Physiotherapy for Knee Pain

In treating many types of knee pain, a common goal is to break the inflammatory cycle. The inflammatory cycle starts with an injury. After an injury, substances that cause inflammation invade the knee, which causes further injury, which leads to further inflammation, and so on. This cycle of inflammation leads to continued or progressive knee pain. The cycle can be broken by controlling the substances that cause inflammation and by limiting further injury to tissue.

Some common home-care techniques that control inflammation and help to break the inflammatory cycle are protection, rest, ice, compression, and elevation. This regimen is summarized by the mnemonic PRICE.

PROTECT the knee from further trauma.

This can be done with knee padding.

A pad over the kneecap, for example, helps to control the symptoms of some knee injuries (an example is a form of bursitis sometimes called housemaid's knee) by preventing further repetitive injury to the prepatellar bursae. 

REST the knee.

Rest reduces the repetitive strain placed on the knee by activity.

Rest both gives the knee time to heal and helps to prevent further injury.

ICE the knee.

Icing (cold application) the knee reduces swelling and can be used for both acute and chronic knee injuries.

Most authorities recommend icing the knee two to three times a day for 20-30 minutes each time.

Use an ice bag or a bag of frozen vegetables placed on the knee.

COMPRESS the knee with a knee brace or wrap.

Compression helps accomplish two goals:

First, compression is another way to reduce swelling.

Second, in some knee injuries, compression can be used to keep the patella aligned and to keep joint mechanics intact.

ELEVATE the knee.

Elevation also helps reduce swelling.

Elevation works with gravity to help fluid that would otherwise accumulate in the knee flow back to the central circulation.

Prop your leg up when you are sitting, or use a recliner, which naturally elevates the legs.

Over-the-counter pain control medications: Commonly used pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (Aleve or Naprosyn) and ibuprofen (Advil or Motrin) also play a role in the treatment of knee pain.

These drugs directly control pain and, at higher doses, act as anti-inflammatory agents, helping to stop inflammation. Like all medications, however, these drugs have potential side effects.

You should not use NSAIDs if you have a problem with bleeding or stomach ulcers or some types of kidney disease.

Acetaminophen (Tylenol) can also be used to control knee pain but does not have the anti-inflammatory properties of the NSAIDs. Still, this treatment is remarkably useful in many types of knee pain such as osteoarthritis.

If you have to take any of these medications for more than seven days, you should have your knee pain evaluated by a health-care provider.

EXERCISE

Stretching the muscles that support the knee with knee exercises is also important in preventing injury. Flexible muscles are not as easily injured as tight muscles. Tightness of muscles connected to the knee can also pull the knee out of alignment.

When doing stretching knee exercises, be careful to go slowly and not to overstretch. You do not want to tear a muscle.

You need to increase the duration of your knee exercises gradually to avoid overuse injuries and knee pain. Be patient. You will see results.

  

Strength must be built up gradually. When muscles, tendons or ligaments are stressed slightly beyond their limits, microscopic tears occur. This is normal, and as these tears heal the muscles actually become bigger, firmer and stronger. These microscopic tears must be given adequate time to heal or chronic problems can develop. Try not to exercise the same muscle groups two days in a row to give your body a chance to recover. Doing strengthening knee exercises three or four times a week is enough. Stretching knee exercises can be done more often.

The goal is to prevent injury and knee pain, not cause it.

Don’t ignore pain. Pain is your body’s way of protecting you from hurting yourself further. It is not unusual to experience mild stiffness and aching of the muscles that lasts up to a day after exercising. But hardly being able to move for a few days after exercising means you have overdone it. It’s difficult to know when to quit when you doing knee exercises. Often, the pain doesn't’ set in until a day or two later. It happens. If it does, you will have a greater understanding of your body’s limitations.

When you have overdone your knee exercises.

Rest is important for inflamed muscles/tendons. Applying ice wrapped in a cloth can help reduce inflammation and pain and speed up healing. See Treatment for Overuse Injuries. Knee pain should be completely gone before fully resuming your knee exercises program, however, lightly exercising the sore muscle may help decrease muscle soreness.

If you are currently experiencing knee pain or have a knee condition/injury and/or have a very limited range of motion, or are simply not sure which knee exercises are safe for you to do, see a physical therapist (physiotherapist). A doctor or physical therapist can assess your condition and give you a customized treatment / exercise plan.

Main Muscle Groups Affecting Knee Stability

Several muscle groups support the knee. The two main muscle groups that control knee movement and stability are the quadriceps and the hamstrings.

