Dr. Shamanthakamani Narendran K N E E P A I N M.D. (Pead), Ph.D. (Yoga Science)
What is causing the knee pain?
How old is the patient?
Was there a traumatic event?
Where is the pain located?
Did the symptoms develop immediately or over time?
Once these questions are answered, can begin to investigate the symptoms. Putting the symptoms together with the history often leads to a diagnosis.
Common Knee Symptoms
Front of the knee : Pain over the front of the knee is most commonly related to the knee cap. Kneecap pain can be caused by several different problems.
Inside of the knee : Pain on the inside, or medial aspect, of the knee is commonly caused by medial meniscus tears, medial collateral ligament injuries, and arthritis of the joint.
Location of Pain
Outside of the knee : Pain on the outside of the knee, or lateral aspect of the knee joint, is commonly caused by lateral meniscus tears, lateral collateral ligament injuries, IT band tendonitis, and arthritis of the joint.
Pain in the back of the knee : Pain in the back of the knee can be due to the formation of a cyst, called a Baker's Cyst, in the back of the knee joint. Also common is for kneecap pain to be felt in the back of the knee.
Some common situations cause pain typical of certain conditions.
While going down stairs : Pain while walking down steps is very commonly associated with kneecap problems, such as chondromalacia.
Morning pain : Pain after first waking in the morning that resolves with gentle activity is typical of early arthritis. Often patients loosen the knee over the course of the day.
Timing of Pain
ARTHRITIS OF THE KNEE Any of the rheumatic diseases may commence in the form of isolated arthritis of the knee
A skilled examiner can often detect the injury to the knee prior to ordering tests such as x-rays or MRIs.
These tests and maneuvers are performed to detect specific problems within the knee joint.
While any one test may not be diagnostic of a particular problem, by performing a good knee examination most common knee problems can be properly diagnosed.
Characteristics of pain
Mechanical or inflammatory
Patellar pain aggravated by walking
Episodes of locking: caused by meniscal tears, by articular loose bodies (of osteochondritis dissecans), or by patellar dysfunction (usually less dramatic)
Signs of inflammation
Swelling, redness, heat, and pain
Synovial effusion: patellar tap, bulge sign
Site of the pain
Mobilization of the patella: with the knees extended, the patella is slid over the femoral condyles; catching, irregular sliding and pain indicate femoropatellar pathology
Lateral ligament laxity is sought with the knee in extension (lesions of the collateral ligaments)
Drawer sign (cruciate ligaments): with the knee flexed at 90 degree the tibia shows abnormally increased anteroposterior mobility.
Range of movement
Flexion can be evaluated by measuring the distance from the knee to the gluteal fold
Normal extension amounts to approximately 5 degrees and is rapidly lost in the presence of a chronic knee disorder
Meniscal signs: pain at the joint line in response to rotation of the lower leg during flexion of the knee (grinding test)
Popliteal cyst: painful swelling behind the knee.
Atrophy of the quadriceps: knee effusion invariably gives rise to atrophy of the quadriceps
Joint Line Tenderness is a very non-specific test for a meniscus tear. The area of the meniscus is felt, and a positive test is considered when there is pain over the area where the meniscus is found.
McMurray's test is performed with the patient lying flat (non-weight bearing) and the examiner bending the knee. A click is felt over the meniscus tear as the knee is brought from full flexion to 90 degrees of flexion.
Tests to Detect a Meniscus Tear
Ege's test is a specific maneuver to detect a meniscus tear. With a patient squatting, an audible and palpable click is heard/felt over the are of the meniscus tear. The patient's feet are turned outwards to detect a medial meniscus tear, and turned inwards to detect a lateral meniscus tear.
Lachman test is the best test to diagnose an ACL tear.
Anterior/Posterior Drawer test is the sliding of the tibia indicating laxity
Pivot Shift test is a maneuver to detect a deficiency of the anterior cruciate ligament of the knee; a sudden subluxation of the lateral tibial condyle upon the distal femur is positive
Varus and Valgus Instability check the LCL and MCL
Dial test checks the rotation allowed at the knee joint.
Tests to Detect Ligament Injury
Patellar Grind Test is a nonspecific test where the examiner feels for abnormal grinding sensations under the kneecap with movement of the joint. If pressure on the kneecap recreates the symptoms this may indicate the kneecap is the culprit.
Patellar Facet Tenderness , The examiner can slightly lift up the kneecap and place direct pressure on the undersurface of the kneecap. By doing so, the examiner is looking for sensitive regions of cartilage underneath the kneecap.
Tests to Detect Kneecap Problems
Patellar Apprehension Test is a sign of an unstable kneecap. While the examiner places pressure on the kneecap, the patient may complain of the sensation that the kneecap is going to 'pop out' of its groove. This is a sign of kneecap instability.
A knee effusion can easily be aspirated.
The main aim of this procedure is to establish a diagnosis.
Analysis of the synovial fluid must include
Appearance of the fluid
Synovial fluid viscosity
Culture of the synovial fluid
Examination for crystals
X-rays : anteroposterior (standing) and lateral views are necessary in cases of persistent pain.
When patellar symptoms are present, skyline views of the patella should be taken, preferably during weight bearing with the knee flexed at 30 degrees.
Arthroscopy : is possible during this intervention to repair small meniscal lesions or to resect synovial folds.
Biopsy and subsequent culture of tissue removed during arthroscopy also enables one to exclude the possibility of a chronic infection.
Treatment for the primary disease
If the arthritis is limited to the knee, provided that the possibility of the infection has been excluded, intraarticular corticosteroid injections can be given.
In the event of recurrence after 2-3 injections, recourse to synoviorthosis or synovectomy should be considered.
