Last week's post discussed our approach to examining the knee pain. As a reminder, we have two parts to our examination: the joint-specific exam, and the functional exam.

We then make a two-part diagnosis: #1) Pain generator; and #2) Relevant functional impairments. This tells us what's hurting and why.

From there, we develop a treatment plan. While this is always individualized, we typically guide our patients with knee injuries through three broad phases of recovery.

Phase 1: Pain control, restoration of normal knee mechanics, and fundamental muscle activation

Goal #1: Pain reduction. Exactly how we do this depends on the pain generator. However, manual therapy is often effective in decreasing pain and promoting a healing response. Generally, if the joint is involved, knee joint traction or rotary mobilizations are immediately helpful. If tendons or superficial ligaments are involved cross friction massage is almost always effective. Soft tissue mobilization of the muscles can be useful in treating sensitive muscles or painful muscular trigger points. These are all factors to consider.

Goal #2: Restore normal knee range of motion (if limited). This depends on the cause of the motion limitation. Most often, limited range of motion is due to joint effusion, and/or irritation of an intracapsular structure such as the meniscus. Stretching is rarely indicated to improve range of motion. Rather, joint-specific mobilizations based on the joint arthrokinematrics can help to painlessly improve range of motion

Goal #3: Fundamental muscle activation. Depending on the injury, the quadriceps, hamstrings, and glutes can be inhibited. This means that there is a nervous-system level issue that is preventing proper muscle activation. Pain seems to cause, or at least be associated with, this neurological inhibition. So, as we address pain, we also prescribe specific exercises to provide muscle activation. These are often unloaded, isolation exercises that target the specific muscle that is inhibited. Other practitioners commonly skip this step and jump to more complex movements. We find that certain muscles, such as the gluteus medius, can stay inactive unless targeted specifically.

You can generally think of Phase 1 phase as focused on the outcomes from the joint specific examination. We address the pain generator head-on, get your knee feeling and moving better as soon as possible, and provide essential muscular support to the injured structures.

We can start to progress to phase 2 when your pain is greatly reduced, knee motion is approaching normal, and you can consistently activate the key muscles around your knee and hip. Depending on the injury, this might take one 60-minute session, or several weeks. Everyone and every injury is different, and while the right approach can speed up your healing process, certain aspects of anatomy cannot be rushed.

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Phase 2: Improve motor control, balance, movement mechanics, and force absorption capacity

Just as phase 1 addressed the joint-specific examination, phase 2 addresses elements identified in the functional examination. Goals here begin to have more individualization, because everyone moves and presents different. Some factors to consider include:

Movement mechanics: Is there a specific movement that you routinely do that causes irritation? Often this is knee valgus, or uncontrolled hip adduction/internal rotation. We need to practice moving differently.
Balance: This is associated with injury risk, and is also impaired with injury to the knee joint and knee ligaments, as these tissues serve not just as structural tissues, but as proprioceptors as well.
Motor control, particularly eccentric control: We find clinically that the ability to perform eccentric movements is often impaired in individuals with knee pain. Eccentric movements include hiking or running downhill, depending stairs, squatting, lunging. Concentric movements can also be painful, but are often not the primary issue as they have less muscle and motor control demands.
Force absorption: How well do your muscles act as shock absorbers? Can you absorb force using all that we’ve practiced above (good movement mechanics, balance, and control)? Or does everything fall apart when we add speed and load? The knee and its surrounding musculature is one of the primary lower extremity joints that dissipates load while walking, running, jumping, hiking, etc.

When you begin to move with more control, then it's time to progress to phase 3.

Phase 3: Long-term program knee-specific strength and movement program that builds on phases 1 and 2

We find that most traditional rehabilitation programs fail at several points along this process. Often, pain generators are not adequately addressed, which can lead to altered muscle activation and altered movement biomechanics. So, addressing all elements of Phases 1 and 2 is essential. However, where we see traditional rehab failing most often is by neglecting Phase 3 entirely. Phase 3 is about building bulletproof knees, for life.

This phase builds on the foundation of the prior phases. Consistency in muscle activation, balance, motor control, and force absorption is ensured through strategically programmed warm ups. The elements of Phases 1 and 2 are consistently monitored over time. We do this because we've found clinically that without consistent training, the factors addressed in Phases 1 and 2 can return. (You won't feel like you have to "go do your physical therapy exercises" forever. We build in key drills into the DNA of Phase 3 to make it easy to stay consistent.)

Phase 3 then adds strength training to improve tendon, bone, and muscle durability, and overall lower extremity work capacity. We believe that appropriately dosed heavy loading of muscles, tendons, bones, and joints is essential to the later stages of rehabilitation. If you only complete Phases 1 and 2, you'll likely be feel better, but be at a high risk of recurrence. Heavy loading is a stimulus that forces additional adaptation, such as collagen reorganization or increases in muscle cross-sectional area. With proper loading, we can improve the resiliency of your musculoskeletal system. However, this adaptation takes time. It cannot be completed within the confines of a traditional 4-6 week course of physical therapy. This strength training is always tailored to individual goals, skill-level, and sport.

For athletes desiring to return to play, Phase 3 also adds high-speed and sport-specific plyometric and movement training. You should challenge your knee in real-life scenarios, and practice moving and reacting to unpredictable circumstances in a safe environment, prior to returning to higher-risk activities.

Finally, Phase 3 builds in evidence-based testing to ensure that injury risk factors are being managed. Examples of this are the tuck jump assessment, star or Y-balance tests, and single leg hop tests. These tests should be monitored over time and addressed as needed.

We've found that many patients with knee injuries do not go through this 3-phase process. Most often, Phase 3 is incomplete or skipped altogether. For this reason, we’re launching a long-term knee injury strength and movement program, starting January 2018. This program will incorporate the principles outlined above, with the goal of helping individuals who have suffered knee injuries to fully recover and regain confidence in their knees. Stay tuned for more information, or enter your information be the first to official hear about the program's details.

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