Knee braces are supports to be worn when you have pain in your knee. Some people use them to prevent knee injuries during sports. Braces are made from combinations of metal, foam, plastic, or elastic material and straps.
Scientific research hasn’t given a clear answer but there are different reasons for their use.ellness
– Functional braces
These give support to knees that have been injured in the past. Clients often wear them after a major injury has healed. They stabilize the knee and control motion to prevent another injury.
– Rehabilitative braces
These are usually used for a period of weeks right after an injury or surgery. They keep the knee stable but still allow limited movement while it is healing. Some specialists haven’t seen a benefit from these braces and no longer recommend them.
– Unloader braces
These are designed to relieve pain in people who have arthritis in their knees. They shift the weight (“unload” it) from the damaged area of the knee to a stronger area.
– Prophylactic braces
These are designed to protect knees from injuries during contact sports such as football. They have become popular among athletes. Research has not proven that they work, but studies are ongoing.
– Knee sleeves
These are not technically braces, but they are the most common type of knee support. They are designed to provide compression around the knee joint. This helps support the knee, and can control pain and swelling.
Things to consider
– Companies that make knee braces claim that their products work well. Scientific studies have not completely agreed. Some physios are afraid that knee braces may actually increase the number of knee injuries in athletes. But many people who wear knee braces feel that they help.
– Knee braces are the least important part of preventing knee injuries or healing after an injury. Good strength and flexibility are much more important. You should focus on stretching the muscles around your knee, strengthening your leg, and improving your techniques.
– Make changes in activity intensity or training schedules little by little, to limit knee stress.
– Researchers are trying to learn more about how well knee braces really work and when it’s best to use them.
What indicates conservative or surgical management pathways?
The main clinical issue currently is the lack of research regarding the efficacy of arthroscopic meniscal repairs compared to a conservative approach (Englund, Roemer, Hayashi, Crema, & Guermazi, 2012).
There is minimal literature regarding clinical prediction rules or protocols which indicate surgery rather than conservative management. There are multiple articles displaying the benefits of physiotherapy following meniscectomy, however only two articles exist (that I’m aware of) comparing surgical and conservative management following meniscal tears.
Herrlin and associates (2007) analysed a group of 90 individuals with degenerative medial meniscus tears, half receiving arthroscopy and supervised exercise program while the remaining individuals received only the exercise program. The exercise program consisted of twice-weekly sessions for eight weeks, consisting of stationary bicycle, calf and quadriceps strengthening, lunges, stairs, leg press, balance training and knee stretching, enhanced by a similar home exercise program. At eight weeks and six months follow-up both groups improved in VAS scores, knee function measures and satisfaction measures, with no significant difference between groups. This article is a landmark paper as it justifies an eight week targeted exercise program, compiled and delivered by a physiotherapist, is as effective as a surgical procedure (Herrlin et al., 2007). Using literature, we can validate our treatment is more cost-effective, time-effective and provides less risk for the patient.
A more recent study by Katz and colleagues (2013) randomly assigned 351 individuals, aged 45 years or older with meniscus tears and mild to moderate osteoarthritis evident on imaging, into a surgical group (who then received physiotherapy) and a physiotherapy group (with individuals able to receive surgery if indicated or chosen by the patient). The physiotherapy group consisted of a standardised program (addressing range of motion, muscle strength, aerobic capacity, proprioception and balance) where exercises were individually progressed as the patient’s objective measures improved. The WOMAC Index was used as the primary outcome measure, assessed at baseline, 3, 6 and 12 months post-intervention. There was no significant difference between groups at 6 months, however 30% of individuals in the physiotherapy group underwent surgery within 6 months (Katz et al, 2013). Although this appears less enchanting than the Herrlin study, 70% of individuals had full return to function without requiring surgery. We are still able to justify the efficacy of physiotherapy as a valid alternative to surgical intervention, with only 30% requesting surgery.
A case report by Stensrud and colleagues (2012) provided a twelve week neuromuscular and strengthening program, progressing to single leg exercises, which also produced these positive results, however the physiotherapy group was compared to control rather than an arthroscopy group.
We must remember that Herrlin’s study looked only at degenerative meniscal tears, with traumatic injuries being excluded. Katz’s study does not dictate whether the tears were traumatic or degenerative, so extrapolation to treating traumatic meniscus tears is difficult. With traumatic tears, the severity ranges from mild pain to severe pain and locking or restricted knee range. Brukner & Khan (2012) state a locked knee requires immediate arthroscopy. However, the majority of patients present with moderate pain and mechanical symptoms, with some catching rather than true locking. The management for these patients must be made considering the patient’s signs and symptoms, work and sporting demands, timeframes, financial status and MRI findings.