Never forget quadriceps exercises
Do not immobilize the knee in the flexed position because this involves the risk of flexion deformity.
Treatment for osteoarthrosis of the knee
The treatment is similar to that for osteoarthrosis of the hip, its aim being to relieve pain and to maintain both mobility and musculature.
It vastus medialis atrophy is present, isometric exercises are indicated.
Lying on his back, the patient contracts the quadriceps muscles, while at the same time keeping the legs immobile.
As treatment of bouts of inflammation occurring in osteoarthrosis, intraarticular corticosteroid injections prove effective, but limited to a maximum of 3-4 a year per joint
The slow, controlled physical movement of joints is helpful for Arthritis patients.
It improves the blood circulation in joints, removing unwanted toxins and other waste products, but the problem in the patients is if patient tries to move his limbs & joints then pain increases so patient does not move the limbs and problem increases.
So it is vicious cycle, because of pain no movements and because there is no movement, the situation becomes worse.
So patient should keep doing the movements which are possible for him.
Simple asanas, movements help increase the circulation in the joints and limbs.
Slow, steady and controlled movements are especially recommended.
ASANAS Yoga certainly helps in Arthritis
Simple Pranayama is recommended, which involved deep breathing, special type of Pranayama with Inhalation via right nostril and exhalation via both nostrils but creating a sound of Hmm.. (Honey bee Sound) from the throat is found to be very effective in Arthritis patients.
INTEGRATED YOGA MODULE FOR KNEE PAIN
Sithilikarana Vyayama (loosening exercises)
Knee cap tightening
Sitting position knee loosening
Patella movement (passive)
Straight leg raising (sitting on a chair)
Knee cap tightening
Quick relaxation technique (QRT)
Deep relaxation technique (DRT) (leg resting on wall)
Vibhaga pranayama (Sectional breathing)
Meditation (Dhyana Dharana)
A light massage of medicated Ayurveda Herbal oil is very effective, especially after application of heat (moderate and bearable with heat bags).
Massage makes the joint movements easier and then patients can perform physical movements, so if massage is followed by Asanas, it has been found to be more fruitful.
HEAT TREATMENT AND MASSAGE
Basti (Enema) with sesame oil (15 cc) between 5.30 to 6.30 pm (This treatment is recommended in Ayurveda)
In the morning drink warm water + fresh lime on empty stomach
Sun bath for 10 to 15 minutes
Yoga Life Style – Man has moved away from the nature and has found himself surrounded by stress and unhealthy life style, leading a stress free life is essential to good health.
NATURE CURE FOR ARTHRITIS
Drinking boiled water with dry ginger once a day
During meals eating 1 to 2 tea spoons of Coconut Oil (Please consult medical advisor before)
Before taking shower / bath, massage the painful part / joint with Castor Oil.
Before going to bed, drink 2 spoons of Castor oil + 1 spoon Honey + ¼ cup warm water (This has given some wonderful results in many Yoga Therapy Center, this remedy has been discussed in Ayurveda.)
HOME REMEDIES FOR ARTHRITIS
Fresh and light diet, consume food immediately when it is cooked & warm (avoid stale and cold food)
Wheat bread / brown bread, boiled vegetables, green vegetables, rice cooked with green gram
Garlic, spinach, dates, fenugreek
All fruits except bananas, mangos, grapes
Eat lunch by 12 noon & dinner before 7 pm
Fasting once a week, eat fruits during the fast but avoid any other food rich in calories
Non vegetarian food
High protein diet
Hot & spicy food
Deep fried food
Cold drinks, soft drinks, aerated drinks
Do not overeat
STRICTLY AVOID FOLLOWING FOOD
ACL knee surgery SURGICAL TREATMENT ACL removed Tunnels are drilled Acromio Clavicular Ligament
Partial replacement arthroplasty
Indicated in order to repair local destruction of medial or lateral compartments, proving that ligamentous stability is preserved.
Total condylar knee replacement
These replace the two articular surfaces; that of the femur by a steel shield, that of the tibia by a piece of plastic on a metal plaque.
These may or may not be cemented in place and yield good functional results
Total knee replacements (hinged)
Severe deformation or instability, as well as when replacing a total condylar prosthesis.
ARTHROSCOPIC KNEE SURGERY
ARTIFICIAL KNEE SURGERY
VIRTUAL KNEE SURGERY
AFTER KNEE SURGERY
Calf stretch Hamstring stretch REHABILITATION Hip abductor strengthening Quadriceps strengthening
Hip adductor strengthening Hip and buttock stretch Iliotibial band and buttock stretch Iliotibial band stretch
General considerations : Knee pain is non-inflammatory joint disease (typically at the knee or the hip joint). It is more common in middle and old age.
Contraindications : Straining the joints with body weight. Fortunately jumping is not common in yoga, but Suryanamaskar or some balancing standing asanas may not be suitable. Some people, especially with these problems, may find it difficult to sit in any yoga meditative asana and an alternative using a chair may be more appropriate for them.
Recommendations : People with non-inflammatory joint diseases usually benefit from practices which gently exercise the joint without pressure. (e.g. Pavanmuktasana, or cycling from Pavanmuktasana). These practices exercise the joints and strengthen the muscles around them, which gives better support to the joint.
Recommended asanas :
Vajrasan - relieves pain of calves and knees
Vrikshasan (Tree pose) & Gomukhasan (Cow's face and jaw pose) - exercises finger joints, toes, ankles, knees and hip joints; activates muscles of joints therefore removing waste products from joints; restores joint fluid thereby removing spasticity and pain.
Shavasan (Corpse pose) - relaxes all muscles, nerves and organs