Knee rehab

1. Degenerative Joint Diseases
Knee Osteoarthritis
BY
Dina Othman Shokri

2. Objectives

4. Osteoarthritis (OA)
OA is the most common disease of the joints worldwide, with the knee
being the most commonly affected joint in the body. It mainly affects
people over the age of 45 years old. OA can lead to pain and loss of
function, but not everyone with radiographic findings of knee OA will be
symptomatic: In one study only 15% of patients with radiographic
findings of knee OA were symptomatic. OA affects nearly 6% of all
adults. Women are more commonly affected than men. Roughly 13% of
women and 10% of men 60 years and older have symptomatic knee
osteoarthritis. Among those older than 70 years of age, the prevalence
rises to as high as 40%.

5. Knee osteoarthritis (OA), also known as degenerative joint disease, is
typically the result of wear and tear and progressive loss of articular
cartilage. Osteoarthritis predominantly involves the weight-
bearing joints, including the knees, hips, cervical and
lumbosacral spine, and feet. More correctly called osteoarthrosis
because it is not inflammatory condition. It is a degenerative joint
disease involving the different structures of the joint. The degradation of
joints, including articular cartilage and subchondral bone. But also
ligaments, the capsule and the synovial membrane degenerate. It never
by reversed.

6. The pathogenesis of knee OA have been linked to biomechanical and
biochemical changes in the cartilage of the knee joint. The cartilage
ensures that the bone surfaces can move painless with low friction to
each other. In OA, the cartilage decreases in thickness and quality, it
becomes thinner and softer, cracks may occur and it will eventually
crumble off. Cartilage that has been damaged, cannot recover. Finally the
cartilage will disappear. The cartilaginous tissue is not the only one
involved. Given its lack of vasculature and innervation, the cartilage, by
itself is not capable of producing inflammation or pain at least on early
stages of the disease.
Pathogenesis of OA

7. Hence, the source of pain is mainly derived from changes to the non-
cartilaginous components of the joint, like the joint capsule (degenerated
and inflamed), synovium (synovial effusion), subchondral bone (the
bone will expand and spurs (osteophytes), ligaments (laxity of the
ligaments), and peri-articular muscles (muscle atrophy). Common
sources of pain near the knee are anserine bursitis and iliotibial band
syndrome. Most of these are not visualized by the x-ray, and the severity
of x-ray changes in OA correlates poorly with pain severity..

8. Normal Knee Joint
Degenerative Begins

9. Degeneration Progresses

10. OA can occur in either or both of the articulations of the knee (Tibiofemoral
joint, Patellofemoral joint). In the knee joint, these changes affect are greater in
the medial tibiofemoral and the patellofemoral joint with the lateral
tibiofemoral joint less severely affected. A affects the medial compartment of
the knee, and as the bone wears away medially a varus or “bowlegged”
appearance develops. Much less frequently patients develop lateral
compartment OA that results in a valgus or “knock-kneed” deformity.

11. OA is classified into two groups according to its etiology:
1- Primary (idiopathic or non-traumatic): It is OA without obvious causes. It affect mostly
elderly people especially women in post-menopausal period. It is related to aging process. As
water content decreases due to reduction of proteoglycans content, cartilage becomes less
resilient and becomes more susceptible to injury. There is a hereditary (genetic) factor in
primary OA.
2-Secondary OA (usually due to trauma or mechanical misalignment).
Secondary to other causes as:
a- Trauma
A-Intra-articular fracture (If it isn't properly reduced and fixed------articular cartilage become
irregular ----friction force increase).
B-Extra –articular fracture (If they are malunited-----maldistrubtion of load on joint surface).
b-Repeated minor trauma: or stress usually a result of some types of occupation or sports.
c-Infection: as pyogenic arthiritis
d-Inflamations: as gout and RA
e-Deformities: as genu varum /coxa valga------maldistrubtion of load on joint surface.
f-Metabolic disorders: e.g. rickets
Etiology and Classification