Patients who appear to respond best to arthroscopy present with increasing pain, some locking and/or catching and have a displaced meniscus tear on MRI (Suter et al., 2009).
Certain therapists are more conservative in their approach and will try three to six weeks of conservative management, monitoring symptoms. If no improvements occur they will be referred for a surgical consultation. This greatly depends on sporting and work timelines, if a deadline is looming and surgery can return a player to function faster, surgery may be indicated. However, with greater knowledge of bone oedema and osteoarthritis secondary to trauma, therapists are trending towards a more conservative approach.
There is no clear definition of anterior knee pain and patients can present with various symptoms. There may be a functional deficit, crepitus and /or instability.
With activities of daily living pain often occurs or worsens when walking down stairs, squatting, depressing the clutch pedal in a car (in the case of left knee pain), wearing high-heeled shoes or sitting for long periods with the knees in a flexed position (‘‘movie sign’’).
Patients also experience a certain degree of instability ‘‘in a straight line’’ especially going up and down stairs or ramps.
Individuals with overuse injuries may report a feeling of instability or giving way, although this may not a true giving way (usually associated with internal injury to the knee) but a neuromuscular inhibition as a result of the pain, muscle weakness, patellar or joint instability
In order to manage anterior knee pain you knee to KEEP exercising! Patellofemoral pain can be hard and you won’t get better over night. However some people do but in general it should take a minimum of 6 weeks before you will start to see changes.
Here are 5 tips to help with you knee pain that specifically target muscles that need to be worked in order to get better.
1) Fire Up the Gluts
Most patients we see, tend to have weak or inactive glutes. This causes all sorts of problems at the knee.
The primary movers of your legs are the muscles of your hips and thighs. When the muscles of your hips aren’t working properly, that means the muscles of your thighs have to pick up the slack.
1. Glute Bridges
2. Single-Leg Glute Bridges
You may also benefit from performing a hip flexor stretch prior to these warm ups, as it will release some of the tissue on the front of your hip and should allow you to take advantage of improved hip extension.
2. Work Your Glutes
The three best options for specific glute activation that simultaneously reduce stress on the front of the knee are weighted glute bridges, box squats, and dead lifts.
On all of these movements, it is important to focus on proper alignment of the knees. If your knees are constantly caving, even on a bridge, you’re missing out on activating the glute med, which is one of the most important muscles for stabilizing the knee during movement.
3. Learn to Land
Landing mechanics are a problem for a lot of people, particularly in untrained individuals who have recently started an intense exercise program. Learning to land softly and with control while running etc will make life a lot easier on the knees.
4. Turn Your Feet Out
The vastus medialis oblique (VMO) is one of the muscles of your quadriceps that is directly responsible for proper patellar motion. If your VMO is weak, your patella may get stuck or click as you move, which will cause pain.
A simple method of VMO strengthening is to turn your foot out. You can do this on leg raises, leg extensions, squats, or pretty much any movement that involves the quads. This will increase activation of the VMO.
5. Mobilize Your Adductors
Frequently, when you have weak glutes and weak hip abductors, you will also have tight adductors.
Tight adductors can cause all sorts of problems and may also prevent you from being able to perform some of the exercises outlined above. It’s hard to move your knees out when your muscles are constantly pulling them inward.
So, get on those adductors with a foam roller for a few minutes.
Rozelle Physio offers real time ultrasound assessment and rehabilitation.
Real Time ultrasound (RTUS) is a useful tool in assessing the structure and function of important muscles. RTUS allows the physiotherapist to see how the muscles are working in real time. Often when we injure ourselves or are in pain, the normal timing and pattern of muscle control is affected. If untreated, this can lead to long term problems and increase the risk of re-injury.
Physiotherapists commonly use real time ultrasound to assess and rehabilitate the core muscles in relation to lower back pain, the muscles around the shoulder blades for shoulder, upper back and neck pain and the pelvic floor muscles for patients pre and postnatal and for those with continence issues.
In the video below, physiotherapist Stuart Turner demonstrates using real time ultrasound to image the core muscles.
At Rozelle Physio we treat a variety of conditions related to throwing in sport. Below are some of the factors that contribute to throwing injuries and tips on how physio can help rehabilitate a throwing injury.
There are several biomechanical reasons why throwing related shoulder injuries occur some of which include:
- alterations in throwing mechanics,
- muscle fatigue, muscle weakness or imbalance
- and excessive capsular laxity.
