Mr Colin Walker- Consultant Orthopaedic Surgeon MB ChB, FRCS
Mr Frank Gilroy- Senior Physiotherapist MSc MCSP
This programme does not attempt to diagnose knee pain and it is important that your doctor is aware that you are following this programme and is happy for you to use it.
The Acute knee pain or injuries programme accompanies the Joint Recovery Video series which is available here
Background Briefing
Patients can notice pain, swelling and loss of movement in their knee for a
number of reasons. Often these symptoms are a result of injury, but pain
and swelling can also be associated with degenerative or arthritic
conditions in the knee.
This exercise regime is designed to help settle pain and swelling in your
knee and restore the range of movement and function of your knee as well
as helping you understand the rationale for following the exercises.
The knee is the biggest joint in the body. It is enclosed in a capsule which
contains any swelling within its walls. The capsule extends about one hand’s
breadth above your patella (kneecap). This means that any blood or
swelling within the knee stays within the capsule. Quite a considerable
amount of fluid can collect within this large joint before it becomes
noticeable.
If an injury to the knee results in swelling, it can be helpful to consider how quickly the swelling appears. If it swells almost immediately, this suggests that the injury has caused bleeding within the knee. This is most often due to an injury to the cruciate ligaments within the knee, a fracture of bone within the joint or dislocation of the patella. Therefore, if a knee has “ballooned” after an injury, medical attention should be sought with view to having an x-ray.
Swelling within the knee has a number of effects. It can cause pain, restrict movement, both straightening (extension) and bending (flexion), and it can cause weakening of the quadriceps muscles which provides the power to extend the knee. Weak quadriceps muscles will cause the patient to walk with a limp and cause pain at the front of the knee due to more force travelling through the patella-femoral joint (the joint between the knee cap and the femur bone). Sometimes, this results in the knee giving way.
The principle of treating an acute knee injury is therefore to reduce the swelling in the knee, restore the full range of motion and strengthen the quadriceps muscles.
Phase 1- RICE and Gentle Exercises
Every injury is different and therefore the length of the acute phase will vary.
The acute phase is defined by significant swelling, joint stiffness and sometimes weakness in the quadriceps muscles. For most people, the acute phase lasts between 48 hours and 7 days.
Immediately after the onset of your symptoms, we advise following the “RICE” principle and a programme of gentle excercises to reduce swelling, restore full movement and to encourage the quadriceps muscles to fire.
REST
Once the knee is swollen and inflamed, it is important to let it settle
by resting it. Excessive exercise or activity will cause the knee to swell further.
You should therefore reduce your activity as much as possible -walking shorter distances and restricting day to day activities to only the most important tasks.
If your injury is more severe, crutches may be required. In general, it is better to walk with crutches and a normal gait pattern than hobble around on a bent knee!
Occasionally your doctor may prescribe a brace to protect the knee.
ICE
From the moment you sustain an injury or start to experience acute pain in your knee, you should apply ice regularly to your joint.
Place an ice pack on your knee 3 to 4 times a day for 15 minutes. To prevent ice burns, cover the ice pack with a tea towel so that it is not directly against your skin.
You do not need to use commercially available ice packs. We find that two bags of frozen peas works just as well. Wrap the bags of frozen peas in tea towels and apply them to the back and front of your knee, gently breaking up the peas to allow them to conform to the shape of your knee.
COMPRESSION
Compression also helps reduce acute knee pain and swelling. Use an appropriately sized compression bandage to reduce swelling. Apply the bandage evenly from mid thigh to mid calf.
It is important to take the compression bandage off in bed at night to avoid circulation problems.
ELEVATE
Fluid from swelling moves down under gravity. If you sit with your leg hanging down towards the floor, swelling will remain in the leg. If the leg is elevated, the fluid will move out of the leg and therefore the swelling will reduce.
Therefore, try to elevate your leg for as much of the day as possible, ideally keeping your ankle higher than your heart. This can be achieved by lying along the sofa with your foot propped up on the arm of the sofa or on some pillows when you are watching TV! This isn’t always practical but at least try to have your ankle higher than your hip when you are sitting.
