Knee Pain

Patellofemoral syndrome

Often pain felt on the inside of the knee is connected to Anterior Knee Pain explained in more detail by clicking on ‘Pain over front of knee‘.

Medical meniscus pain

There are 2 meniscus. These are half moon shaped pieces of cartilage that sit between the tibia (shin bone) and femur (thigh bone) within the joint of the knee. The medial meniscus is the one on the inside of the knee joint. They help to lubricate the knee joint and provide shock absorption on impact. Sometimes if the knee is twisted then they can become inflamed or torn. There can be pain or clicking on certain activities ie getting out of the car or rolling over in bed. If the tear is significant then there can be significant pain and swelling.

Physiotherapy can help by performing tests to determine whether you have injured your meniscus. Treatments offered are advice on relieving any swelling and inflammation and progression through a number of exercises to regain movement of the knee and strength around the knee. If your physiotherapist feels you need a medical review we can recommend top Singapore knee consultants.

Synovial plica

A capsule surrounds the knee. There can be 4 parts of this capsule called the medial plica, suprapatella plica, inferior plica and lateral plica. The medial plica is the most common and found in the inside of the knee. Sometimes these plica can rub on the bone. This can give rise to pain on the inside of the knee and clicking. There may be sharp pain felt when squatting.

Physiotherapy can help by performing certain tests to determine if this may be the cause of your symptoms and treat appropriately.

Pes anserinus tendinopathy or bursitis (‘gooses foot’)

Tendons of 3 muscles of the thigh called the Sartorius, gracilis and semitendinosis all combine together and insert into the same location on the inside of the lower leg near the knee. The pes anerinus is a small fluid filled sac called a bursa which lies between these tendons and the bone of the leg (tibia). Sometimes this bursa can become inflamed particularly in breaststroke swimmers, cyclists and runners. Symptoms include tenderness on the inside of the knee and swelling. Stretching and working of hamstrings can cause pain.

Physiotherapy can help by reducing the inflammation and taking you through specific exercise programme.

Medial collateral ligament injury

The medial collateral ligament runs down the inside of the knee and connects the femur (thigh bone) to the tibia (leg bone). This ligament can be sprained or torn. The sprain can be grade I where a few fibers of the ligament have been stretched. Grade II sprain means a large number of ligament fibers have be stretched and a grade III sprain is a complete tear of the ligament.

Physiotherapy can help by treating to stop any stiffness of the knee happening and encourage healing of the ligament. Exercises will be set to encourage strength and stability around the knee. If your physiotherapist feels the ligament sprain is severe enough to require a medical review we can recommend top Singapore knee consultants who you can see. A brace may be required to fully protect the ligament and allow healing.

Osteoarthritis

This involves degeneration (wear and tear) of the joint surfaces of the inside of the knee. It is more common in later life and difficult to tell whether osteoarthritis or injury of the medial meniscus. Often an injury to the medial meniscus causes more stress on the inside of the knee and therefore makes the process of degeneration faster.

Physiotherapy can help with advice, setting exercises, pain relief. Being overweight contributes to the quickening the process of degeneration therefore weight loss is advised.

Slipped capital femoral epiphysis

This is a problem with the femur which can cause pain on the inside of the knee. IT tends to be more common in boys around the age of 12-15 and being overweight can contribute. The slip of the growth plate over the femur can happen suddenly or more gradually.

Perthes disease

This is a breakdown of bone over the femoral head (top of the thigh bone) which particularly affects males between the age of 4 and 10. Symptoms commonly include a limp and ache in the thigh, groin and knee. Some movement of the hip may be stiff and reduced.

Physiotherapy can help with providing appropriate exercises and advice.

Referral of pain

Pain felt on the inside of the knee may be coming from other parts of the body ie. trigger points in other muscles or from a problem in the pelvis, lower back or hip.

Rheumatoid Arthritis

Rheumatoid Arthritis is when the immune system goes haywire and attacks the body rather than defending it causing inflammation of the lining of the joints and tendons of the muscles. Affected joints in the body that have the arthritis become swollen, painful and stiff. Morning stiffness on waking is very common. Muscles around the joints often become weaker and doing certain activities of daily living can become more difficult.