The most frequently observed throwing injury is posterior glenoid impingement. Also referred to as internal impingement, excessive anterior instability causes the vulnerable rotator cuff tendons to impinge against the acromion during the follow through phase of throwing. This condition can be resolved by simply stretching and strengthening the rotator cuff muscles.
Rehabilitation following a shoulder injury needs to follow a very structured, multiphase approach of:
- controlling inflammation,
- restoring muscle imbalance,
- improving soft tissue flexibility, and
- enhancing proprioception and neuromuscular control.
During the acute phase of the injury in is important not to aggravate the condition and let the pain settle before commencing any strengthening exercises. In the initial phases of rehabilitation, restoring the range of motion should come before any strengthening can be started. All the athlete’s activities need to be modified to a pain free level. Once pain free range of motion is achieved more aggressive strengthening exercises can be started. It is important to note that in an optimal shoulder the external rotators are approximately 65% in strength when compared to the internal rotators. Therefore exercises that strengthen the external rotators are the main focus for early strengthening exercises. Once significant strength has been achieved the athlete can now begin to slowly introduce a throwing program. Throwing programs are designed to slowly increase the distance the athlete is throwing taking note that the athlete should be able to throw from a distance pain free before progressing to a longer distance. Once an athlete has reached a functional distance they can return to training and athletic completion.
- Posture has much to do with mechanics at the shoulder as well. Rounded shoulder and a forward head posture are said to lead to weakness in the rotator cuff and tightness of the muscles of the anterior chest wall such as pectoralis minor.
- Even if the shoulder is asymptomatic, simply throwing does not essentially keep the muscles strengthened sufficiently. Every thrower should be complementing their training with a stretching and strengthening program for rotator cuff muscles especially.
Wind-up The wind-up may look different in every thrower but the outcome is always the same. The purpose is to set up a rhythm that synchronizes the timing of all body parts. The rhythm is set up so that all parts of the body from the legs to the arms contribute to the balls propulsion.
Early Cocking In this phase the arm is positioned from being in front of the body to behind the head in preparation of the acceleration phase. In early cocking the scapula is retracted and the humerus is abducted, externally rotated and horizontally extended. The body’s centre of gravity is lowered because the support knee and hip are flexing and the hips and pelvis begin to rotate forward.
Late Cocking In this important phase the stresses to the glenohumeral joint are at its greatest. The late cocking phase begins once the stride foot hits the ground. At this point the static stabilizers of the shoulder perform the vital role to limit further motion into external rotation. Muscles active here include the shoulder forward flexors, external rotators, subscapularis, pectoralis major and latissimus dorsi. By the end of this phase the shoulder’s internal rotators are on maximum stretch and the body is optimally “wound” for elastic energy transfer.
Acceleration This phase starts with maximal internal rotation and adduction and ends when the ball leaves the fingers. The serratus anterior and pectoralis major are strongly active as the arm moves forwards and the scapula protracts.
Follow Through Begins when the ball is released and ends when the support foot moves forward and contacts the ground. This is sometimes one of the most overlooked phases and is very important to prevent repetitive strain to the rotator cuff. The rotator cuff muscles work eccentrically to decelerate the arm and work against distraction forces at the glenohumeral joint. It is important to allow the arm to come across the body toward the opposite hip to minimize impinging forces on the rotator cuff muscles from the coracoachromil arch structures.
Houglum, P. (2011). An analysis of the biomechanics of pitching in baseball. Retrieved from http://www.humankinetics.com/excerpts/an-analysis-of-the-biomechanics-of-pitching-in-baseball
Lowe, W. Interval Throwing Program, Throwing off the Mound
Lowe, W. Thowers Ten Exercise Program
Wilk, K., Meister, K., & Andrews, J. (2002). Current concepts in the rehabilitation of the overhead throwing athlete. The American Journal of Sports Medicine, 30(1), 136-151
Wolf, B. & Wolstenholme, K. (2010). Throwing injuries: biomechanics, injury mechanisms and rehabilitation. Current Orthopaedic Practice, 21(5), 467-471
At Rozelle Physio, most of our patients come to see us after they have suffered an injury, and we are happy to help them; but in the world of professional sports, one of Physiotherapists responsibility is to prevent injuries from actually occurring in the first place. This occurs through pre-season screening and injury prevention or “prehab”. So what does the physio assess and measure and can it be used to prevent injuries in the normal population?
