44 Knee Pain

Knee Pain

Physicians now more than ever are recommending conservative treatment including but not limited to low-impact exercise, acupuncture, and manual therapy as part of a multi-modal approach for patients suffering from knee pain.

Pathophysiology

Patellofemoral Pain Syndrome is an umbrella term used to describe pain around or behind the patella, it is common in individuals between 10 and 50 years of age. Patients often present with pain during daily activities such as stair walking, squatting or running (Winters et al., 2020).

Degenerative meniscus and osteoarthritis of the knee is a common finding in the general population, and in a majority of cases these degenerative knee changes are asymptomatic (Hortga et al., 2020). However in some cases this condition involves sensitization of nociceptive pathways, which may result in patients with osteoarthritis perceiving relatively low level stimuli as being overtly painful (Hunter & Bierma-Zeinstra, 2019).

Patellar tendinopathy is the preferred term for persistent patellar tendon pain and loss of function related to mechanical loading.

 

Knee Pain
Physicians, now more than ever are recommending conservative treatment options for patients suffering from knee pain.

Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)
  • The Western Ontario and McMaster Universities Arthritis Index (WOMAC)
  • Lower Extremity Functional Scale (LEFS)

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

  • Bounce Home
  • Apley’s Test (Compression/Distraction)
  • McMurry’s Test
  • Valgus Stress Test (Medial Collateral Ligament)
  • Varus Stress Test (Lateral Collateral Ligament)
  • Noble’s Compression
  • Lachman’s Test
  • Anterior Drawer Test
  • Posterior Drawer Test
  • Posterior Sag Sign
  • Coronary Ligament Stress Test
  • Patellar Grind Test (Clarke’s Sign)
  • Thessaly Test
  • Bragard’s Sign
  • Mediopatellar Plica Test (Hughston Plica Test)
  • Plica “Stutter” Test
  • Ballotable Patella (Major Effusion or Patellar Tap Test)
  • Brush Test (Minor Effusion, Stroke, OR Wipe Test)
  • Fluctuation Test
  • Waldron’s Test
  • McConnell Patellofemoral Knee Test
  • Q-Angle
  • Patellar Apprehension Test

Treatment

Education

Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from hip pain may include neurovascular structures and investing fascia of:

  • Erector Spinae (iliocostalis, longissimus, spinalis) & Multifidus
  • Quadratus Lumborum
  • Thoracolumbar Fascia & Latissimus Dorsi
  • Hip Adductors (adductor brevis, adductor longus, adductor magnus, pectineus, gracilis)
  • Quadricep Muscles (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)
  • Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)
  • Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)
  • Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius)
  • Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)
  • Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior, popliteus)
  • Proximal Tibiofibular Joint
  • Ankle Joint (talocrural joint, subtalar joint and inferior tibiofibular joint)

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as hydrotherapy, stretching, and strengthening exercises have been shown to be useful for patients with knee pain (Kolasinski et al., 2020; Willy et al., 2019).


Massage Sloth: Massage Tutorial – Knee Pain

Prognosis

Physicians now more than ever are recommending conservative treatment options for patients suffering from knee pain. Two recent randomized clinical trials have highlighted the effect of conservative treatment options for patients suffering from osteoarthritis related knee pain. In one randomized clinical trial published in the Journal of General Internal Medicine massage therapy was shown to improve function in patients who suffer from osteoarthritis related knee pain (Perlman et al., 2019). In addition, a randomized trial published in The New England journal of medicine demonstrated the benefits of a conservative multimodal approach (manual therapy + exercise) for patients with symptomatic osteoarthritis of the knee (Deyle et al., 2020).