We can provide experienced physiotherapists to see you at home and work with you to help manage your condition. The first time the physiotherapist visits they will carry out a thorough assessment which includes looking at your mobility and walking aids, muscle strength, joint movement, posture and function. Following the assessment the physiotherapist will discuss any treatments they can provide and set goals with you to improve your general function and mobility and achieve the maximum potential in your home, work and social life. These treatments can include advice on ice, exercise programmes, massage, taping, acupuncture and mobility programmes.

We can also provide occupational therapists to come to your home. They help people to regain the ability to carry out activities that have purpose and meaning to them and become or remain as independent as possible. Some of the services they can offer include:

• Home assessments including modifications such as rearranging furniture, building ramps, widening doorways, grab bars, special toilet seats etc
• Wheelchair assessments
• splinting

Fibromyalgia

This condition does not involve inflammation but affects the fibrous tissues in many parts of the body ie. tendons, muscles, connective tissue etc. There can be a large number of tender points and a feel of generalized aching. One of the common tender points is on the inside of the knee. There a number of other symptoms including fatigue, sleep disturbances, sensitivity to temperature, morning stiffness, numbness and tingling, irritable bowel, depression and dry eyes and mouth.

Physiotherapy can help people with this condition. There are pain relieving techniques that can be used and they are experienced in pacing you back to being able to exercise again and return to activities whether sport, work or hobbies that you were able to do before the condition started. They also are able to provide advice on how to cope with your condition and manage flare ups of pain.

Chronic Pain

Acute pain is the pain we feel immediately after injuring ourselves and while the injury is healing. Chronic pain is pain that continues even though healing has occurred and it is not unusual to find no direct link between the pain and the original injury that may have healed a long time ago. Chemical changes happen in the brain and spinal cord to re-route signals to pain centres in the brain. Then any normal sensation such as a movement, touch, pressure, stretching etc can be felt as pain. In some instances the pain system can be activated without any physical stimulus ie changes in weather, mood, thoughts or no stimulus at all.

Physiotherapy for chronic pain has to involve many aspects and address other factors that come into play rather than just the pain itself. They will treat the pain and also use methods to help you manage your pain including advice on pacing and coping with flare ups and negative thoughts, graduated exercise programmes and goal setting. They will aim to return to you being able to participate again in activities you were involved in before developing chronic pain whether work, sport of hobby related.

Complex Regional Pain Syndrome

This condition as the name suggests is complex. The pain is often constant and of a burning type. The body part affected is often very sensitive to touch and just a stroke can cause pain. There can be changes in temperature and colour of the body part and on occasions growth of excess hair and swelling. The wrist can be affected by this syndrome and the pain can extend over the hand and up the arm. The exact cause of it is not clearly known and can happen with no cause but there can be an event before it occurs such as a fracture. ‘The sympathetic nervous system’ has been shown to be involved which controls blood flow and skin temperature.

Physiotherapy can help with this condition by keeping the part of the body affected moving and stop it stiffening up. They can help to use techniques to desensitise the area and acupuncture can help the pain in some cases. Your physiotherapist will also recommend a top Singapore pain consultant to you who can use treatments to block the sympathetic nervous system from firing and provide appropriate medication to help with the pain.

Other possible causes

Your physiotherapist will take a detailed history of your symptoms and past medical history before performing a full physical examination. There are a number of other possible causes of your symptoms which are not appropriate for a physiotherapist to treat in any way or that need a medical opinion alongside physiotherapy treatment. In this case they will recommend you to your GP or an appropriate specialist doctor or specialist consultant. These possible causes include:

• cardiovascular symptoms
• respiratory (breathing) symptoms
• gynaecological symptoms
• urinary or genital symptoms
• digestive symptoms
• immune system symptoms
• lymph system symptoms
• hormonal symptoms
• neurological symptoms
• dermatological (skin) symptoms
• medication side-effects
• virus
• infection
• cancer
• disease process
• psychological problem ie. depression, anxiety

Lateral collateral ligament sprain or tear

This ligament runs from the bottom outside of your thigh bone and attaches to the small bone called the fibula on the outside of your lower leg. If stress is applied to this ligament then you can sprain the ligament or a tear of some of the ligament fibers can happen. If all the fibers are torn then the ligament has been ruptured. If a severe strain or rupture is suspected then a medical review is recommended by one of the top Singapore knee consultants we work with.

The knee may need to be braced to support full healing of the ligament.