12. Risk Factors
1-Obesity: Increases pressure on the knees. Every pound of weight you gain adds 3 to 4
pounds of extra weight on your knees. Obesity also increases circulating level of
chemical substances such as leptin, C-reactive protein, and other pro-inflammatory
cytokine that may promote cartilage matrix degeneration.
2-Weak muscle, poor knee Stability and abnormal mobility: due to ligamentous
laxity or poor mobility and proprioception.
3-Gender: Females are more affected.
4-Repetitive stress injuries: usually a result of the type of occupation and athletics: as
in soccer, tennis, or long-distance running.
5-Overuse and underuses: As both cause improper nutrition to the hyaline cartilage.

13. Clinical presentation
1-Joint pain and stiffness: This is a 'mechanical' type of pain which is
generated by activity (Pain when standing up from a chair, pain when going up
and down stairs and walking for long distance), decreases with rest. Joint pain
which is less in the morning and stronger at the end of the day following
activity. Pain with joint palpation or ROM.
Gelling phenomenon: Stiffness after periods of inactivity, passes over within
minutes (approx 15min.) of using joint again. In OA, morning stiffness lasting
no longer than 30 minutes.
2- Swelling (Edema, Effusion): Caused by synovial irritation, edema of the
periarticular structures and inflammation of the bursa are among other cause of
joint swelling. and lead to enlarged joints.

15. 6-Crepitation, deformity and instability: Crepitation: due to flakes of
cartilage break off and move freely inside the joint leading to joint
locking, deformity due to unequal load distribution and muscle
imbalance and instability due to ligaments stretch and muscle weakness.
7-Antalgic gait: Painful gait, short stance duration on affected leg
relative to the swing phase, longer step on affected side, shorter step on
sound or least affected leg.
Diagnosis of OA:Clinical findings (joint pain) +Radiologic
findings(osteophytes)

16. Imaging
Knee MRI
Knee X
ray

18. Management Of Knee OA
It has been found that the optimal management of OA requires a combination of
non pharmacological and pharmacological modalities.
1-Medical treatment:
A-NSAIDS: Used to relieve pain and inflammation for more advanced cases,
however, it has side effects.
B-Intra-articular injections of corticosteroids.
C-Topical and injectable medications.
D-Glucosamine and hyaluronic acids: Acts as a lubricant and shock absorbing,
helps rebuild cartilage.
2-Surgical Treatment (when conservative treatment failed):
Osteotomy: Performed to change bone alignment
and alter load on joint surface and correct deformities.
High tibial corrective
osteotomy

19. Arthroscopy for debridement and lavage (cleaning ) of the joint.
Arthroplasty: Joint replacement can relieve pain and restore loss of
function for patients with advanced disease.
Uni-Condylar/Compartmental Arthroplasty
Total Knee Arthroplasty

20. Physical Therapy Management
Assessment:
ROM.
Tests for Intra-Articular Fluid (The Bulge Test-The Patellar Tap)
Muscle Strength.
Joint stability.
Proprioception
Posture.
Gait and Function.
Psychological status.
Aims Of Physical Therapy Treatment:
Decrease load on the joint.
Decrease pain, inflammation and swelling.
Increase mobility and ROM.
Improve muscle strength and endurance.
Improve joint stability and proprioception.
Prevent or minimize deformity formation.
improve function and independence in ADL.
Improve Gait.

21. Physical Therapy Management
I. To decrease the load
1-Weight reduction
Weight increases load on joints. Losing weight directly decrease the load on joint by decrease
the joint reaction force during weight bearing and activities. During ambulation, 3 to 5 times the
body weight passes through the knee joint, small changes in weight result in large increase in
force across the joint. Weight reduction could be achieved either by exercises and/or diet.
Weight reductions is highly recommended especially in obese patients in order to maintain the
average BMI(18.5 to 25).
2-Walking aids
Assistive devices like canes, crutch and walkers to increase the base of support and decrease
load. Provide effective unloading of the knee and hip when held contra lateral side. Increase
joint stability. Frames or wheeled walkers are preferable for those with bilateral OA. Walking
aids is highly recommended. (The cane is held in the hand contralateral to the affected limb
and moves together with the affected limb).