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for knee pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Alentorn-Geli, E., Samuelsson, K., Musahl, V., Green, C. L., Bhandari, M., & Karlsson, J. (2017). The Association of Recreational and Competitive Running With Hip and Knee Osteoarthritis: A Systematic Review and Meta-analysis. The Journal of orthopaedic and sports physical therapy, 47(6), 373–390. doi:10.2519/jospt.2017.7137

Ali, A., Rosenberger, L., Weiss, T. R., Milak, C., & Perlman, A. I. (2017). Massage Therapy and Quality of Life in Osteoarthritis of the Knee: A Qualitative Study. Pain medicine (Malden, Mass.), 18(6), 1168–1175. doi:10.1093/pm/pnw217

Chughtai, M., Mont, M. A., Cherian, C., Cherian, J. J., Elmallah, R. D., Naziri, Q., … Bhave, A. (2016). A Novel, Nonoperative Treatment Demonstrates Success for Stiff Total Knee Arthroplasty after Failure of Conventional Therapy. The journal of knee surgery, 29(3), 188–193. doi:10.1055/s-0035-1569482

Courtney, C. A., Steffen, A. D., Fernández-de-Las-Peñas, C., Kim, J., & Chmell, S. J. (2016). Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee. The Journal of orthopaedic and sports physical therapy, 46(3), 168–176. doi:10.2519/jospt.2016.6259

Culvenor, A. G., van Middelkoop, M., Macri, E. M., & Crossley, K. M. (2020). Is patellofemoral pain preventable? A systematic review and meta-analysis of randomised controlled trials. British journal of sports medicine, bjsports-2020-102973. Advance online publication. https://doi.org/10.1136/bjsports-2020-102973

Deyle, G. D., Allen, C. S., Allison, S. C., Gill, N. W., Hando, B. R., Petersen, E. J., Dusenberry, D. I., & Rhon, D. I. (2020). Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. The New England journal of medicine, 382(15), 1420–1429. https://doi.org/10.1056/NEJMoa1905877

Eckenrode, B. J., Kietrys, D. M., & Parrott, J. S. (2018). Effectiveness of Manual Therapy for Pain and Self-reported Function in Individuals With Patellofemoral Pain: Systematic Review and Meta-analysis. The Journal of orthopaedic and sports physical therapy, 48(5), 358–371. https://doi.org/10.2519/jospt.2018.7243

Garcia, A. N., Cook, C. E., & Rhon, D. I. (2020). Adherence to stepped care for management of musculoskeletal knee pain leads to lower healthcare utilization, costs, and recurrence. The American journal of medicine, S0002-9343(20)30778-6. Advance online publication. https://doi.org/10.1016/j.amjmed.2020.08.006

Gregori, D., Giacovelli, G., Minto, C., Barbetta, B., Gualtieri, F., Azzolina, D., … Rovati, L. C. (2018). Association of Pharmacological Treatments With Long-term Pain Control in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis. JAMA, 320(24), 2564–2579. doi:10.1001/jama.2018.19319

Hamstra-Wright, K. L., Earl-Boehm, J., Bolgla, L., Emery, C., & Ferber, R. (2017). Individuals With Patellofemoral Pain Have Less Hip Flexibility Than Controls Regardless of Treatment Outcome. Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine, 27(2), 97–103. https://doi.org/10.1097/JSM.0000000000000307

Hunter, D. J., & Bierma-Zeinstra, S. (2019). Osteoarthritis. Lancet (London, England), 393(10182), 1745–1759. doi:10.1016/S0140-6736(19)30417-9

Horga, L. M., Hirschmann, A. C., Henckel, J., Fotiadou, A., Di Laura, A., Torlasco, C., … Hart, A. J. (2020). Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal radiology, 10.1007/s00256-020-03394-z. Advance online publication. https://doi.org/10.1007/s00256-020-03394-z

Jette, D. U., Hunter, S. J., Burkett, L., Langham, B., Logerstedt, D. S., Piuzzi, N. S., Poirier, N. M., Radach, L., Ritter, J. E., Scalzitti, D. A., Stevens-Lapsley, J. E., Tompkins, J., Zeni, J., Jr, & American Physical Therapy Association (2020). Physical Therapist Management of Total Knee Arthroplasty. Physical therapy, 100(9), 1603–1631. https://doi.org/10.1093/ptj/pzaa099

Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J., … Reston, J. (2020). 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis & rheumatology (Hoboken, N.J.), 72(2), 220–233. https://doi.org/10.1002/art.41142

Kompel, A. J., Roemer, F. W., Murakami, A. M., Diaz, L. E., Crema, M. D., & Guermazi, A. (2019). Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought?. Radiology, 293(3), 656–663. doi:10.1148/radiol.2019190341

Kraus, V. B., Sprow, K., Powell, K. E., Buchner, D., Bloodgood, B., Piercy, K., … 2018 PHYSICAL ACTIVITY GUIDELINES ADVISORY COMMITTEE* (2019). Effects of Physical Activity in Knee and Hip Osteoarthritis: A Systematic Umbrella Review. Medicine and science in sports and exercise, 51(6), 1324–1339. doi:10.1249/MSS.0000000000001944

LaPrade, F., & Chahla, J. (2021). Evidence-Based Management of Complex Knee Injuries: Restoring the Anatomy to Achieve Best Outcomes. Elsevier.

Li, L. W., Harris, R. E., Tsodikov, A., Struble, L., & Murphy, S. L. (2018). Self-Acupressure for Older Adults With Symptomatic Knee Osteoarthritis: A Randomized Controlled Trial. Arthritis care & research, 70(2), 221–229. doi:10.1002/acr.23262

Matthews, M., Rathleff, M. S., Claus, A., McPoil, T., Nee, R., Crossley, K. M., Kasza, J., & Vicenzino, B. T. (2020). Does foot mobility affect the outcome in the management of patellofemoral pain with foot orthoses versus hip exercises? A randomised clinical trial. British journal of sports medicine, 54(23), 1416–1422. https://doi.org/10.1136/bjsports-2019-100935

Nascimento, L. R., Teixeira-Salmela, L. F., Souza, R. B., & Resende, R. A. (2018). Hip and Knee Strengthening Is More Effective Than Knee Strengthening Alone for Reducing Pain and Improving Activity in Individuals With Patellofemoral Pain: A Systematic Review With Meta-analysis. The Journal of orthopaedic and sports physical therapy, 48(1), 19–31. https://doi.org/10.2519/jospt.2018.7365

Newberry, S.J., FitzGerald, J., SooHoo, N.F., Booth, M., Marks, J., … Shekelle, P. (2017). Treatment of Osteoarthritis of the Knee: An Update Review. Rockville (MD): Agency for Healthcare Research and Quality (US). DOI: https://doi.org/10.23970/AHRQEPCCER190

Perlman, A., Fogerite, S. G., Glass, O., Bechard, E., Ali, A., Njike, V. Y., … Katz, D. L. (2019). Efficacy and Safety of Massage for Osteoarthritis of the Knee: a Randomized Clinical Trial. Journal of general internal medicine, 34(3), 379–386. doi:10.1007/s11606-018-4763-5

Petushek, E. J., Sugimoto, D., Stoolmiller, M., Smith, G., & Myer, G. D. (2019). Evidence-Based Best-Practice Guidelines for Preventing Anterior Cruciate Ligament Injuries in Young Female Athletes: A Systematic Review and Meta-analysis. The American journal of sports medicine, 47(7), 1744–1753. doi:10.1177/0363546518782460

Price, A. J., Alvand, A., Troelsen, A., Katz, J. N., Hooper, G., Gray, A., … Beard, D. (2018). Knee replacement. Lancet (London, England), 392(10158), 1672–1682. doi:10.1016/S0140-6736(18)32344-4

Rogan, S., Haehni, M., Luijckx, E., Dealer, J., Reuteler, S., & Taeymans, J. (2019). Effects of Hip Abductor Muscles Exercises on Pain and Function in Patients With Patellofemoral Pain: A Systematic Review and Meta-Analysis. Journal of strength and conditioning research, 33(11), 3174–3187. doi:10.1519/JSC.0000000000002658