Physiotherapy can help with soft tissue techniques, ultrasound, advice on swelling and controlling inflammation and taking you through a progressive rehabilitation programme. By regaining full movement and strength in the leg then sport specific rehab can take place helping you to safely return to sport.

Lateral collateral ligament Rupture

This is when the ligament described above ruptures completely and a medical referral will be required. We can recommend a top Singapore knee consultant to you in this case.

Lateral meniscus tear

There are 2 meniscus. These are half moon shaped pieces of cartilage that sit between the tibia (shin bone) and femur (thigh bone) within the joint of the knee. The lateral meniscus is the one on the outside of the knee joint. They help to lubricate the knee joint and provide shock absorption on impact. Sometimes if the knee is twisted then they can become inflamed or torn.

Physiotherapy can help by performing tests to determine whether you have injured your meniscus. Treatments offered are advice on relieving any swelling and inflammation and progression through a number of exercises to regain movement of the knee and strength around the knee and return you to sport.

Osteoarthritis

This involves degeneration (wear and tear) of the joint surfaces of the outside of the knee. It is more common in later life and difficult to tell whether osteoarthritis or injury of the lateral meniscus. Often an injury to the meniscus causes more stress on the outside of the knee and therefore makes the process of degeneration faster.

Physiotherapy can help with advice, setting exercises and pain relief using manual treatments or acupuncture. Being overweight contributes to the quickening the process of degeneration therefore weight loss is advised.

Patellofemoral syndrome

Often pain felt on the inside of the knee is connected to Anterior Knee Pain explained in more detail by clicking on ‘Pain over front of knee’.

Biceps femoris tendinopathy

The biceps femoris muscle is one of the hamstring muscles that runs down the back of the thigh. The tendon of the muscle joins it to the smaller bone on the outside of the lower leg called the fibula. Pain can arise in this tendon if injured or with overuse particularly activity involving excessive acceleration and deceleration.

Physiotherapy can help by performing manual treatments, release to the hamstring muscle itself, correcting any biomechanical issues in your walking or running style, acupuncture and taking you through an appropriate exercise programme.

Iliotibial band friction syndrome

The iliotibial band is a large piece of connective tissue that attaches to the pelvis and runs down the outside of the thigh to attach to the outside of the knee at the bottom. The bottom end runs over the lateral epicondyle (piece of bone) of the thigh bone. There is a small piece of adipose tissue (fat) which lies between this piece of bone and the iliotibial band and this contains nerve fibers and if becomes inflamed can cause pain. The pain tends to be sharp and burning and usually becomes worse as the activity ie. running continues. Often running downhill is worse.

Physiotherapy can help with reducing the inflammation of the adipose tissue and using manual treatments to work on the soft tissues that are connected to the ilitobial band. Massage and acupuncture to the gluteal muscles and iliotibial band itself can help. Advice on how to avoid pain provoking activites and correction of any problems with your walking or running style will help stop the rubbing on the bursa. It is important to be taken through a specific exercise programme to stretch any tight muscles and strengthen any weak muscles that may be contributing to the problem.

Tibiofibular joint sprain

The top of the main shin bone (tibia) and smaller outside shin bone (fibula) are connected. If certain muscles are weak or tight then this can cause an excessive force to this joint causing pain.

Physiotherapy can help by working directly on the joint with manual treatments and devising an exercise programme to strengthen weak muscles and stretch tight muscles that are causing excessive force to the joint.

Common peroneal nerve pain

This nerve spirals around the top of the fibula bone and if directly injured or over time becomes irritated then can give rise to pain on the outside of the knee.

Physiotherapy can help by determining if this is the source of your pain. Manual treatments on the fibula itself can be used along with releasing any restricting soft tissues around the nerve. Nerve gliding exercises can also be set for the nerve itself to help its mobility.

Synovial plica

A capsule surrounds the knee. There can be 4 parts of this capsule called the medial plica, suprapatella plica, inferior plica and lateral plica. The lateral plica is found on the outside of the knee. Sometimes this plica can rub on the bone. This can give rise to pain on the outside of the knee and clicking. There may be sharp pain felt when squatting.

Physiotherapy can help by performing certain tests to determine if this may be the cause of your symptoms and treat appropriately.

Slipped capital femoral epiphysis

This is a problem with the femur which can cause pain on the inside of the knee. It tends to be more common in boys around the age of 12-15 and being overweight can contribute. The slip of the growth plate over the femur can happen suddenly or more gradually.