GENERAL EXERCISES
After an injury to the knee or after the onset of knee pain, the quadriceps muscles can stop working very quickly, even to the extent that the muscles fail to fire.
Immobilising your knee can lead to significant problems with stiffness and weakness of the muscle which can have the long term effect of slowing your recovery.
In order to avoid these complications, it is therefore important to start gentle exercises during the acute phase of your injury, almost immediately if you can, as they will encourage both movement of the knee and recovery of the quadriceps muscles.
However, it is important to remember at all times during the acute phase of recovery to maintain the RICE routine and to ensure that you are resting, icing, compressing and elevating your knee, around your gentle exercise sessions.
The following gentle exercises should be repeated every 2 hours during the day
Exercise 1: Flexion/Extension Movement
1. Lie on the floor with your legs together and extended out straight.
2. Bend your hip and knee by sliding your foot towards your buttock as far as feels comfortable.
3. Then straighten your hip and knee back to the floor.
4. Try to repeat up to 10 times as pain allows.
Exercise 2: Static Quadriceps
1. Lie on the floor with your legs together and extended out straight.
2. Pull your toes back towards you until they are pointing to the ceiling and push your knee down onto the floor. You will see and feel your quadriceps muscles contract
3. Count to 5 and release
4. Repeat this up to 10 times as your pain allows
Exercise 3 Straight Leg Raising
1. Lie on the floor with your legs together and extended out straight.
2. Pull your ankle back until your toes point to the ceiling. Tighten your thigh muscles and straighten your knee.
3. Now lift your straight leg about 30 cm or 12 inches off the floor.
4. Hold for 5 seconds then gently lower the leg to the floor.
5. If you are able, repeat 10 times as your pain allows.
Completion of the Acute Phase
By the end of the acute phase, you should have achieved the following goals before you are ready to progress on to the next phase of exercises which will concentrate on increasing muscle strength:
• Knee swelling significantly reduced
• Almost full range of motion of the knee
• Able to straight leg raise
If you are unable to straight leg raise (exercise 3) after 72 hours, you should arrange to see your doctor or a physiotherapist and you should continue using crutches
Phase 2- Strengthening and Basic Stretches
Once the acute phase goals have been achieved, the next phase will concentrate on stretching and strengthening the muscles around the knee.
As mentioned earlier, the quadriceps muscles, in particular, weaken after any significant knee injury. One of the effects of quadriceps muscle wasting is to cause more force to travel through the patellafemoral joint and this excessive force can cause pain and swelling.
Activities which load the patella-femoral joint involve taking weight on a bent knee, (eg. climbing hills or stairs, lunges, running) should be avoided. This phase of the programme is designed to strengthen the quadriceps muscles through exercises designed to avoid excessive load to the patella-femoral joint and thus avoid pain.
It is important to complete this phase of rehabilitation before progressing to the next phase of conditioning and return to functional exercise.
You do not not need to follow the RICE routine at this stage, however it is worth continuing some icing of your knee after performing your excercises to discourage swelling of the knee.
You should perform the following strengthening and stretching exercises at least 4 times a day
STRENGTHENING
Perform the strengthening excercises until the the muscle feels tired. This should not increase pain in the knee. If it does, reduce the duration and resistance of the strengthening excercises.
All these excercises can be performed lying on your back on the floor. If you find this uncomfortable or difficult, you can lie on a bed with a couple of pillows under your head and shoulders to allow you to sit up a small amount.
Level 1:
Begin at level 1 in each of the following strengthening exercises and only progress to level 2 when you feel the exercise is too easy.
Level 2:
These exercises are performed using resistance. You can perform resistance excercises using either therabands or ankle weights.
Start with lower resistance therabands or lower weights which you can manage with relative ease. As the exercise becomes easier, either increase the resistance of the theraband or increase the weight.
Therabands
A theraband is a stretchy elastic band which is extremely
useful when incorporated into a number of rehabilitation
excercises. For knee strengthening exercises, the theraband is placed around your ankles in order to create some resistance whilst carrying out the exercises. This makes the muscles work a little harder.
They can easily be purchased online and offer a range of resistances, from low resistance yellow therabands to high resistance black therabands
Yellow > Red > Green > Blue > Black
Ankle Weights
It is possible to buy commercially made ankle
weights however, it is very easy to make up ankle weights yourself using a plastic bag and some sand.
