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Knee Pain Occurrence and Prevention
Part 2: Chronic Knee Pain
By Anne C. Terry, RN, MSN, ARNP
This is the second in a three-part series on knees. Knee injuries can happen to any active outdoor enthusiasts, particularly those who participate in high force activities such as skiing, snowboarding and jumping sports, climbing, and sports involving lateral or sprinting movements such as soccer, rugby, football, basketball and lacrosse. In December, Annie Terry, RN, MSN, ARNP discussed acute (sudden onset) knee pain including ligament strains, meniscal tears and patellar dislocations (see Part 1 www.bodyresults.com/e2kneepain1.asp). This month she takes a closer look at chronic knee pain associated with overuse. February we will feature a series of sport-specific free weights leg exercises and stretches that will help you recover from and prevent future recurrence of knee pain.
Chronic Knee Pain
- Illiotibial Band Syndrome (ITBS)
- Patellar malalignment
- Patellar Tendonitis
- Patellofemoral Syndrome
- Popliteal Cysts
- Prepatellar bursitis
Iliotibial Band Syndrome
Patients (particularly runners) that experience chronic pain on the outside of the knee may encounter a condition known as illiotibial band syndrome (ITBS). In this condition, patients feel a burning and/or aching pain over the exterior surface of the knee. This pain often radiates up towards the outside of the thigh. Management is conservative, involving rest, stretching, and as needed, use of NSAIDs for pain. Additional treatment strategies include replacing worn shoes, using orthotics, and avoiding exercise on uneven terrain. (3,4)
This common form of arthritis is the result of overuse, obesity and/or family history, and age, and occurs more often in people over 55. Degeneration and calcification of the articular (joint) cartilage results in pain, swelling, and/or joint stiffness. Patients often feel that their knees are buckling, locking or catching. They typically have early morning stiffness and have difficulty climbing and descending stairs. Deposits of minerals are likely to form in the joint space causing a restriction in joint movement and/or a clicking or popping sensation. Treatment involves use of NSAIDs, glucosamine and/or chondroitin supplementation, and/or injection of steroids into the joint space. Severe arthritis may require a joint replacement. Strengthening exercises for the lower leg with improvement in coordination, balance and timing can help protect against future injuries. (1,5)
Recurrent patellar dislocation may lead to chronic instability of the patella. After recurrent injury, the muscles and ligaments of the knee may not be able to keep the patella in its place across the front of the knee surface. This generally causes pain behind the kneecap, or retropatellar pain. Pain may be exacerbated with flexion movements, such as climbing stairs, sitting or squatting. Treatment involves limiting activities which provoke repetitive pain or reducing range of motion to what is pain-free for the patient.
The patellar tendon links the femur to the tibia. It becomes inflamed with overuse and causes knee swelling and pain over the front surface. Patients may feel a crackling sensation (known as crepitus) in this large anterior ligament. Treatment involves reducing inflammation in the tendon through ice application, limited activity and possible use of NSAIDs. Rehabilitation generally involves increasing strength and flexibility of the hamstrings, as well as in the rectus femoris (one of the quadriceps muscles). (1,2)
Also known as chondromalacia, patellofemoral pain is described as chronic, diffuse anterior knee pain. This pain seems to be aggravated with high-impact activities such as running, climbing up and down stairs, and even knee flexion exercises such as squatting. Prolonged flexion, such as sitting, may also elicit pain. This type of pain may result from chronic overuse and/or a history of knee trauma to the patellar surface. Treatment is most effective in a rehabilitation program including quadriceps strengthening and limiting painful activities. Patients may also benefit from improving quadriceps and hamstring flexibility, weight loss (if overweight) and NSAIDs. Severe chondromalacia may require surgery. (1,2) For more on this condition, see our previous article at http://www.bodyresults.com/E2patellofemoral.asp.
Popliteal cysts, or Bakerís cysts, are recurrent, often progressive synovial cysts that form in the back of the knee. They are often asymptomatic. However, patients may note pain and restricted motion with an increase in size. These often occur as a result of a previous meniscal tear or bony abnormality in the knee. Treatment strategies involve immobilization, reduction of swelling, and pain management. Aspiration is controversial, since the cyst wall often remains intact and can reform. Acute rupture of a large cyst presents with acute swelling and pain in the superior aspect of the calf which may mimic a blood clot in the leg. Ultrasound is thus necessary for accurate diagnosis. (2,3)
Prevention of injuries to the knee is vital for participation in any strenuous activity such as mountaineering. Simple prevention strategies include performing regular athletic exercise, avoiding prolonged kneeling and knee flexion, wearing comfortable, supportive shoes and evaluating potential foot injuries. In addition, athletes should maintain strength and flexibility in the quadriceps, hamstrings and calf muscles. Participation in activities which prepare you for climbing, such as hiking with appropriate weight over rocky terrain, rock climbing in the gym and performance of athletic feats within your abilities are also important.
See Part 3 for specific training www.bodyresults.com/e2kneepain3rehab.asp.
Anne Terry is a nurse practitioner in Seattle with interests in orthopedics, wilderness medicine and womenís health. She is a mountain climber, a triathlete and a cyclist. She has been a Seattle Mountaineers member since 1994.
- Knee Pain. IN: Essentials of Musculoskeletal Pain, pp. 164-197.
- Masear, V. Primary Care Orthopedics. p. 242.
- Messier SP, Edwards DG, Martin DF, et al. Etiology of Iliotibial band friction syndrome in distance runners. Med Sci Sports Exert 1995: 27: p. 951.
- Spence, A. Basic Human Anatomy. pp. 160-170.
- Vad V, Hong HM, Zazzalit M, Agi N, Barai D. Exercise recommendations in athletes with early osteoarthritis of the knee. Sports Med 2002; 32 (11): pp. 729-39.