Perthes disease

This is a breakdown of bone over the femoral head (top of the thigh bone) which particularly affects males between the age of 4 and 10. Symptoms commonly include a limp and ache in the thigh, groin and knee. Some movement of the hip may be stiff and reduced.

Physiotherapy can help with providing appropriate exercises and advice.

Referral of pain

Pain felt on the outside of the knee may be coming from other parts of the body ie. trigger points in other muscles or from a problem in the pelvis, lower back or hip.

Rheumatoid Arthritis

Rheumatoid Arthritis is when the immune system goes haywire and attacks the body rather than defending it causing inflammation of the lining of the joints and tendons of the muscles. Affected joints in the body that have the arthritis become swollen, painful and stiff. Morning stiffness on waking is very common. Muscles around the joints often become weaker and doing certain activities of daily living can become more difficult.

We can provide experienced physiotherapists to see you at home and work with you to help manage your condition. The first time the physiotherapist visits they will carry out a thorough assessment which includes looking at your mobility and walking aids, muscle strength, joint movement, posture and function. Following the assessment the physiotherapist will discuss any treatments they can provide and set goals with you to improve your general function and mobility and achieve the maximum potential in your home, work and social life. These treatments can include advice on ice, exercise programmes, massage, taping, acupuncture and mobility programmes.

We can also provide occupational therapists to come to your home. They help people to regain the ability to carry out activities that have purpose and meaning to them and become or remain as independent as possible. Some of the services they can offer include:

• Home assessments including modifications such as rearranging furniture, building ramps, widening doorways, grab bars, special toilet seats etc
• Wheelchair assessments
• splinting

Chronic Pain

Acute pain is the pain we feel immediately after injuring ourselves and while the injury is healing. Chronic pain is pain that continues even though healing has occurred and it is not unusual to find no direct link between the pain and the original injury that may have healed a long time ago. Chemical changes happen in the brain and spinal cord to re-route signals to pain centres in the brain. Then any normal sensation such as a movement, touch, pressure, stretching etc can be felt as pain. In some instances the pain system can be activated without any physical stimulus ie changes in weather, mood, thoughts or no stimulus at all.

Physiotherapy for chronic pain has to involve many aspects and address other factors that come into play rather than just the pain itself. They will treat the pain and also use methods to help you manage your pain including advice on pacing and coping with flare ups and negative thoughts, graduated exercise programmes and goal setting. They will aim to return to you being able to participate again in activities you were involved in before developing chronic pain whether work, sport of hobby related. We can also recommend top Singapore pain consultants who can help you.

Complex Regional Pain Syndrome

This condition as the name suggests is complex. The pain is often constant and of a burning type. The body part affected is often very sensitive to touch and just a stroke can cause pain. There can be changes in temperature and colour of the body part and on occasions growth of excess hair and swelling. The knee can be affected by this syndrome and the symptoms can extend up or down the leg. The exact cause of it is not clearly known and can happen with no cause but there can be an event before it occurs such as a fracture. ‘The sympathetic nervous system’ has been shown to be involved which controls blood flow and skin temperature.

Physiotherapy can help with this condition by keeping the part of the body affected moving and stop it stiffening up. They can help to use techniques to desensitise the area and acupuncture can help the pain in some cases. Your physiotherapist will also recommend a top Singapore pain consultant to you who can use treatments to block the sympathetic nervous system from firing and provide appropriate medication to help with the pain.

Other possible causes

Your physiotherapist will take a detailed history of your symptoms and past medical history before performing a full physical examination. There are a number of other possible causes of your symptoms which are not appropriate for a physiotherapist to treat in any way or that need a medical opinion alongside physiotherapy treatment. In this case they will recommend you to your GP or an appropriate specialist doctor or specialist consultant. These possible causes include:

• cardiovascular symptoms
• respiratory (breathing) symptoms
• gynaecological symptoms
• urinary or genital symptoms
• digestive symptoms
• immune system symptoms
• lymph system symptoms
• hormonal symptoms
• neurological symptoms
• dermatological (skin) symptoms
• medication side-effects
• virus
• infection
• cancer
• disease process
• psychological problem ie. depression, anxiety

Pain over the front of knee in the medical world can be classified as ‘Anterior knee pain’ or ‘Patellafemoral syndrome’

What does it mean?