Using kitchen scales, fill plastic bags with ½ kg or 1lb of sand then tie off the plastic bag.
Obviously, patients of different size and strength will need to use different weights and so you may
need to add more sand. As a rule, start with a lighter weight and only progress to a higher weight if you find the weight too easy. We suggest starting with a ½ kg or 1 lb weight and increasing it as needed.
Place the bag of sand over the front of the ankle to act as a weight. If this is not enough weight for you, you can add a second bag on top of the other bag.
Exercise 1: Straight Leg Raise
1. Lie on the floor with your legs together and extended out straight.
2. Pull your ankle back until your toes point to the ceiling
3. Now push the back of your leg into the floor or bed
4. You should feel your quadriceps muscle contract
5. Now lift your heel about 30 cm or 12 inches off the floor with your toes still pointing to the ceiling
6. If you can, hold this position for a count of 5
7. Now lower your leg back to the floor or bed
8. If you are able, try to repeat this exercise 10 times as your pain allows.
Level 1: Perform this exercise without any resistance
When this exercise becomes too easy, progress to level 2
Level 2:
Theraband
1. Put the theraband round both ankles
2. Hold the theraband down using the uninjured leg.
3. Perform the straight leg raise using the same technique
4. When you feel this is too easy, you are ready to increase
the resistance of the theraband
Ankle Weight
1. Start with a 1/2kg or 1lb weight and increase as required
2. Place the weight over the front of the ankle
3. Perform the straight leg raise using the same technique
Exercise 2: Straight Leg Raise with 45 Degrees Rotation
1. Lie on the floor with your legs together and extended out straight.
2. Pull your ankle back until your toes point to the ceiling
3. Now push the back of your leg into the floor
4. Rotate your leg out by 45 degrees
5. You should feel your quadriceps muscle contract
6. Now lift your heel about 30 cm or 12 inches off the floor with your leg still rotated by 45 degrees
7. If you can, hold this position for a count of 5
8. Now lower your leg back to the floor or bed
9. If you are able, try to repeat this exercise 10 times as your pain allows.
Level one:
Perform this exercise without any resistance. When this exercise becomes too easy,
progress to level 2
Level 2:
Theraband
1. Put the theraband round both ankles
2. Hold the theraband down using the uninjured leg
3. Perform the straight leg raise with 45 degrees rotation excercise using the same technique
4. When you feel this is too easy, you are ready to increase the resistance of the theraband
Ankle Weight
1. Start with a 1/2kg or 1lb weight and increase as required
2. Place the weight over the front of the ankle
3. Perform the straight leg raise with 45 degrees rotation excercise using the same technique
Exercise 3: Inner Range Quads
1. Lie on the floor with your legs together and extended
out straight
2. Bend your injured knee and place a rolled up towel or foam roller behind it to keep it slightly flexed
3. Pull your ankle back so it is pointing to the ceiling
4. Now straighten your knee with the toes pointing to the ceiling
5. Your heel should be 15-20 cm or 6 inches off the floor or bed
6. If you can, hold this position for a count of 5
7. Now lower your leg back to the floor or bed
8. If you are able, try to repeat this exercise 10 times as your pain allows.
Level 1:
Perform this exercise without any resistance
When this exercise becomes too easy, progress to level 2
Level 2:
Theraband
1. Put the theraband round both ankles
2. Hold the theraband down using the uninjured leg
3. Perform the inner range quads excercises using the same technique
4. When you feel this is too easy, you are ready to increase the resistance of the theraband
Ankle weight
1. Start with a 1/2kg or 1lb weight and increase as
required
2. Place the weight over the front of the ankle
3. Perform the inner range quads excercises using the same technique
BASIC STRETCHES
When you perform these stretches, you will need to stand close to a wall or a piece of furniture to steady yourself.
