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Why Knee is important?
The Knee is the largest human joint in terms of
its volume and surface area of articulating
cartilage.
The Knee joint has the greatest susceptibility to
injury, age-related wear and tear, inflammatory
arthritis, and septic arthritis
Knee pain accounts for approximately one third
of musculoskeletal problems seen in primary
care settings.
54 percent of athletes have some degree of
Knee pain each year.
History
Characteristics of the patient's pain
Mechanical symptoms
Locking- Meniscal injury,
Popping – Ligament injury,
Giving wayJoint effusion Dislocation
Timing:- Rapid – ACL / Bone #/ Gout ,
Slow- Meniscal /RA /OA
Recurrence:- Meniscal injury
Amount:-Mechanism of injury:-
Physical Examination
Inspection & Comparison of the knee
Palpation for point tenderness
Assessment of joint effusion
Range-of-motion testing

Evaluation of ligament and Meniscal
integrity
Investigations
CBC ESR
CRP
RA Factor
Uric Acid
X-Ray - Standing AP view & Lateral
Causes of Knee Pain
• Tendinopathies
• Bursitis
• Chondromalacia
• Meniscal Injuries
• Cruciate Ligament Injuries
• Medial & Lateral Collateral
Ligament Injuries
• Osgood-Schlatter Disease
• Iliotibial Band Syndrome
• Osteochondritis Dissecans
• Arthritis OA / RA
Tendinopathies
Palpate these points!
Palpate these points!
Palpate these points!
Tendinopathies
• Painful conditions in and around tendons in
response to overuse
• Histo-pathology – Degeneration &
disorganization of collagen fibres with no
inflammation
• Matrix Metalloproteinases, tendon cell
apoptosis, IGF 1, NOS
• Not much benefitted from NSAIDS
OA KNEES-Grading -0
OA grade I
Grade II
Grade- III
Grade IV
Physiatric Management of Knee Pain
•
•
•
•
•
•
•
•

Physical Modalities
Orthotic
Viscous supplementation
Effusion – Ozone therapy
Proliferative injection therapy - Prolotherapy
Intra-Articular steroids
Pharmacotherapy
Weight reduction & Exercises
Physical Modalities
•
•
•
•

TENS
IFT
US
SWD
Advanced Electrotherapy
Advantages
Different modes in one
program
Long lasting
Sympathetic block
Dental to Cancer pains
Modality-Pulsed Magnetic Field
• High Energy Pulsed Magnetic Field- 400 to
700Gauss
• 20 to 30 mts.
• Chen CY, Chen CL, Hsu SC, et al. Effect of magnetic knee wrap on
quadriceps strength in patients with symptomatic knee
osteoarthritis. Arch Phys Med Rehabil. 2008;89:2258-2264
• Harlow T, Greaves C, White A, et al. Randomised controlled trial of
magnetic bracelets for relieving pain in osteoarthritis of the hip
and knee. BMJ. 2004;329:1450-1454.
• Nicolakis P, Kollmitzer J, Crevenna R, et al. Pulsed magnetic field
therapy for osteoarthritis of the knee—a double-blind shamcontrolled trial. Wien Klin Wochenschr. 2002;114:678-684.
• Segal NA, Toda Y, Huston J, et al. Two configurations of static
magnetic fields for treating rheumatoid arthritis of the knee:
double-blind clinical trial. Arch Phys Med Rehabil. 2001;82:14531460.
• Trock DH, Bollet AJ, Markoll R. The effect of pulsed
electromagnetic fields in the treatment of osteoarthritis of the
knee and cervical spine. Report of randomized, double blind,
placebo controlled trials. J Rheumatol. 1994;21:1903-1911.
• Trock DH, Bollet AJ, Dyer RH Jr, et al. A double-blind trial of the
clinical effects of pulsed electromagnetic fields in osteoarthritis. J
Rheumatol. 1993;20:456-460.
Modality – LASER Therapy
• Mechanisms of action
•
•
•
•
•
•

Photons – Energy –Repair
Fibroblast proliferation
Vasodilatation- Lymphatic drain
Blocking neuronal transmission
Endorphin secretion
Angiogenesis
PHOTOMECHANICAL EFFECT

Pressure waves stimulate the lymph
draining system leading to dissolution
of inflammatory mediators
PHOTOCHEMICAL EFFECT