Up to 25% of the active population will at some time present to a physiotherapist with this type of pain¹. This can have a significant impact on their daily function, causing pain on activities such as running, squatting and stair climbing. This condition can affect athletes and novice sports people alike and although it can occur at any age, is commonly seen in a young population, thereby affecting their enjoyment of their sport and having significant impact on fitness and lifestyle².

It is a condition that affects the knee cap (patella) and the structures surrounding and supporting it. The patella needs to track in a groove in the thigh bone as we bend and straighten our knee. Commonly, mal-tracking or a change to the biomechanics of the joint can change the forces acting on the patella and its surrounding structures, causing pain and loss of function. To make things more complex, many different structures at the front of the knee can be the cause of this pain, including the fat pad, bursa, tendon and cartilage.

What structures to treat?

This type of knee pain is challenging to treat because normally caused by a combination of factors. A thorough assessment of the anatomy of the lower leg and how it is working is needed to understand each individual presentation². A physiotherapist will assess the strength and length of the muscles surrounding the knee as well as the joint itself and movement patterns of an individual to identify the potential causes of the knee pain.

What treatment options are there?

A physiotherapist can assess you for the appropriateness of many different treatment options. Identifying and targeting your rehab programme for the specific muscles that you are weak in has been shown to be effective in reducing pain² Working on the patella itself and releasing surrounding soft tissues can provide pain relief. These techniques, if useful can also be taught to you to do independently at home.

Recent evidence has suggested that taping techniques can be a useful adjunct to other treatment options for anterior knee pain. The tape can help to improve muscle control around the patella and reduce pressure going through the patella, allowing effective rehabilitation and exercise progression4. If a success then the surround patella strap is a good purchase shown below. (sold by www.orthopaedicsandtrauma.com).

http://www.orthopaedicsandtrauma.com/acatalog/Patellofemoral_Braces.html

An assessment of your lower limb kinematics (the relationship between the hip, knee, foot and ankle and how they move) can be useful in identifying areas of weakness or poor movement. Your footwear is an important part of this chain and should be fitted to your needs and changed when they reach their fatigue point.

The over-riding message….

Identify and seek advice and treatment early for anterior knee pain from a qualified physiotherapist. When pain in the body is present for more than 6 weeks it can be termed chronic and then is much harder to cure. Ensure that any changes to your training regime are done slowly and with adequate time for your body tissues to adjust. Don’t assume that after a period of time off (that includes Christmas holidays!) that you will be able to pick up your training at the same intensity and frequency as a few weeks back.

Try to ensure that core strength and muscle tone and flexibility are kept to an optimum to allow you the biomechanical advantage for impact activities such as running.

Traumatic causes of anterior knee pain

Knee cap

Three main injuries can occur to the knee cap and include the following:

1. Fracture of knee cap – will result in extensive pain and swelling and the pain will be located to the knee cap when feeling
2. Rupture of the patella tendon – this tendon passes from the end of the rectus femoris muscle over the knee cap and inserts into the front of the top of the lower leg (tibia). If the tendon is ruptured it will cause sudden onset of intense pain, standing will be difficult and the knee will not be able to be straightened. The knee cap will move position.
3. Knee cap dislocation – this is when the knee cap moves out of its normal position. It will feel like the knee cap popped out. Sometimes the knee cap will reposition itself back alone or may require medical assistance to relocate it. Pain will be intense and swelling will begin immediately.

With the above 3 traumatic causes of pain over the front of the knee a medical review will be required and we can recommend top London knee consultants in this case. The decision will be made by the consultant whether a brace needs to be worn or surgery carried out. In all cases physiotherapy is very important to take you through a specific rehabilitation programme to reduce swelling and regain movement, strength and stability in the knee. They will be able to gradually progress you back to sport as you become physically able.

Posterior Cruciate Ligament (PCL) Tear

The PCL is one of the 4 main ligaments of the knee. It is located deep within the knee joint and joins the bottom of the thigh bone (femur) to the top of the lower leg (tibia). It is important for stability of the knee and can be torn or even ruptured if there is a direct hit to the lower leg while the knee is bent or if the knee is pushed backwards. The pain is most often felt at the back of the knee and not easy to pinpoint exactly where it is coming from. Swelling does not often happen if injured. Your physiotherapist will be able to perform tests to determine whether this ligament has been injured and the severity of the injury. If the tests show significant injury to the ligament or even possible rupture a medical review with a top London knee consultant will be required. The consultant will investigate the problem and decide whether to operate to repair the ligament or treat with physiotherapy only.