23. 3-Braces and orthoses
A-Knee brace
1-“Rest” braces: are not advised due to weakening of the quadriceps muscle.
N.B. Complete rest is commonly unnecessary; instead relative joint resting by splints
or brace is advised (to rest the joint and decrease the load).
2-Corrective braces: used by patients with moderate or severe knee OA. Valgus braces
is the most common, it reduces pain and adduction moments, reduce compression of the
joint and improve proprioception. However, it is not tolerated by patients, its prolonged
use may lead to compartment syndrome, research evidence is weak in its use. It is not
recommended as a standard treatment for patients with OA unless patient’s show
need for it.

25. B-Foot orthosis
Insoles offer great potential as simple, inexpensive treatment strategies for knee OA.
Lateral wedge insoles have been advocated for medial compartment OA and
medial wedge insoles for lateral compartment OA.
Lateral wedge inserts -----By placing the calcaneus in a valgus position, a medial
unloading may take place more proximal up the kinematic chain at the knee.
If orthosis to be used, lateral foot insert and medial foot arch should be used
simultaneously. The two inserts should be different in height so that the net wedge
angle is related to the desired amount of knee unloading. It is not standard
Lateral wedge insole

29. 6-Tapping techniques: Theoretically, tapping stabilizes the joint, alters
load distribution, realigning the patella and reduce strain on inflamed
tissue. the effectiveness depend on strapping technique and duration of
application. It has short-term effect.
Knee taping (medial patella
glide).

30. Knee mobilization
Patients with symptomatic knee OA may benefit from hip mobilizations (caudal
glides-, anterior-posterior glides-posterior-anterior glides- posterior-anterior
glides in the FABER position), if they have two or more of the following
criteria: (1) hip or groin pain or paresthesia, (2) anterior thigh pain, (3) passive
knee flexion less than 122 degrees, (4) passive hip internal rotation less than 17
degrees, and (5) pain with hip distraction.

31. Hip mobilization

32. III.To improve mobility and ROM:
1-Active free ROM exercise within painless ROM.----Help in joint nutrition and
washing out of pain metabolites by enhancing the synovial fluid circulation.
2-Joint Mobilization grade III,IV and distraction (anterior, posterior glide).
3-Stretching exercise for tight muscles: (Hip adductors, Hip Flexors, Hamstring,
Quadriceps, Calf, Iliotibial band).
Hip Flexors stretch
Hamstring stretch
Iliotibial band
stretch
Calf stretch

35. V. To improve Proprioception, Functional and gait training:
1-Proprioceptive exercise: Reduced proprioception in older adults may be responsible
for the initiation or advancement of knee degeneration. This may be due to a process
termed neurogenic acceleration of osteoarthrosis. Neurogenic acceleration is the loss of
afferent proprioceptive input combined with joint instability that speeds up the arthritic
process. The use of elastic knee bandages was found to increase the proprioceptive
ability of joint position sense. This finding indicates that external supports or tape may
be useful in giving proprioceptive feedback by allowing the patient to access afferent
information from other receptors or to use existing proprioception more efficiently.
2-Balance exercise.
3-Under water walking and closed kinematic chain exercises

39. Advices to the patient
Lose weight to reduce load on the joints.
Modification of life style and daily routine.
Not to put the joint in extremes of range.
Not to stand, sit or lie in a fixed position for long periods.
Use walkers, crutches or canes during outdoors walking.
Drinking enough amount of water.
Eat healthy food rich in fibers.
Not to be exposed to extreme weather or temperature changes.
Avoid high impact sports & activities as jumping &stair climbing.