Sports Injuries: Expert Care for Athletes’ Knee Pain in Singapore

Arthroscopy is a relatively minor surgical technique that is frequently used in the diagnosis and treatment of problems in the knee joint and is often performed as a day case or overnight stay in the hospital. An arthroscope is a small telescope that is connected to a camera and video screen. The surgeon makes a small incision in the knee and then inserts the arthroscope to help locate the exact source of the problem within the knee joint. This is an extremely useful tool for the treatment of many knee injuries and conditions, particularly those that will require some form of surgery.

Another knee condition common among active physically inclined individuals is patella tendonitis or tendinosis. This involves damage and sometimes tiny tears within the tendon connecting the patella to the shin bone. It makes running and jumping painful and activities such as kneeling, squatting, or climbing stairs difficult. Both these conditions are difficult to treat and can become ongoing chronic problems if not managed correctly from the onset. Initial diagnosis may often require an MRI scan to assess the extent of damage within the joint. Most treatment can be undertaken without the necessity to undergo surgery.

Repetitive loading and high forces on the knee joint are often related to certain sports activities, which can lead to a condition called patellofemoral pain syndrome or chondromalacia patella. This painful knee condition is quite common and is often associated with anterior knee pain. The articular cartilage on the undersurface of the patella can soften and break down, leading to pain and swelling within the knee joint. This may lead to difficulty in walking, running, or negotiating stairs.

Causes of Knee Pain

The knees of athletes are at acute risk for a traumatic injury. It can occur in a fall or from a direct blow to the knee or an awkward twist of the knee. A high-speed, forceful impact such as a hard football tackle can be very dangerous for the knee. Any of these can cause serious damage to the knee, and it is quite often that damage is done to more than one part of the knee. Traumatic injuries can be quite painful and can be a severe detriment to the long-term health of the knee. They also may increase chances of developing osteoarthritis.

Specifically, overusing the knee can cause pain and injury. Athletes who continually use their knees in high-intensity sports have a greater chance of injuring a knee. Some examples of people who overuse their knees are runners, basketball players, and soccer players. Although it is not an activity related to sports, people who perform tasks with a lot of kneeling put a high stress load on their knees. Some examples are carpet layers and gardeners. These activities all have in common a repetitive stress on the knee which can cause an inflammation of the patellar or quadriceps tendon. Another common overuse injury is patellofemoral pain syndrome. This involves pain around or under the knee cap. This pain comes from the wearing down of the articular cartilage around the knee cap. With excessive overuse, this cartilage can soften and break down. Once this happens, every step can cause damage and inflammation to the underside of the knee cap. In very serious overuse injuries, muscles can weaken due to the inflammation of tendons around the knee. This loss of strength of the quadriceps and hamstring muscles can lead to serious knee injuries while doing simple activities.

Overuse Injuries

Another example is iliotibial band friction syndrome. This is a common cause of lateral knee pain in runners and cyclists. The iliotibial band rubs against the distal femur and/or lateral femoral epicondyle, causing pain usually at 30 degrees of knee flexion. This is an early, stage of iliotibial band syndrome, and if activity continues, it may progress to a full-thickness inflammation of the iliotibial band at the lateral femoral epicondyle.

The traditional example of an overuse injury is patellofemoral pain. This is a common cause of activity-related anterior knee pain in the young and physically active population. The etiology is an imbalance between the vastus medialis and lateralis oblique muscles. Through a variety of mechanisms, this results in an increased lateral force of the patella against the femur during knee flexion. The pain is due to stress in the patellofemoral joint and/or overloading of the patellar tendon. The spectrum of patellofemoral pain includes structural damage such as chondromalacia patellae and patellar subluxation or dislocation.

Repetitive loading of the joint without sufficient recovery initiates a cascade of events leading to soft tissue structural damage. In the acute situation, there is inflammation of the involved structure and pain. If the athlete does not modify activity to allow the tissue to heal, a chronic overload state develops and ultimately results in pain and dysfunction. This may force the athlete to reduce or stop the causative activity.

Overuse injuries of the knee in athletes are common and may lead to significant morbidity. Stress across the joint produced by muscle contraction is a normal part of many sports activities. The magnitude of the load may be an important stimulus for functional adaptation, but there is a critical level above which structural damage occurs.