Physiotherapy is vital to your recovery in respect of taking you through a specific rehabilitation programme whether the decision was to operate or not. This programme will help to reduce swelling, regain movement, strength and stability in the knee. They are experts in gradually returning you back to your sporting activities when you are physically ready.

Anterior Cruciate Ligament (ACL) Tear

The ACL is one of the 4 main ligaments of the knee. It is located deep within the joint with the PCL and joins the bottom of the thigh bone (femur) to the top of the lower leg (tibia). It is important for stability of the knee and be torn or even ruptured from activities that involve twisting the leg with foot planted or decelerating suddenly. Symptoms often include intense pain, extensive swelling and feeling of pop or something moving within the knee. It will be too difficult to continue with the activity you are doing and there will be a feeling of the leg giving way with activity. The pain can be felt in the back of the knee also. If this injury is suspected a medical referral is required. We can recommend top London knee consultants to see in this case. Depending on a number of factors and the extent of the injury to the ligament the consultant will make the decision whether to operate or not.

Physiotherapy is vital to your recovery in respect of taking you through a specific rehabilitation programme whether the decision was to operate or not. This programme will help to reduce swelling, regain movement, strength and stability in the knee. They are experts in gradually returning you back to your sporting activities when you are physically ready.

Other possible causes of anterior knee pain

Chronic Pain

Acute pain is the pain we feel immediately after injuring ourselves and while the injury is healing. Chronic pain is pain that continues even though healing has occurred and it is not unusual to find no direct link between the pain and the original injury that may have healed a long time ago. Chemical changes happen in the brain and spinal cord to re-route signals to pain centres in the brain. Then any normal sensation such as a movement, touch, pressure, stretching etc can be felt as pain. In some instances the pain system can be activated without any physical stimulus ie changes in weather, mood, thoughts or no stimulus at all.

Physiotherapy for chronic pain has to involve many aspects and address other factors that come into play rather than just the pain itself. They will treat the pain and also use methods to help you manage your pain including advice on pacing and coping with flare ups and negative thoughts, graduated exercise programmes and goal setting. They will aim to return to you being able to participate again in activities you were involved in before developing chronic pain whether work, sport of hobby related.

Complex Regional Pain Syndrome

This condition as the name suggests is complex. The pain is often constant and of a burning type. The body part affected is often very sensitive to touch and just a stroke can cause pain. There can be changes in temperature and colour of the body part and on occasions growth of excess hair and swelling. The knee can be affected by this syndrome and the symptoms can extend up or down the leg. The exact cause of it is not clearly known and can happen with no cause but there can be an event before it occurs such as a fracture. ‘The sympathetic nervous system’ has been shown to be involved which controls blood flow and skin temperature.

Physiotherapy can help with this condition by keeping the part of the body affected moving and stop it stiffening up. They can help to use techniques to desensitise the area and acupuncture can help the pain in some cases. Your physiotherapist will also recommend a top London pain consultant to you who can use treatments to block the sympathetic nervous system from firing and provide appropriate medication to help with the pain.

Medically related possible causes

Your physiotherapist will take a detailed history of your symptoms and past medical history before performing a full physical examination. There are a number of other possible causes of your symptoms which are not appropriate for a physiotherapist to treat in any way or that need a medical opinion alongside physiotherapy treatment. In this case they will recommend you to your GP or an appropriate specialist doctor or specialist consultant. These possible causes include:

• cardiovascular symptoms
• respiratory (breathing) symptoms
• gynaecological symptoms
• urinary or genital symptoms
• digestive symptoms
• immune system symptoms
• lymph system symptoms
• hormonal symptoms
• neurological symptoms
• dermatological (skin) symptoms
• medication side-effects
• virus
• infection
• cancer
• disease process
• psychological problem ie. depression, anxiety

References:

1. McConnell J (1996) Management of Patellofemoral Problems. Manual Therapy.1: 60-66.
2. Witvrouw et al (2003) The effect of exercise regimens on reflex response time of the vasti muscles in patients with anterior knee pain: a prospective randomized intervention study. Scand J Med & Sci in Sports. 13: 251-258.
3. Powers CM (2003) The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Ortho & Sports Phy Ther. 33: 639-646.
4. Chen et al (2008) Biomechanics Effects of Kinesio Taping for Persons with Patellofemoral Pain Syndrome During Stair Climbing. IFMBE proceedings. Vol 21 (3): Part 7: 395-397.

