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Physiotherapy for knee osteoarthritis

Symptomatic knee osteoarthritis occurs in 10% of men and 13% of women aged 60 years or older as reported in epidemiological studies.¹  Degenerative joint changes come with living life. Sports injuries, years of hobbies or job stresses, hereditary factors, or just “wear and tear” over the course of your life leads to the degeneration of cartilage in your knees. Degenerative changes may also be exacerbated by nonmechanical factors such as smoking, type 2 diabetes, hereditary factors, etc. 

Joint changes that occur with osteoarthritis are as follows:

1. Synovial fluid within the knee becomes less viscous with more severe grades of arthritis causing increased friction between the bones.
2. Inflammation occurs due to excessive impact and shear forces resulting in fluid build up in the joint, scarring and joint stiffness
3. Osteophytes form on areas of bone on bone contact where there is excessive forces causing the bone to react and grow to form spurs.
4. One or both meniscus may tear and adopt a more flattened, spread out, shape resulting in a loss of congruity (that nice concave/convex shape)
5. Surrounding muscles become weakened and atrophy due to inhibitory influences from the inflamed joint that results in joint instability and can lead to increased shearing forces across the joint.

This, of course, is a gradual process that is classified by your medical staff into different stages. In later stages of advanced knee osteoarthritis (ie grade 4) there is little space between the bones seen on xray reflecting the lack of cartilage to provide cushioning and joint congruity. This is commonly diagnosed with xray or MRI. An MRI can help us determine if meniscal tearing is traumatic (sports or trauma related) or degenerative (wear and tear).

How is Knee Osteoarthritis Diagnosed?

Your physiotherapist or family physician may suspect osteoarthritis based on how you describe your symptoms. Examination often reveals loss of range of motion, there may be fluid built up within the joint, tenderness at the joint line. Questions related to morning stiffness, and the pains relationship to activity can help determine the source of the pain. They can conduct a series of tests that can help them identify signs of arthritis, and an xray may confirm their diagnosis although some people may be symptomatic before signs are obvious on an xray.

Are X-rays Important?

Characteristics of joint pain are widely variable in patients even though their xrays may look similar. ² Some people will experience severe pain with a stage 1 osteoarthritis, and some with stage 3 may have minimal pain. We now know that X-ray findings correlate poorly with a patient’s symptoms.³  Studies show that 85% of adults with no knee pain have x-rays that show osteoarthritis.⁴  

So where does the pain come from?

A lot of this damage that occurs gradually over the years, you may not even notice until there are stresses on pain sensitive structures. These structures are as follows:

Synovial Tissues and the Joint Capsule – The synovial tissues line the inside of the joint capsule which is the sac that contains fluid that lubricates and provides nutrients to the joint. These tissues are highly innervated and therefore can be a generator of pain when they become inflamed, pinched, or stretched.⁵  

Over time, scarring occurs as part of the inflammatory process, and this can start to limit mobility and cause joint stiffness. You will notice a reduced ability to bend your knee fully, and may not be able to straighten your knee fully.

Subchondral Bone and Periosteum– The bone just underneath the articular cartilage in one’s knees may become irritated resulting in a fluid build up (edema) in the marrow. ⁶ This bone marrow swelling results in an increased pressure within the bone that can be painful.

How can Physiotherapy Help?

Your physiotherapist will address problems of pain, loss of joint range of motion, weakness, gait, and exercise tolerance. We can’t reverse the damage done to the cartilage, but we can reduce pain, improve your mobility and function and slow down joint deterioration. If you’re not a candidate for a knee replacement, then we can do plenty to help you get back to your life and control the symptoms of knee arthritis.

Surgery has become less of an option recently as the evidence shows that physiotherapy alone is just as effective in relieving pain and improving function as surgery combined with physiotherapy in knee arthritis less than a grade 4.

We use 

• electrotherapeutic modalities such as ultrasound and IFC and ice to assist with reduction of pain and inflammation. Electrotherapeutic modalities aid in reducing pain and inflammation.^{7 ,8}
• manual therapy to restore normal joint mechanics and range of motion and to modulate pain. Joint mobilization has shown to reduce pain and improve joint range of motion⁹
• stretching and range of motion exercises to restore mobility
• education, because we believe the more you understand, the more you can take control of your condition, learn how to exercise with your condition, get back to normal activities, and be less reliant on health care professionals.
• functional retraining and gait training with any aids that may be required
• strengthening and stabilization exercises to improve joint stability and reduce abnormal joint forces. Exercise has been proven effective for pain management and to improve function.¹⁰
• Taping to alter mechanical forces on the patellofemoral joint if it is involved so that strengthening may be undertaken. ¹¹

We use treatments that are based on higher levels of evidence to address pain, inflammation, stiffness, and weakness, and take into account what is important to the patient. We also use manual therapy techniques and strengthening to address issues that may be at the knee, ankle, or hip that could be contributing to the degenerative changes occurring at the knee..

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References

1. Massicotte, F. (2011). Epidemiology of osteoarthritis. Underst. Osteoarthr. from Bench to Bedside, 1-26.
2. Ikeuchi, M., Izumi, M., Aso, K., Sugimura, N., & Tani, T. (2013). Clinical characteristics of pain originating from intra-articular structures of the knee joint in patients with medial knee osteoarthritis. Springerplus, 2(1), 628.
3. Bruyere, O., Honore, A., Rovati, L. C., Giacovelli, G., Henrotin, Y. E., Seidel, L., & Reginster, J. Y. L. (2002). Radiologic features poorly predict clinical outcomes in knee osteoarthritis. Scandinavian journal of rheumatology, 31(1), 13-16.
4. Bedson, J., & Croft, P. R. (2008). The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC musculoskeletal disorders, 9(1), 116.
5. Hill, C. L., Hunter, D. J., Niu, J., Clancy, M., Guermazi, A., Genant, H., … & Felson, D. T. (2007). Synovitis detected on magnetic resonance imaging and its relation to pain and cartilage loss in knee osteoarthritis. Annals of the rheumatic diseases, 66(12), 1599-1603.
6. Starr, A. M., Wessely, M. A., Albastaki, U., Pierre-Jerome, C., & Kettner, N. W. (2008). Bone marrow edema: pathophysiology, differential diagnosis, and imaging. Acta radiologica, 49(7), 771-786.
7. N.C. Mascarin et al., Effects of kinesiotherapy, ultrasound and electrotherapy in management of bilateral knee osteoarthritis: prospective clinical trial, BMC Musculoskeletal Disorders, 2012, 13: 182-191.
8. A. Loyola-Sánchez et al., Efficacy of ultrasound therapy for the management of knee osteoarthritis: a systematic review with meta-analysis, Osteoarthritis Research Society International Journal, 2010, 18: 1117-1126]
9. G.D. Deyle et al., Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a Home Exercise Program, Physical Therapy Journal, 2005, 85(12): 1301-1317
10. Supplementing a home exercise program with a class-based exercise program is more effective than home exercise alone in the treatment of knee osteoarthritis ,C. J. McCarthy, P. M. Mills1, R. Pullen, C. Roberts, A. Silman and,J. A. Oldham, Rheumatology 2004;43:880–886.
11. Kakar, R. S., Greenberger, H. B., & McKeon, P. O. (2020). Efficacy of Kinesio Taping and McConnell Taping Techniques in the Management of Anterior Knee Pain. Journal of sport rehabilitation, 29(1), 79-86.

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