Traumatic Injuries

A traumatic injury is usually a result of a direct blow to the knee or a sudden movement that forces the knee to move in a way it is not built to do. This usually occurs from a fall, an impact during contact or a twisting/rotating movement. A traumatic injury can damage the cartilage, the bone or the ligaments in the knee. The breakdown of traumatic injuries are: – Fractures – the most common bone broken or bruised is the patella. This is often caused by a direct blow to the patella or a fall. High energy fractures to the end of the femur or top of the tibia can also occur in athletes, often as a result from a high speed or high impact collision. – Dislocation – this is a very painful injury where the end of the bone is forced out of its usual position. A dislocation will cause damage to the ligaments and can result in long-term instability in the knee. – Anterior Cruciate Ligament (ACL) injuries – this is one of the most common and severe injuries in the knee. It is usually a result from a sudden stop, a twist or a change in direction. The ACL is often torn or ruptured during contact sports. An injury to the ACL can also damage the cartilage in the knee and an ACL reconstruction may be needed. This injury often occurs in combination with damage to other ligaments or the meniscus.

Age-related Degeneration

As our bodies age, degenerative changes occur in many of the structures in the knee, and this can then result in knee pain. Examples of this are degeneration of the meniscus or articular cartilage that lines the joint surface. Often, a patient may have sustained minor twisting injuries many years earlier that damaged the meniscus. If this was not symptomatic at the time and the meniscus subsequently tears because of a trivial stressor (such as getting up from a chair), the patient might not relate the current pain to the old injury. Another common example is someone who had a moderate impact injury to the front of the knee (for example, in a road traffic accident) that left the patella (knee cap) with a hairline fracture. This might not have been diagnosed at the time but leads onto pain and intermittent swelling several years later when the post-traumatic arthritic process starts. In general, an episode of bleeding into the joint (termed a haemarthrosis) years earlier often leads onto a quicker arthritic process in the future.

Diagnosis and Treatment Options

When an athlete with a knee injury seeks medical attention, the knee pain doctor Singapore performs a physical examination and gets a history of the injury. These are the most important parts of diagnosis. During the examination, the doctor will look for tenderness, swelling, and instability of the knee. Tenderness along the joint line is a sign of a possible meniscus tear. Swelling may indicate damage to the ligaments or the meniscus. Instability is usually associated with ligamentous injuries. The patient’s symptoms and the physical findings help the doctor to decide where the injury is and what might be damaged. This is particularly important when the injury is due to chronic or overuse, and the patient cannot remember a specific incident that caused the problem. A medical history of the injury is also very important. Many knee problems can be diagnosed with a good history. The doctor may ask several questions about the injury: how it occurred, when it occurred, whether there was any “popping” or “giving way” of the knee, and which specific symptoms are. For example, a “popping” in the knee at the time of injury, severe pain and swelling, and the inability to bend the knee would suggest a possible ligament or cartilage injury. A “giving way” of the knee, meaning a feeling of the knee buckling under, is a common symptom of ligament damage.

Physical Examination and Medical History

The best treatments depend on the proper diagnosis, and different conditions require different treatments. Physical examination is an important aspect of diagnosing the problem. Dr. Tan will inspect your knees for swelling, deformity, and tenderness, and assess the range of motion and stability of your knee. Findings from these tests will give a clearer picture of the affected structures in your knee. It will help in the diagnosis of soft tissue tears, inflamed tendons, and ligament injuries. In times where the correct diagnosis is unclear, it may be necessary to withdraw some fluid from your knees for testing. This is performed by numbing the skin with local anesthetic, and then a needle is inserted into the joint to aspirate some fluid. This procedure is known as joint aspiration. The aspirated fluid will then be sent to the laboratory for investigation. This could provide useful information on the presence of infection, general inflammation, crystal-induced inflammation, or bleeding within the joint. This could help to exclude certain diagnoses, therefore narrowing the possible diagnoses for an unclear case. A thorough medical history is important to identify systemic problems such as gout or rheumatoid arthritis that can also affect the knees. Dr. Tan will also need to discuss the history of your knee pain. This will include questions on how the pain started, when it is at its worst, what makes it better, and whether there are any mechanical symptoms such as locking or giving way. This information will give an idea of the nature of the problem and help select the most appropriate investigations.