Posterior Cruciate Ligament (PCL) Tear

The PCL is one of the 4 main ligaments of the knee. It is located deep within the knee joint and joins the bottom of the thigh bone to the top of the lower leg (tibia). It is important for stability of the knee and can be torn or even ruptured if there is a direct hit to the lower leg while the knee is bent or if the knee is pushed backwards. The pain is most often felt at the back of the knee and not easy to pinpoint exactly where it is coming from. Swelling does not often happen if injured. Your physiotherapist will be able to perform tests to determine whether this ligament has been injured and the severity of the injury. If the tests show significant injury to the ligament or even possible rupture a medical review with a top London knee consultant will be required. The consultant will investigate the problem and decide whether to operate to repair the ligament or treat with physiotherapy only.

Physiotherapy is vital to your recovery in respect of taking you through a specific rehabilitation programme whether the decision was to operate or not. This programme will help to reduce swelling, regain movement, strength and stability in the knee. They are experts in gradually returning you back to your sporting activities when you are physically ready.

Anterior knee pain

Often pain felt on the back of the knee is connected is actually a result of a problem with the front of the knee. Anterior knee pain is explained in more detail by clicking on ‘Pain over front of knee’.

Biceps femoris tendinopathy

The biceps femoris muscle is one of the hamstring muscles that runs down the back of the thigh. The tendon of the muscle joins it to the smaller bone on the outside of the lower leg called the fibula. Pain can arise in this tendon and can feel like pain on the back of the knee if injured or with overuse particularly activity involving excessive acceleration and deceleration.

Physiotherapy can help by performing manual treatments, release to the hamstring muscle itself, correcting any biomechanical issues in your walking or running style, acupuncture and taking you through an appropriate exercise programme to stretch tight muscles and strengthen weakened muscles.

Gastrocnemius tendinopathy

The top of the gastrocnemius (main calf muscle) attaches to either side of the back of the thigh bone by 2 tendons. Pain can arise in these tendons from repetitive activity involving knee flexion and rising onto toes.

Physiotherapy can help by performing manual treatments, release to the calf muscles, correcting any biomechanical issues in your walking or running style, acupuncture and taking you through an appropriate exercise programme to strengthen weak muscles and stretch tight muscles.

Popliteus muscle strain

There is a small muscle in the back of the knee called the popliteus that can be strained giving pain in the back of the knee.

Physiotherapy can help with advising on ice, massage, soft tissue techniques, ultrasound and setting appropriate exercises.

Bakers cyst

This is a fluid filled swelling that can develop in the back of the knee and lead to pain at the back of the knee and a clicking sensation. Sometimes the swelling can rupture leading to swelling of the lower leg. Causes include osteoarthritis, gout, rheumatoid arthritis and injuries to the knee. It can however occur without cause.

Physiotherapy can help with anti-inflammatory advice and to give exercises to help keep the knee moving and strengthen the knee. They will also treat the underlying causes behind it. If your physiotherapist feels you need a medical review they will recommend that you see your GP or a knee specialist.

Deep Vein Thrombosis

This can occur occasionally following calf injury or surgery due to a lack of movement therefore not using the pump effect of muscles and the effect of swelling may lead to problems with blood flow. Symptoms include constant calf pain and tenderness, swelling and possible redness and heat. Occasionally pain can be felt also in the back of the knee. Immediate medical evaluation is required.

Referral of pain

Problems with the lower back and sciatic nerve can cause pain in the back of your knee. Your physiotherapist will be able to determine whether they are causing the pain when examining you and treat the cause appropriately.

Anterior Cruciate Ligament (ACL) Tear

The ACL is one of the 4 main ligaments of the knee. It is located deep within the joint with the PCL and joins the bottom of the thigh bone (femur) to the lower leg (tibia). It is important for stability of the knee and can be torn or even ruptured from activities that involve twisting the leg with foot planted or decelerating suddenly. Symptoms often include intense pain, extensive swelling and feeling of pop or something moving within the knee. It will be too difficult to continue with the activity you are doing and there will be a feeling of the leg giving way with activity. The pain can be felt in the back of the knee also. If this injury is suspected a medical referral is required. We can recommend top London knee consultants to see in this case. Depending on a number of factors and the extent of the injury to the ligament the consultant will make the decision whether to operate or not.

