education, as well as using the resistance of the water to initiate muscle strengthening in the leg and build your confidence in walking unaided.

Average recovery time

Typically, it takes a year to make a full recovery from knee replacement surgery and return to your usual sporting activities. By 6 to 12 weeks you should be walking unaided and have full range of movement in the knee, and by 6 months you should have regained around 80 percent of your muscle strength.

Read our article on Preparing for a knee replacement

Knee osteotomy

A Knee osteotomy is preformed when arthritic changes on one side of your knee joint cause your knees to either bow in or outwards – commonly known as bowed legs or knock knees. The surgery involves cutting wedges out of the femur (thighbone) or tibia (shinbone), and the joint surfaces being realigned to reduce load on the arthritic side of the knee. These are then pin-and-plated into position. This surgery is an alternative to a unilateral or half-knee replacement, allowing you to preserve your own joint surface.

Common causes

This surgery is usually required due to the effects of osteoarthritis on the knee.

Rehabilitation after a knee osteotomy

After the surgery you will stay in hospital for a day or two to manage your pain and ensure you can safely walk with crutches on the flat and up and down stairs. You should be able to fully weight bear and the crutches will be for comfort and security. Physiotherapy after your surgery will include regaining full range of movement in the knee with manual therapy and joint mobility exercises, working with you to regain a normal gait pattern, and a progressive strengthening and proprioceptive exercise programme, which will be tailored to areas of weakness and ensure that you can get back to general physical activity and any sporting activities.

Average recovery time

It will take a full year to recover fully, but by 6 months you should have regained 80 percent of your normal capacity and be able to return to most sporting activities.

Read our article on Preparing for your knee surgery

Knee arthroscopy

In a knee arthroscopy, small incisions are made in the front of your knee to perform a meniscal repair, remove a meniscal tear or other loose bodies, or reconstruct ligaments in your knee.

Reasons for a knee arthroscopy

A knee arthroscopy is typically performed to preserve your natural knee joint and remove or repair a soft tissue injury that may be limiting your range of movement or the stability of your knee.

Rehabilitation after a knee arthroscopy

Physiotherapy will be required after your surgery to help reduce swelling and regain full range of movement. Depending on what repair the surgeon performs, you may be non-weight-bearing for a few weeks, and we will help you progressively move back to full weight-bearing as the surgeon feels it is safe to do so, ensuring that you don’t keep or adopt any irregular movement patterns while you’re recovering.

Your physio will then provide you with a graded strengthening programme to get you back to participating in your activity of choice. Depending on your original injury, you may also require gait re-education for walking and/or running, and we will assess the rest of the leg to see whether there are any other factors that may have contributed to the original soft tissue damage in your knee and address these.

Average recovery time

Depending on the reason for the knee arthroscopy, it can take between three months and a year to make a full recovery.

Read our article on Preparing for your knee surgery

Lateral (outside) knee pain

Lateral knee pain could be due to Iliotibial band (ITB) syndrome or a lateral collateral ligament (LCL) sprain or tear. Typically, with an LCL sprain you will have localised pain on the outside of your knee, more to the back of the knee, and when assessed there may be some laxity and pain when the knee is pushed outwards. The iliotibial band is the band of connective tissue that runs from the outside your hip down the side of your leg to the lateral side of your knee. When it’s overworked or overly tight it can cause localised pain on the side of the knee.

Common causes

An LCL sprain is usually the result of having a force pushed against the inside of you knee, causing your knee to move outwards with force. Iliotibial band syndrome is usually seen in runners and may be caused by a criss-cross style gait which causes an increased pull along the outside of the leg. It can also be due to a reduced medial arch in the foot and weakness in the hip abductors, which can cause your hip to rotate inwards and increase strain between the two insertion points of your iliotibial band.

Recovery from lateral knee pain

If your pain is due to the ligament tear or sprain it depends on the grade of the injury (from 1 to 3), how long this would take to recover and whether you’ll need surgery. Therefore, it would be beneficial to have an MRI scan and a review with a consultant. If it is a grade 1 strain, this can be treated conservatively, starting with gentle range of movement exercises and then progressing onto a graded strengthening programme. Grade 3 strains will require surgery and physiotherapy afterwards with a similar approach to grade 1 sprains, although it will take longer to fully recover. Hydrotherapy may be beneficial post-surgery if you are not fully weight bearing straight away.

When treating ITB syndrome, we will look at the whole leg to see what is causing it. This could be your hips or your feet. We will then provide you with a strengthening programme to improve the control of the load through your knees and may address your gait pattern to reduce the pull between the two insertional points of your iliotibial band. You may need soft tissue release for the muscles that attach into the ITB to provide short-term relief of the ITB being pulled tight.

Average recovery time

It can take up to 6 months to recover from a lateral ligament sprain, depending on the level of the strain and if surgery was required. ITB syndrome should settle within 6 weeks, but to reduce the risk of it returning, it can take up to 6 months to improve muscle strength and motor control.

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