Imaging Tests

Imaging tests, including X-rays and magnetic resonance imaging (MRI), provide a clear picture of the injured knee. This is a decisive factor in choosing the best treatment options. For example, an option for arthroscopic meniscus repair may not be suitable if an MRI shows significant wear and tear of the affected meniscus. This is advantageous to both the patient and the doctor, as any form of treatment will be targeted specifically to the problem and thus bring about the best results. A better result from treatment often means a faster and more successful return to the patient’s work or sporting activity. This is the ultimate goal in treating all knee injuries. Step-by-step rehabilitation/treatment programs can also be formulated through consistent monitoring of the knee condition via imaging tests. This ensures effective results are being obtained during the rehabilitation process and allows modification to the program if improvement is not obtained.

Non-surgical Treatments

The type of treatment prescribed will vary depending on the severity of the TFP injury. There are a variety of non-surgical approaches to treating TFP injuries, the most widely used being rest, ice, compression, and elevation. Also known as R.I.C.E, this treatment is generally effective for athletes with mild acute pain and swelling. Patients using R.I.C.E rest their knee as much as possible to avoid aggravating the injury and use crutches when walking long distances to prevent further stress to the patellar tendon. Ice is used to reduce pain and swelling, and it is recommended that patients ice their knee after activities that cause pain. Compression with an elastic bandage helps to reduce swelling, and elevation (keeping the knee raised above the level of the heart) helps to minimize swelling when the leg is not being used. This treatment approach is generally continued for 2-3 weeks, longer if symptoms persist. At times, despite the use of R.I.C.E, anti-inflammatory medication and/or various forms of physiotherapy may be prescribed by a doctor to patients with patellar tendon injuries to alleviate pain and swelling. Although R.I.C.E is most effective in reducing pain and swelling from mild patellar tendon injuries, and rehabilitation is an important part of treating all patellar tendon injuries, regardless of their severity. This may involve exercises to correct flexibility and strength imbalances in the leg muscles or to correct abnormal lower limb biomechanics. A physiotherapist or doctor will recommend the most suitable rehabilitative approach based on the nature and severity of the injury. Physiotherapy is most effective in treating chronic patellar tendon injuries and patellar tendon tears but is also recommended for patients with tendinitis or acute strains or tears.

Surgical Interventions

High tibial osteotomy (HTO) is used to correct specific knee deformities such as bowleggedness or knock-knees. This is done by cutting and repositioning the tibia (shinbone) or femur (thighbone). This is useful for patients who experience pain on only one side of the knee that may have early onset osteoarthritis. The aim is to reduce pain by unloading the damaged part of the knee. This can delay the need for joint replacement, but it is quite a complex procedure with a lengthy rehabilitation phase.

For example, arthroscopy is a surgical procedure often used as a partial intervention in the treatment of knee pain. This procedure involves the use of a special camera called an arthroscope, which is then inserted through a small incision in the knee. This is done under a local anesthetic and it enables the surgeon to clearly visualize the inside of the knee so that he can better understand the extent and nature of damage to the knee in order to best treat it. This damage may include a meniscus tear, ligament damage, or articular cartilage wear. Treatment of such damage can improve pain relief and delay progression to osteoarthritis. This is usually achieved with meniscectomy, repair of the damaged ligament, or some form of cartilage restoration procedure. This option is generally considered for patients who have significant symptoms from a specific lesion, and for whom medical treatments have failed. Although the goals of the procedure sound promising, it is not always successful and the benefit may not be long lasting. Therefore, it is not suitable for all patients with knee pain. Meniscectomy and meniscal repair can be associated with a good outcome, but has not been proven to be greater than that provided by exercise therapy.

When knee pain does not improve by simple treatments, surgical interventions such as arthroscopy, partial knee replacement, or total knee replacement may be necessary. By examining the patient’s own situation, severity of knee pain and its underlying cause, as well as the patient’s general health and activity level, a physician helps the patient to choose the best option.

Rehabilitation and Prevention

To decrease the likelihood of future knee injuries, strengthening exercises should be continued long after the surgical recovery period. Studies have shown that those who’ve suffered an ACL injury are more likely to sustain further knee injuries compared to someone who has not injured their knee. It is also believed that the risk of re-injuring the ACL is significantly higher in patients who have undergone delayed reconstruction when compared with patients who did so immediately after the initial injury. This evidence gives much reason to promote the idea of ACL injury prevention. Since the ACL strain usually occurs during pivoting or aggressive change in direction, it is important to improve strength in the muscles around the knee to help provide dynamic stability during these activities. Specific exercises to improve balance and knee control have been shown to reduce ACL injuries in female athletes. This has led researchers to develop programs that coach athletes on safer methods of pivoting and landing from jumping.

