You wake up one morning saying to yourself: “In any case, I'm not twenty anymore & it shows! ".
Through the work routine & weekly obligations, you try to keep in shape with a few sessions at the gym per week.
Squats, it must be good you tell yourself…
The first few days are fine, but knee discomfort gradually begins to set in.
You change exercises & try different machines. "If people use it, it must be good!" »
Flexion, extension…flexion, extension…Flexion, extension…Over and over again, but this annoying pain persists.
You start to feel it when going up & down the stairs…even when walking.
It gets worrying.
"Monique" the neighbor opposite tells you that it's probably osteoarthritis. She's been there, she says, friendly reminding you that… “It's normal! You are no longer twenty as you say.
But is knee pain really attributable to osteoarthritis QUESTION MARK?...
Maybe not!
Indeed, osteoarthritis can often have a wide back 😉
What is gonarthrosis?
First, osteoarthritis is joint damage involving the progressive breakdown of cartilage and eventually causing a decrease in the space between the bony surfaces in the joint. This is a normal condition, to varying degrees, occurring with advancing age.
Osteoarthritis specific to the knee joint is called gonarthrosis .
In cases of advanced & symptomatic knee osteoarthritis, we can normally find swelling, pain and crackles, but above all stiffness. In this regard, significant morning stiffness that gradually decreases over the following hours is one of the significant signs most often found in cases of knee osteoarthritis.
Regarding pain, it is usually associated with stiffness & felt within the first few minutes of physical activity. However, it should normally decrease significantly as one progresses in the activity and should not necessarily be felt in the hours following the latter.
Be aware that the only way to make a definite diagnosis of knee osteoarthritis is via X-ray imaging.
If it's not osteoarthritis, what's the problem then?
Unfortunately, the answer to this question is not simple...
Indeed, a physiotherapy consultation is recommended in order to analyze the mechanism of injury & assess knee function before arriving at an accurate diagnosis.
However, in a majority of cases in training, knee pain often appears insidiously & spontaneously, without really being associated with a specific or traumatic mechanism of injury.
… Which excludes a lot of possibility of pathological condition.
On these words, the problem can often involve an overload of the extensor apparatus of the knee (tendon of the quadriceps muscle) or a muscle imbalance causing dysfunction in the patella.
Patellar tendinopathy
The term “ tendinopathy ”, also called tendinitis , refers to damage to the tendon of a muscle & is used when there is irritation and/or inflammation of it.
In the case of patellar tendinopathy, the pain is located just below the patella & is especially aggravated by activities that increase the muscle demand of the knee extensor muscles:
- Power sports (basketball, volleyball, football)
- deep squat
- Go down the stairs
- Jumps or other repeated impact activities.
Interesting fact about tendinopathies is that they are “dose-dependent”!
The study by Maciel & al (2019) demonstrated that the greater the load applied to the tendon, the greater the intensity of the pain felt in the knee.
Being male or overweight can put the individual at risk for developing patellar tendinopathy, but the most significant risk factor to date is poor training load management (Maciel & al., 2019) .
In short, too much training volume and/or inadequate recovery.
Treatment
Different steps are necessary for the proper healing of this overuse injury.
At first :
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Some “selective” rest must be undertaken to allow the tendon to begin its healing process appropriately following the acute period of the injury. Relevant fact, isometric exercises at the knee would be interesting to integrate at this stage in order to calm the pain. Indeed, a systematic review with meta-analysis (Nauge & al., 2012) has highlighted the superior & beneficial effect of isometric exercises compared to exercises against conventional resistance or even of an aerobic nature. |
In a second time :
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An exercise-oriented approach that is specific, tolerable & adapted to the individual of " eccentric " nature should be used to ensure successful rehabilitation of the condition. That is to say, in the case of the knee for example, to exercise only the “ downward ” part of a squat, a lunge, a leg press or a leg extension. In this part of the movement, the quadriceps muscle is allowed to stretch & is subjected to strong tension. The evidence supporting the effectiveness of eccentric exercises in the context of tendinopathy is strong. These allow for better tendon adaptations & better pain control than conventional “concentric – eccentric” type exercises. This type of exercise would rather be reserved for progressing in rehabilitation once the pain felt during the activity has greatly diminished (Malliaras, Barton, Reeves & Landberg, 2013). |
Anti-inflammatory yes or no?
For the treatment of tendinopathies, this is a controversial subject.
One thing is certain, the pain is likely to be greatly improved with the taking of this drug. However, taking an anti-inflammatory could have a negative effect on the “repair” of the tendon & impair the healing process (Ferry & al., 2007).
Indeed, inflammation is not always to be avoided.
On the contrary !
An inflammatory process involves the transport of essential nutrients & cells to the site of healing and necessary for the repair of damaged tissues. It is the chronic inflammation that can become more problematic…
Patellofemoral syndrome
Patellofemoral syndrome (PFS), also called patellofemoral syndrome, refers to pain located in the patella during flexion/extension movements of the knee. In the majority of cases, the pain is the consequence of certain muscular imbalances present in the lower limb, then causing a dysfunction in the normal movement of the patella.
Does a ball joint MOVE??
Surprisingly, yes! And it moves according to a precise movement in addition.
Indeed, when one flexes then extends the knee, the patella makes a movement from bottom to top & from medial to lateral. A muscle imbalance can "misalign" the normal position of the kneecap and increase the compressive forces exerted on it during movement.
Muscle imbalances
First, numerous evidence suggests that a lack of strength in the proximal muscles located at the hip is a contributing factor to patellofemoral syndrome (Meira & Brumitt, 2011). We speak, among other things, of the gluteus medius and medius muscles located laterally of the hip & having an important role in the balance and stability of the lower limb.