Physiotherapy is vital to your recovery in respect of taking you through a specific rehabilitation programme whether the decision was to operate or not. This programme will help to reduce swelling, regain movement, strength and stability in the knee. They are experts in gradually returning you back to your sporting activities when you are physically ready.

Osteoarthritis and Rheumatoid Arthritis

Osteoarthritis can occur in any joint in the body and is a the process of ‘wear and tear’ where the cartilage covering the area of bone that makes up the joint is gradually worn away over time. Rheumatoid Arthritis is when the immune system goes haywire and attacks the body rather than defending it causing inflammation of the lining of the joints and tendons of the muscles. Affected joints in the body that have the arthritis become swollen, painful and stiff. Morning stiffness on waking is very common. Muscles around the joints often become weaker and doing certain activities of daily living can become more difficult.

We can provide experienced physiotherapists to see you at home and work with you to help manage your condition. The first time the physiotherapist visits they will carry out a thorough assessment that includes looking at your mobility and walking aids, muscle strength, joint movement, posture and function. Following the assessment the physiotherapist will discuss any treatments they can provide and set goals with you to improve your general function and mobility and achieve the maximum potential in your home, work and social life. These treatments can include advice on ice, exercise programmmes, massage, taping, acupuncture and mobility programmes.

We can also provide occupational therapists to come to your home. They help people to regain the ability to carry out activities that have purpose and meaning to them and become or remain as independent as possible. Some of the services they can offer include:

• Home assessments including modifications such as rearranging furniture, building ramps, widening doorways, grab bars, special toilet seats etc
• Wheelchair assessments
• splinting

Chronic Pain

Acute pain is the pain we feel immediately after injuring ourselves and while the injury is healing. Chronic pain is pain that continues even though healing has occurred and it is not unusual to find no direct link between the pain and the original injury that may have healed a long time ago. Chemical changes happen in the brain and spinal cord to re-route signals to pain centres in the brain. Then any normal sensation such as a movement, touch, pressure, stretching etc can be felt as pain. In some instances the pain system can be activated without any physical stimulus ie changes in weather, mood, thoughts or no stimulus at all.

Physiotherapy for chronic pain has to involve many aspects and address other factors that come into play rather than just the pain itself. They will treat the pain and also use methods to help you manage your pain including advice on pacing and coping with flare ups and negative thoughts, graduated exercise programmes and goal setting. They will aim to return to you being able to participate again in activities you were involved in before developing chronic pain whether work, sport of hobby related. We can also recommend top London pain consultants to help you.

Complex Regional Pain Syndrome

This condition as the name suggests is complex. The pain is often constant and of a burning type. The body part affected is often very sensitive to touch and just a stroke can cause pain. There can be changes in temperature and colour of the body part and on occasions growth of excess hair and swelling. The knee can be affected by this syndrome and the pain can extend up or down the leg. The exact cause of it is not clearly known and can happen with no cause but there can be an event before it occurs such as a fracture. ‘The sympathetic nervous system’ has been shown to be involved which controls blood flow and skin temerature.

Physiotherapy can help with this condition by keeping the part of the body affected moving and stop it stiffening up. They can help to use techniques to desensitise the area and acupuncture can help the pain in some cases. Your physiotherapist will also recommend a top London pain consultant to you who can use treatments to block the sympathetic nervous system from firing and provide appropriate medication to help with the pain.

Other possible causes

Your physiotherapist will take a detailed history of your symptoms and past medical history before performing a full physical examination. There are a number of other possible causes of your symptoms which are not appropriate for a physiotherapist to treat in any way or that need a medical opinion alongside physiotherapy treatment. In this case they will recommend you to your GP or an appropriate specialist doctor or specialist consultant. These possible causes include:

• cardiovascular symptoms
• respiratory (breathing) symptoms
• gynaecological symptoms
• urinary or genital symptoms
• digestive symptoms
• immune system symptoms
• lymph system symptoms
• hormonal symptoms
• neurological symptoms
• dermatological (skin) symptoms
• medication side-effects
• virus
• infection
• cancer
• disease process
• psychological problem ie. depression, anxiety