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The knee is particularly vulnerable to injury and accidents due to its position in the leg, and injuries lead to pain, joint instability and loss of normal leg function. The initial part of the examination looks at the injury cause and the forces involved, how fast the knee effusion came up, the presence of joint instability on walking and whether the patient is unable to take normal body weight on the knee. The amount of pain a patient suffers indicates the severity of the injury involved and the particular location of the pain can point to which anatomical structures have been injured. As the knee will be very difficult to walk on in the presence of a fracture these injuries are rarely missed in diagnosis. During the examination the physiotherapist will test the knee structures to look for the cause of the injury. The Objective Examination Knee effusion or joint swelling is an indication of the degree of inflammation present in the knee and the physio will check the amount of swelling manually. If the swelling is severe it can be drained using needle aspiration to relieve the pressure which can interfere with normal muscle recruitment and function. The physio records the movements of the knee on the plinth non weight bearing, assessing straightening and bending of the knee (extension and flexion) and the small degrees of rotation. The physiotherapist decides where to start treatment by their findings - how much the patient can easily move the knee, how much pain they have and how the knee behaves on testing. Active movement the patient can do themselves and the physio may gently push the joint further to test weakness or guarding. The physio will test the strength of the quadriceps and hamstrings which straighten and bend the knee respectively, seeing how much the pain or weakness affects the knee function. Manual testing of the knee ligaments by the physiotherapist tells him or her about these important stability structures. The physio levers the knee inwards and outwards to test the medial ligament and the lateral ligament (the collateral ligaments) and pulls the shin bone back and forward to test the anterior cruciate ligament and the posterior cruciate ligament. Manual palpation around the joint and adjacent structures can help indicate which structure has been injured. Physiotherapy treatment of the injured knee An acutely painful knee is treated using the PRICE technique, starting with protection of the joint if necessary by using a brace to stabilise it. Crutches or sticks can be used to reduce weight bearing on the knee and allow a good walking pattern. Ice treatment, or cryotherapy, is a first line treatment for an acute knee, reducing pain and the swelling which permits increased movement and progression of treatment. A neoprene knee sleeve may be worn to squeeze the swelling and increase stability. Exercises to increase the strength and movement are instigated once the pain and effusion have begun to settle, working on the major weight supporting muscles of the thigh, the quadriceps and the hamstrings. The knee extensors (quadriceps) push us up from a chair, control the knee in running and walking and push us steps. Exercise progression by the physiotherapist involves non-weight bearing exercises initially, followed by rehab exercises in the gym and finally sport-focused activities. A normal knee joint involved in activity sends a stream of impulses up to the brain, informing us of the joint position at all times, the degree of muscle activity and movement. This is known as joint position sense (JPS) or proprioception, which is lost to some degree after injury and restoring it to a normal level is vital if the knee is to successfully return to activity. The physio starts with balancing on one leg and progresses to standing on a wobble board and finally works on active, dynamic exercises in preparation for sport.
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Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for Physiotherapists in Kensington.
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