However, since these are muscle groups that are rarely worked in "strength" and in a specific way, they can generally be rather weak.
…Even for those who squat 250 lbs & more 😉!
Weakness at this level can lead to “compensation” of other muscle groups & thus alter the normal biomechanics of the knee.
Then, other evidence raised the presence of imbalance between the vastus lateralis & the vastus medialis oblique (VMO) which constitute the quadriceps muscle. Indeed, in many people, the activation of the VMO is much lower than that of the vastus lateralis, thus pulling the patella more externally during movements at the knee & which can contribute to irritating the subpatellar structures (Na & al., 2021 ).
Treatment
To date, the best option for treating patellofemoral syndrome would be through a specific hip muscle & knee muscle strengthening program.
In this regard, a systematic review by Nascimento & al. (2018) demonstrated clinically significant improvements in pain reduction & improved function by opting for a “combined” reinforcement approach rather than isolation.
In addition, it is recommended to investigate flexibility deficits that can maintain muscle imbalance despite strengthening efforts & have the potential to impair good motor control of the knee. For example :
- Increase quadriceps flexibility through stretching and/or self-massage with a roller
- Increase the flexibility of the ilio-tibial band via self-massage
- Increase flexibility of adductors and/or hamstrings (if needed)
Corrective knee taping is also a proven effective strategy to realign the patella & reduce pain related to patellofemoral syndrome (Chang & al., 2015).
A consultation with a physiotherapist or our kinesiologists is the best thing to do in order to ensure that you have specific care adapted to your specific condition.
Other pathologies
The pain present in the lower limb can be complex to understand considering the close links found between each of its joints. What happens at the hip can dramatically influence the dynamic & postural mechanics of the knee and ankle.
And vice versa !
In this sense, a much wider range of problems can then be at the origin of the symptoms felt in the knee region:
Iliotibial band syndrome…
Crow's feet tendinopathy...
Stretched adductors…
There are several of them !
An exhaustive evaluation of the lower quadrant (lumbar region, hip, pelvis, knee & ankle) is required to arrive at an accurate diagnosis.
Conclusion
Osteoarthritis is a phenomenon that develops naturally & gradually with age. Early osteoarthritis is of course a " real thing ", especially for those who have experienced traumatic knee injuries in the past (e.g. torn ligament, meniscal injury, etc.) or who have practiced high volume endurance sports for several years (e.g. marathon, cycling, etc.).
However, there is not necessarily a correlation between the level of osteoarthritis and the severity of symptoms. A high prevalence of individuals with moderate to advanced knee osteoarthritis will not experience pain on activity (Arya & Vijay, 2013).
By providing better muscle support & joint lubrication, resistance training or just the act of moving in general on a daily basis is, on the contrary, one of the best ways to prevent & treat this joint condition. (Shlenk, 2019).
The pain felt in the gym presenting a causal potential more attributable to muscle imbalance or poor quantification of mechanical stress… This will be the subject of a blog project 😉.
Maxime Deschênes , kinesiologist & graduate in physiotherapy
References
Arya RK, Vijay Jain, Osteoarthritis of the knee joint: An overview, Journal Indian Academy of Clinical Medicine, 2013, 14(2): 154-62
Chang WD, Chen FC, Lee CL, Lin HY, Lai PT. Effects of Kinesio taping versus McConnell taping for patellofemoral pain syndrome: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2015 Jun 21;2015.
Ferry ST, Dahners LE, Afshari HM, Weinhold PS. The effects of common anti-inflammatory drugs on the healing rat patellar tendon. The American Journal of Sports Medicine. 2007 Aug 1;35(8):1326-33.
Nascimento LR, Teixeira-Salmela LF, Souza RB, Resende RA. Hip and knee strengthening is more effective than knee strengthening alone for reducing pain and improving activity in individuals with patellofemoral pain: a systematic review with meta-analysis. journal of orthopedic & sports physical therapy. 2018 Jan;48(1):19-31. Available: https://www.jospt.org/doi/10.2519/jospt.2018.7365
Naugle KM, Fillingim RB, Riley JL 3rd. A meta-analytic review of the hypoalgesic effects of exercise. J Bread. 2012 Dec;13(12):1139-50. doi: 10.1016/j.jpain.2012.09.006. Epub 2012 Nov 8. PMID: 23141188; PMCID: PMC3578581.
Na Y, Han C, Shi Y, Zhu Y, Ren Y, Liu W. Is Isolated Hip Strengthening or Traditional Knee-Based Strengthening More Effective in Patients With Patellofemoral Pain Syndrome? A Systematic Review With Meta-analysis. Orthopedic Journal of Sports Medicine. 2021 Jul 28;9(7):23259671211017503.Available:https://journals.sagepub.com/doi/full/10.1177/23259671211017503 (accessed 2.12.2021)
Maciel Rabello L, Zwerver J, Stewart RE, van den Akker-Scheek I, Brink MS. Patellar tendon structure responds to load over a 7-week preseason in elite male volleyball players. Scand J Med Sci Sports. 2019;29(7):992-9.
Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programs. Sports medicine. 2013 Apr;43(4):267-86.
Meira EP, Brumitt J. Influence of the hip on patients with patellofemoral pain syndrome: a systematic review. Sports health. 2011 Sep;3(5):455-65.Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445210/(accessed 2.12.2021)
Schlenk EA, Xiaojun Shi BS. Evidence based practices for osteoarthritis management. American Nurse Today 2019;14.