THE QUADRICEPS is a four-part powerful muscle that run along the front of the thigh and attach to the front of the shinbone, just below the knee. The quadriceps control the straightening of the knees and movement of the kneecap. The quadriceps is used to extend the leg, and is essential for standing up, walking upstairs, walking uphill, and running.

THE HAMSTRINGS are muscles that run make up the back of the thigh, and attach to the back of the shinbone, just below the knee. The hamstrings are used to bend the knee and are also needed when you are pushing against something.

Other Muscles Affecting Knee Stability

muscles that affect knee stability, to a lesser degree than the quadriceps and hamstrings are the calf muscles, the hip abductors located on the outer thigh, and the hip adductors located on the inner thigh. The body functions as a unit (remember - the hip bone's connected to the knee bone) and even muscles not near the knee can contribute to knee stability.

The iliotibial band (fibrous tissue on the outer thigh, extending front the hip to below the knee) also affects knee stability. The glutes (back of hip muscles / buttocks) inserts into the thigh bone and iliotibial band and also help stabilize the knee.

It is important to do strengthening exercises for all the muscles that support the knee. For example, if you concentrate on strengthening exercises for the quads, and neglect strengthening exercises for the hamstrings a muscle imbalance can be created.

Imbalances in Muscles Supporting the Knee

A physical therapist (physiotherapist) can help determine if you have a muscle imbalance in the muscles supporting the knee and create a personalized exercise program.

Imbalance of the quadriceps is common, especially in women - The quadriceps is divided into 4 divisions. If the inner division if weak, the stronger outer division tends to pull the kneecap toward the outer side of the leg. Tightness of the quads can also pull the knee towards one side so stretching as well as strengthening of muscles that support the knee is important.

In some cases, the quadriceps is significantly stronger than the hamstrings. (The quadriceps should only be about 25% stronger than the hamstrings). This can cause weakness of the knee. If this is the case, concentrating on strengthening exercises for the hamstrings, and stretching exercises for the quadriceps are very helpful.

Stretching or Strengthening Exercises First?

Muscles tend to be tight after strengthening exercises so stretching after strengthening exercise may be more beneficial than stretching first. However it is largely a matter of personal preference - stretching and strengthening exercises can also each be done on separate days if desired. Some people prefer to do stretches both before and after strengthening exercises. If you have knee problems or pain, consult a physical therapist for an exercise plan customized for your needs. Remember to warm up for 5 minutes to prepare your self for any type of exercise.

Strengthening Knee Exercises

Note: If you are experiencing knee pain or have a knee injury or condition, ask your doctor or physical therapist what exercises are appropriate (safest and most effective) for you to do before performing knee exercises.

How Often to do Knee Strengthening Exercises

In general, any strengthening exercises should only be done about every second day or three times per week on non-consecutive days to allow healing and to avoid overuse injury.

How Many Repetitions and Sets of Strengthening Exercises

If you are a beginner to exercise, start with five repetitions of each exercise - or less if the exercise is difficult. If you do not have post exercise pain, slowly add a couple of repetitions each week until you reach 10 - 15 repetitions. To increase endurance add a second set of 10 -15 repetitions after you can handle one set. When two sets because easy to do, you can add a third. Rest about 30 seconds between sets.

: There are several strengthening exercises to choose from for some muscles. Choose one per exercise session for a particular muscle group if you are a beginner just doing one set (unless instructed otherwise by your physician or therapist). If you have progressed to two or three sets, you can mix strengthening exercises for the same muscle group.

not exercise the same muscle group on consecutive days.

WARM UP first! Warming up with 5 minutes of low-impact aerobics, such as walking or riding a stationary exercise bike, increases blood supply to the muscles to help prevent injury.

Quadriceps Strengthening

Note: Only do one quad strengthening exercise on the days you exercise if you are doing no more than one set - with the exception of the quad strengthening contractions, which can be done additionally. See above How Many Repetitions and Sets. If you have progressed to doing two sets of quad exercises, you can pick two different quad exercises.

Quad Strengthening Contractions:

Sit in chair. Move forward so that you are sitting at edge of chair. Extend legs, heels to floor. Keep knees straight (or as straight as possible if you have arthritis.) Tighten thigh muscles. Hold for count of 10. Relax for count of 3. Do 10 repetitions. You can do this several times throughout the day. You can build up to 2 or 3 sets of 10 repetitions at a time.

Quad Strengthening Leg lifts:

Lie flat on back. Bend left knee at 90-degree angle, keeping foot flat on floor. Keeping the right leg straight, slowly lift it until right foot is the height of the left knee. Hold for a count of 3. Repeat 10 times. Switch sides. Work up to 10 sets of 10 over several weeks.