The recovery process after reconstructive knee surgery requires time and patience to achieve the best results. A course of physical therapy is advised in order to regain full function, strength, and the range of movement in your knee. It will be divided into different stages aimed at achieving goals at each level before progressing to the next. Initially, the focus will be on minimizing swelling and pain generated from the surgery while trying to achieve full extension and 90 degrees of knee flexion. This will involve plenty of rest and use of ice packs and compression to control the swelling. The physiotherapist may also use forms of soft tissue massage and/or electrical stimulation to help restore these movements. Once achieved, simple strengthening exercises will be utilized to progress to full quadriceps strength while being able to regain normal walk without any aids. Finally, more rigorous agility and proprioceptive exercises will have to be done to allow a safe return to pre-injury activities. This process will generally take 6-8 months post-surgery.

Physical Therapy

Physical therapy reps are intended to adjust the leg components so that their activities and loads put the least volume of stress and strain on the, and also to manage neuromuscular, an automatic and patient elicited actions that could contribute to further eversion. This is the essence of this point by point article, which discusses the imperfect and incomplete nature of current rehab regimens following knee injury and ACL reconstruction. The article looks at how to prepare the leg to functionally depend on the ACL through practicing maneuvers that cause slight probability of injury. This includes the use of feedback training strategies to encourage certain movements, and a slow progression to more advanced exercises only if lower limb control can be maintained. The article also reviews gait retraining models for both ACL injured subjects and those who have had reconstruction rep using a variety of PT goals to improve kinematics in the hope of reducing the risk of knee OA.

Strengthening Exercises

It is quite rare that the physiotherapist will use isolated strengthening exercises for the hamstrings. The physio will also try to improve muscle coordination and timing of the quadriceps and hamstrings, so that they work effectively to stabilize the patella and knee joint during activity. This can be achieved using closed chain exercises. These are exercises done with the foot planted and in contact with a surface. An example of this type of exercise is a step up. This exercise helps isolate the quadriceps and improve coordination with the hamstrings. This would be useful in exercises that allow a return to play or sport function.

After the acute pain and swelling have subsided, many patients will be guided to the physiotherapist for exercises to start regaining range of motion, strength, and coordination in the knee. The physiotherapist will initially concentrate on range of motion exercises to regain full extension and flexion if this has been lost. This may involve using a bike to aid regaining flexion, provided this can be done without pain in the knee. Static cycling is more likely to strain healing tissue; an upright or recumbent bike would be more effective. Stationary cycling is a good starting exercise because it allows the quadriceps to flex and straighten the knee without the full body weight. This means that the patient can start regaining strength and muscle bulk in the quadriceps without putting too much stress on the joint. If this is done for a few weeks, muscle bulk and strength often return to near pre-injury levels.

Injury Prevention Strategies

Finally, sport-specific conditioning should not be overlooked. Many sports involve actions that put increased stress through the knee. These can include sudden changes in direction, sharp deceleration, or jumping/landing actions. For example, a footballer or basketball player will require good agility and the ability to cut and turn sharply. These athletes could be at risk of knee injury if they have not specifically conditioned their bodies to take these actions.

Repetitive stress and force through the knee can cause small ‘microtraumas’ to occur. The body does have an ability to recover from these; however, if further stress is taken too soon, then these microtraumas can accumulate and lead to serious injury. It usually takes 24 to 48 hours for the body to repair from an episode of prolonged microtrauma. If further stress is taken during this repair phase, then insufficient recovery will occur, resulting in cumulative microtrauma. An example of this is a runner who may run on 3 consecutive days instead of cross-training and will soon develop knee pain. The key to preventing knee pain for this runner is to ensure adequate recovery takes place between each training session.

Keep up the muscle conditioning. Muscle-strengthening exercises are a key element of preventing knee injuries. Your thigh muscles (quadriceps) and hamstring muscles, in particular, are crucial for stabilizing your knees. Weak thigh muscles and tight hamstrings can cause the kneecap to track out of alignment, and this, in turn, puts more stress through the knee joint.

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