Chemical homeostasis is restored.
Leaking of inflammatory mediators
is prevented leading to analgesia
and repair of damaged tissues
PHOTOTHERMAL EFFECT

Laser delivers photons
providing energy for repair
and promotes angiogenesis
Combination of different wavelengths
Laser Apparatus
LASER Application
Efficacy of LASER Therapy
•Efficacy of different therapy regimes of low-power laser in
painful osteoarthritis of the knee: a double-blind and
randomized-controlled trial.[Lasers Surg Med. 2003]
• Laser acupuncture in knee osteoarthritis: a doubleblind, randomized controlled study.[Photomed Laser Surg. 2007]
•Low power laser treatment in patients with knee
osteoarthritis.[Swiss Med Wkly. 2004]
•Influence of various laser therapy methods on knee joint pain
and function in patients with knee osteoarthritis.[Orthopedic &
Traumatol Rehabil. 2012]
•Efficacy of low-level laser therapy in the management of neck
pain: a systematic review and meta-analysis of randomised
placebo or active-treatment controlled trials.[Lancet. 2009metaanalysis of randomised placebo or active-treatment controlled
trials.
Thermogram before and after 8 sessions of LASER Therapy
Acupuncture
Orthotic management –Knee Pain
KNEE TRCTION
Knee Supports-Patella Stabilizing
Knee supports-Varus- valgus Preventing
Knee Supports Varus-Valgus correcting
Valgus deformity -Left
Foot-wear ModificationsLateral or Medial wedges
Viscous supplementation
Hyaluronate sodium
Management of Effusion
OZONE THERAPY
OZONE THERAPY
Ozone- Anti-Bacterial, Anti-Fungal & Virucidal

Proteins in the effusion breaks down – Dehydration
Intra Articular Knee injections
30 micr/ml 4cc + 2ml 2%
Blocks Phosphodiasterase –A2 Xylocaine
Resistant Effusion, Repeated aspirations
– Analgesic & Anti- Inflammatory
Mono-articularto 4 weeks X 5
Repeated 3
Rheumatoid Arthritis & OA with effusion
Baker’s cyst
Kumar Centres

40
Ozone Generator

Kumar Centres

41
Collecting Ozone directly into the
syringe
Mixing Ozone with 2% Xylocaine

Kumar Centres

43
Injecting Ozone

Kumar Centres

44
Proliferative Inj. Therapy
PROLOTHERAPY
• 25% Dextrose
• Fibroblast proliferation – Strengthening of
ligaments – increases stability of Knee joint in
OA.
• Regenerate damaged meniscii.
• Repair ligament injuries
Prolotherapy-Knee
•
•
•
•
•
•
•
•

Medial & Lateral Collateral Ligament Injuries.
Meniscal tears
ACL-Partial tear
Osteo-Arthritis
Bursitis
Tendonitis
Jumper’s Knee
Osgood Sh. Disease
Kumar Centres

46
Hyper mobility & OA Knees

Kumar Centres

47
Prolotherapy sites Knee
Prolotherapy sites Knee
Prolotherapy sites Knee
Knee prolo video
• http://youtu.be/nYeMAIv8bbY
Steroids VS Prolotherapy
•
•
•
•
•
•
•

STEROIDS
Anti-Inflammatory
Suppresses natural repair
Expensive & Painful inj.
Only small areas can be
treated
Can change Diabetic status
Degenerate tendon –
Rupture
Cartilage destructionWorsening of OA

•
•
•
•
•
•

Kumar Centres

PROLOTHERAPY
Controlled Inflammation
Enhances natural repair
Cheap, acceptable &
unique
Large areas and more
volume
No change in Glycaemic
status
Safe to give in tendon
insertions and joints
52
Intra-Articular Steroids
• Depo-Medrol / Triamcinolone
• Indications- RA & Waiting for TKR
• Side effects – Cartilage damage

• Stigmatized
Chondroprotective agents
•
•
•
•
•
•

Glucosamine
Chondroitin
Diacerine
S-Adenosyl Methionine
• NSAIDS, Tramadol & Paracetamol
Type II Collagen Peptide
Vit. D
Management of Obesity
• Most useful single intervention
• Diet

• Sleeve Gastrectomy
Exercises
Non-weight bearing exercises
Cycling

Height Adjustment
Seat width
When to refer for Surgery!
• Major Meniscal Injury
• Complete ACL tear
• Stage III and IV OA knees

• Recurrent Patellar Dislocation
Kumar Centres

60

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