Each stretch should be held for 15-20 seconds
Perform each stretching excercise 3 times
Exercise 1: Quadriceps Muscle Stretch
1. Stand with your feet together
2. Put your weight on the uninjured knee and steady yourself with the same arm
3. Bend your injured knee towards your bottom and bend your hip forwards
4. Now catch your ankle with your hand
5. Now straighten out your hip, trying to stay tall
6. Gently pull your heel towards your bottom until you feel the quadriceps muscle at the front of your thigh stretch
7. Hold this stretch for 15 – 20 seconds
8. Release the stretch gently, initially by bending your hip
forward and then letting go of your ankle
9. Now stand up straight again.
Exercise 2: Calf Stretch
- Stand with your feet together
- Steady yourself on furniture or the wall with both hands
- Move your uninjured foot in front of the other foot
- Now move the foot of your injured leg back about 30 cm or 12 inches
- The further you move it back, the more of a stretch you will get
- Now bend your uninjured knee and both elbows together, keeping the heel of your injured leg firmly on the floor. You will feel the stretch in the calf.
- Hold this stretch for 15-20 seconds.
- To release this stretch, straighten your elbows and uninjured knee, then stand up straight
Exercise 3: Soleus Stretch
- Stand with your feet about 30cm or 15 inches apart
- Stand up straight. Steady yourself on furniture or the wall with both hands
- Keep both heels firmly planted to the floor
- Gently bend your knees taking care to keep your knees directly over your feet when you look down
- You will feel this stretch in your calf muscle
- Hold the stretch for 15-20 seconds
- Release the stretch by slowly standing up straight again
Exercise 4: Hamstring Stretch
1. Stand with your feet together
2. Move the foot of your uninjured knee behind the foot of your injured knee
3. Steady yourself on furniture or the wall with your hand of the uninjured side
4. Put your weight on the uninjured leg
5. Keep the sole of your foot of the injured leg firmly on the floor
6. Put your other hand on your thigh just above the injured knee
7. Now bend your uninjured knee until you feel a stretch in the back of the thigh
8. You can now increase the stretch by bending forward at the waist.
9. Hold this stretch for 15-20 seconds.
10. Release this stretch by straightening at the waist, then straightening your uninjured knee, and then standing up straight.
Completion of Phase 2 (Strengthening and Basic Stretches)
By the end of the phase 2 , you should have achieved the following goals before you are ready to progress on to the next phase of exercises which will concentrate on increasing quadriceps and hamstring muscle strength and sports specific exercise.
• Knee swelling resolved
• Full range of motion of the knee
• Able to straight leg raise with ease and walk with a normal gait pattern
Phase 3- Return to Sport
Phase 3 excercises are dependent on what activities and sport you wish to return to and therefore the programme for a phased return to sport tends to be specific to your particular sport.
However, there are some important principles which should be applied to all return to sport approaches
Principles
• Start gentle low loading activities such as low resistance settings on a static bike or hydrotherapy training, increasing from short periods initially. If it causes the joint to swell or cause pain, reduce or stop the level of activity and return to phase 2 activity.
• If an exercise causes swelling or pain, the intensity should be reduced.
• In the first week or two after starting phase 3, ice the knee for 15 minutes after excercise to avoid further swelling in the knee
• Start with low intensity or resistance excercises. Gradually increase the duration until you can perform it for 20 minutes.
• When you can perform the exercise for 20 minutes, increase the intensity or resistance gradually.
• When you can perform the exercise at high intensity for 20 minutes, you can subsequently increase the duration
– A cross trainer or low resistance bike is a low intensity exercise. An indoor rowing machine is a medium intensity exercise. Jogging is a medium high intensity. Running, lunges and squatting are high intensity exercise
• Do not start running until the power and quadriceps muscle bulk on the injured knee is similar to the uninjured knee. Running with a weak quadriceps muscle is likely to cause pain at the front of the knee from loading the patello-femoral joint excessively.
• Wear supportive footwear. It is important to wear a good quality trainer which fits well and is firmly laced up when performing these excercises. This will keep the knee in a neutral position and provide stability.
BE REALISTIC ABOUT TIMESCALES FOR RECOVERY
Obviously injuries vary in severity and intensity and individuals recover at different rates. The most common cause for re-injury is due to returning to sport or activity too early with inadequate rehabilitation.
It is important to be realistic about how long an injury will take to fully recover and complete a return to sport programme before starting back to normal sporting activities