Salamh, P., Cook, C., Reiman, M. P., & Sheets, C. (2017). Treatment effectiveness and fidelity of manual therapy to the knee: A systematic review and meta-analysis. Musculoskeletal care, 15(3), 238–248. doi:10.1002/msc.1166

Siemieniuk, R., Harris, I. A., Agoritsas, T., Poolman, R. W., Brignardello-Petersen, R., Van de Velde, S., … Kristiansen, A. (2017). Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ (Clinical research ed.), 357, j1982. doi:10.1136/bmj.j1982

Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., … Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group (2013). Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. The New England journal of medicine, 369(26), 2515–2524. doi:10.1056/NEJMoa1305189

Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., … FIDELITY (Finnish Degenerative Meniscal Lesion Study) Investigators (2018). Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Annals of the rheumatic diseases, 77(2), 188–195. doi:10.1136/annrheumdis-2017-211172

Sisk, D., & Fredericson, M. (2019). Update of Risk Factors, Diagnosis, and Management of Patellofemoral Pain. Current reviews in musculoskeletal medicine, 12(4), 534–541. https://doi.org/10.1007/s12178-019-09593-z

Snoeker, B., Turkiewicz, A., Magnusson, K., Frobell, R., Yu, D., Peat, G., & Englund, M. (2020). Risk of knee osteoarthritis after different types of knee injuries in young adults: a population-based cohort study. British journal of sports medicine, 54(12), 725–730. https://doi.org/10.1136/bjsports-2019-100959

Taylor, A. L., Wilken, J. M., Deyle, G. D., & Gill, N. W. (2014). Knee extension and stiffness in osteoarthritic and normal knees: a videofluoroscopic analysis of the effect of a single session of manual therapy. The Journal of orthopaedic and sports physical therapy, 44(4), 273–282. https://doi.org/10.2519/jospt.2014.4710

Tedesco, D., Gori, D., Desai, K. R., Asch, S., Carroll, I. R., Curtin, C., … Hernandez-Boussard, T. (2017). Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-analysis. JAMA surgery, 152(10), e172872. doi:10.1001/jamasurg.2017.2872

Turner, M. N., Hernandez, D. O., Cade, W., Emerson, C. P., Reynolds, J. M., & Best, T. M. (2020). The Role of Resistance Training Dosing on Pain and Physical Function in Individuals With Knee Osteoarthritis: A Systematic Review. Sports health, 12(2), 200–206. https://doi.org/10.1177/1941738119887183

van de Graaf, V. A., Noorduyn, J., Willigenburg, N. W., Butter, I. K., de Gast, A., Mol, B. W., … ESCAPE Research Group (2018). Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial. JAMA, 320(13), 1328–1337. doi:10.1001/jama.2018.13308

Vander Doelen, T., & Jelley, W. (2020). Non-surgical treatment of patellar tendinopathy: A systematic review of randomized controlled trials. Journal of science and medicine in sport, 23(2), 118–124. https://doi.org/10.1016/j.jsams.2019.09.008

Willy, R. W., Hoglund, L. T., Barton, C. J., Bolgla, L. A., Scalzitti, D. A., Logerstedt, D. S., … McDonough, C. M. (2019). Patellofemoral Pain. The Journal of orthopaedic and sports physical therapy, 49(9), CPG1–CPG95. doi:10.2519/jospt.2019.0302

Winters, M., Holden, S., Lura, C. B., Welton, N. J., Caldwell, D. M., Vicenzino, B. T., Weir, A., & Rathleff, M. S. (2020). Comparative effectiveness of treatments for patellofemoral pain: a living systematic review with network meta-analysis. British journal of sports medicine, bjsports-2020-102819. Advance online publication. https://doi.org/10.1136/bjsports-2020-102819

License

Icon for the Creative Commons Attribution-NonCommercial 4.0 International License

Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

Share This Book