Safety Tip:

Leg lifts: Lifting both legs at the same time causes excessive stress on your lower back so

only lift one leg at a time; the opposite leg should be kept slightly bent with foot on floor.

Quad Strengthening Short-Arc Leg Extensions:

Sit or lie on floor. Place a rolled up towel under your thigh for support. Keep you leg straight and raise your foot about six inches off the floor. Hold for 5 seconds. Slowly lower your foot, bending your knee. Do 10 repetitions. Switch sides.

Quad Strengthening Knee Dips:

Stand with knees slightly flexed. Point your toes straight ahead.

Make sure your kneecaps are also pointed straight ahead.

Lift one leg up and balance on the other leg. Slowly lower yourself up and down ONLY a few inches. Keep the knee of the leg you are balancing on slightly flexed. Your knees must remain pointing straight forward. Do not let them turn inward. Stand straight, do not lean you body to one side. Do 10 dips. Switch sides.

If you feel pain in your knees, start with fewer dips.

Quad Strengthening Partial Squats:

Stand. Keep back straight, knees hip-width apart and pointing straight ahead. Slowly lower and move your buttocks backward as if you were sitting in a chair (don't bend your knees beyond a 90-degree angle, if 90 degrees is too difficult bend even less). Hold position for a count of 5. Do ten squats. Stop if you feel pain in your knees.

Safety Tip: Make sure your knees do not extend beyond your toes when doing partial squats. Keeping your weight behind your knees reduces the pressure on the knee joint during the squat. Bending the knees beyond 90 degrees (a right angle) places excessive strain on the knee.

Hamstring Strengthening

Note: Only do one hamstring strengthening exercise on the days you exercise - if you are doing no more than one set. If you have progressed to doing two sets of hamstring exercises, you can pick two different hamstring exercises or do the same one twice. See How Many Repetitions and Sets above.

Seated Hamstring Strengthening Contractions:

Sit in chair, with knees bent to 45 degrees and heels on floor (toes lifted up). Don't move heels but pull back on them, digging heels into floor. You will feel tension in you hamstrings. Hold for count of 5 - 10 seconds. Relax for count of 3. Do 10 repetitions.

Lying Hamstring Strengthening Contractions:

Lie on back, knees bent about 45 degrees. Dig heels into floor. You will feel tension in your hamstrings. Hold for count of 5 - 10 seconds. Relax for count of 3. Do 10 repetitions.

Hamstring Strengthening Curls:

Lie on stomach. Place left foot onto the back of the right heel. Slowly pull your right heel toward your buttocks - resisting with the left leg. This contracts the hamstrings. Hold for a count of 10. (Keep pressing your left foot and right heel against each other) Hold for a count of ten and relax for count of 3. Do 10 repetitions.

Walking backwards helps to develop the hamstrings. When walking backwards, your weight is distributed more evenly, resulting in less strain on your knees.

Other Strengthening Exercises for Knee Stability

Hip Adductors (Inner Thigh) / groin muscle and inner quad muscle (VMO) Strengthening:

Sit in chair, put fist between knees, squeeze together knees. Hold for count of 10. Relax for count of 3. Do 10 repetitions.

Lie on floor on your right side, shoulder and hips aligned. Use your right hand to prop up your head. Place the left hand on floor in front of you to help balance yourself. Bend left leg and bring it to the floor in front of you. Slowly raise your right leg about 10 inches off the floor then, hold for a second, then slowly lower leg to ground. Lift 10 times on each side.

Hip Abductors (Outer Thigh/Hip) strengthening:

Lie on floor on your right side, shoulder and hips aligned.

Bend right leg (leg on floor) to 90 degrees.

Slowly raise you left leg about 18 inches, hold for a second, then slowly lower leg.

Do 10 repetitions. Repeat on other side.

Glutes Strengthening Backward leg swing:

Hold onto back of chair for support. Swing leg back at a diagonal until you feel your buttocks tighten. Tense muscles as much as you can and swing leg back a couple more inches. Return leg to floor. Repeat 10 times.

Switch sides. Do 10 repetitions. Repeat on other side.

Strengthening the ankles and calves may help with pronation.

Calf Raise (strengthens Calves and Ankles):

Stand with feet shoulder-width apart. Do not lock knees.

Place one hand on wall to help with balance.

Raise heels off the floor as high as you can and slowly lower to starting position.

Do 15 repetitions.

To increase difficulty, do this exercise on one foot at a time.

This exercise can also be done with the balls of the feet on the edge of a stair (or other low platform) and the heels hanging over the edge

Hold on to rail for support.

Slowly lower the heels as far as your can - this stretches the calves

Slowly raise heels as high as you can (stand on toes)

Do 15 repetitions.

Balancing Knee Exercises

(Helps in knee stability)

Hold onto back of chair or counter top for support. Stand on one leg for one minute. Switch sides.

As your balance improves, use one hand only for support. Next use one finger only for support, then progress to letting go, but keeping your hands within a couple of inches above chair in case you lose your balance. Do not lean your trunk to one side.

To increase difficulty, shift weight onto the ball of the foot.

Stretching Knee Exercises

Note: If you are experiencing knee pain or have a knee injury or condition, ask your doctor or physical therapist what exercises are appropriate (safest and most effective) for you to do.

How Often to do Stretching Exercises

In general, stretching exercises may be done daily but every second day or 3 times per week is enough. Stretching exercises are often prescribed twice per day or more by physical therapists for the treatment of knee pain, the specific exercises recommended depend on the cause of the pain.

How Long to Hold a Stretch

For stretching exercises, the stretch should generally be held for a total of about 60 to 90 seconds. Holding a stretch for 30 seconds only requires 2 or 3 repetitions. Some people prefer to do more repetitions of 5 or 10-second stretches or just one 60-second stretch.

WARM UP before stretching with 5-10 minutes of low-impact aerobics (e.g. walking, stationary bike). Warmed up muscles are more responsive to stretches and less likely to tear.

Stretches should be performed without any bouncing and in a slow & controlled fashion

Calf Muscles Stretch:

To stretch left calf muscle, step back with left leg, forward with right. Bend right knee (keep left leg and back in a straight line as you lean forward) until you feel a gentle stretch in the left calf. Do not roll foot out to side. Keep heel flat, foot forward. Hold 30 seconds. Repeat on other side.

Quad Muscle Stretch:

Stand. Bend right knee, grab front of right ankle and bring heel to buttocks with hand. Keep knees together. Do not arch back. Do not let leg go to side. Point knee toward floor. Tighten buttocks and tuck tailbone under to increase stretch.

Hold for 30 seconds. Repeat on other side.

Hamstring Stretch:

Standing position

Keep one leg on ground; put one foot on chair with leg straight. Bend forward at the hip. Hold for 30 seconds. Repeat on other side. *Do not attempt to touch your toes as this will stretch your back, and the goal of this exercise is to isolate your hamstring muscles in the leg that is being supported by the chair.

Sitting in chair hamstring: Straighten one leg, keeping heel on floor. Lean forward at hips, keeping back straight. Don't try to touch your toes. Hold for 30 seconds. Repeat on other side.

Gluteal Stretch (also stretches lower back):

Lie on back. Bend left knee. Grasp left leg behind the knee/back of thigh and pull knee towards chest. Hold 30 seconds. Switch sides and repeat.

Glute Stretch II:

Sit in chair.

Cross your left ankle over right thigh (just above right knee).

Lean forward (bend from hips - do not round back) while gently pushing left side of knee towards ground until you feel a gentle stretch.

Hold for 30 seconds.

Switch sides and repeat.

Iliotibial Band Stretch:

Stand up. To stretch the right side, cross right leg behind left leg. Bending from the hip, lean torso to the left - pushing hips to the right. The stretch is felt on the outer right hip and thigh. Keep right leg straight, left knee slightly bent. Hold for 30 seconds. Repeat on other side.

Hip Adductors (Upper Inner Thigh) Stretch:

Standing: Step off to the side with the right leg. Bend left knee slightly (do not extend knee beyond toe) and move your right foot further to right until your feel a stretch in your right inner thigh. Hold stretch for 30 seconds. Repeat on other side.

Sitting position: Sit on floor, spread legs into a V position. Slowly lean forward from your hips, keeping your back straight, until you feel the stretch. Do not bounce. Then lean towards the right, foot then left foot. Hold for 30 seconds.

Hip Abductors (Upper Outer Thigh and outer Hip) Stretch:

Sit on the floor, legs extended in front of you.

Bend right leg and place right foot on floor on outside the left knee.

Twist upper body to right and use left elbow to gently push against outside of right knee until you feel a gentle stretch in the right hips, buttocks, and lower back.

Hold for 30 seconds. Repeat on other side.

Hip Flexors (front of hips) Stretch:

Tightness in these muscles can affect the alignment of the knee bones.

Standing Exercise: Step forward with the right leg, bending right knee (to increase the stretch, take a larger step). Do not extend right knee past toes. Keep left knee slightly bent with heel off the ground. Keep back upright. This stretches the front of the hip on the left side. Push the left hip forward to increase the stretch.

Hold for 30 seconds. Repeat on other side.