Strength: Strength is relatively easy to measure and a lack of strength is a good indicator of future injury. A neat trick for objectively measuring strength is to use a sphygmomanometer to measure the force generated by an isometric muscle contraction. In football we measure commonly injured muscles (hamstrings, groins, hip flexors), but shoulder strength and lower back endurance are easy to measure also. If weakness or imbalance is found exercises are given to strengthen that area.
Normal Range of movement: We measure joint and muscle range of movement using standard orthopaedic tests and a goniometer or tape measure. Where possible we aim to improve range of movement with flexibility programs or manual therapy. While it is not always possible to improve range of movement at a joint, deterioration in range of movement during the season from baseline is a good indicator treatment or rest is needed.
Functional Movement: We assess functional movements such as squats, walking and running to see if there are problems with normal movement patterns. These can be addressed through stability and functional exercises in many cases. The most common problems we see here are usually related to weakness in the core and glute med muscle groups in the lower limb and scapula dyskinesia in the upper limbs.
Age, Hyper/Hypomobility, Foot Posture: These are examples of factors that we measure even though we cannot directly influence them. However it is important to be very aware of them for reasons such as training load, footwear and prehab exercises. For example we can’t change age, but for older athletes we are aware they will have a greater need for recovery whereas a younger athlete may be at risk for certain injuries such as groin injuries in adolescent soccer players. Athletes who are hypermobile need less stretching and more stability and the reverse is true for hypomobile athletes.
These tests are crucial for professional athletes however they can also be very helpful for the average population. In particular for individuals who are about to commence an exercise or weight loss program, or for people who have had a recurrent injury or injuries. The value of screening like this is in providing objective measures of factors that are known to increase the chance of injury so that they can be addressed in a straight forward and systematic injury prevention plan.
A 31 year old male presented to physiotherapy following an acute knee injury at soccer training the previous day. The injury occurred whilst the patient was sliding in to tackle an opponent, the patient felt that direct contact was made with the knee but could not remember if the knee was twisted, or if it was planted on the ground at the time, he denied hearing a pop or crack and has not had any clicking locking or giving way.
The knee was moderately swollen. Passive extension was extremely painful and passive flexion was mildly painful, there was pain on palpation of the posteromedial joint line. Ligaments testing of the ACL, PCL, MCL and LCL revealed no pain or laxity. McMurray’s test caused pain 8/10 without any clicking. A provisional diagnosis of a medial meniscal tear was made.
Because the patient was unable to fully extend the knee and a meniscus tear was suspected, the patient was referred to their GP who then referred the patient for an MRI under item number 63560. MRI confirmed the findings of a medial meniscus tear, a flap tear of the posterior third of the medial meniscus.
The patient was counseled on the likelihood the tear would not heal and the option of referral to an orthopaedic surgeon. However the patient wanted to try a conservative approach first.
Physiotherapy treatment included soft tissue massage and ultrasound to decrease pain and swelling, as well as quadriceps strength and control exercises. At 2 weeks full pain free range of motion with full resolution of swelling was achieved. A return to sport program then commenced and full successful return to soccer was achieved at 8 weeks.
- Acute meniscus tears are common amongst the sporting population
- They are usually the result of a twisting force on a planted foot
- The most common area for a tear is the posterior horn
- Classic signs: Joint line tenderness, effusion, clicking, and locking.
- Most common clinical test is McMurray’s: This involves internal and external rotation of the tibia on the femur while flexing and extending the knee (pictured left). Positive test = reproduction of pain and may cause clicking.
- MRI is >95% sensitive for detecting meniscus tears.
- Item 63560 now gives a medicare rebate for MRI referrals from GPs when extension is limited and meniscus is the expected cause.
- Most meniscus tears will not heal without intervention, however in some cases conservative management does allow resumption of desired activities without a return of symptoms.
Carpal Tunnel Syndrome
Carpal tunnel syndrome is the most common neuropathy in Australia. It occurs in 1 in 1000 men and 4 in 1000 women.
What is the Carpal Tunnel?
The carpal tunnel is a rigid tube through your wrist made of bone and collagen. The median nerve runs from the forearm into the hand through the middle of this tube along with tendons for the hand.
What is the cause of CTS?
CTS results when the median nerve becomes pressed or squeezed at the wrist. This is most likely due to the fact that some people have a smaller carpal tunnel than others.
Other contributing factors include trauma or injury to the wrist that causes swelling (eg fracture), overactivity of the pituitary gland, hypothyroidism, rheumatoid arthritis, work stress, repetitive use of vibrating tools, fluid retention during pregnancy or menopause, or the development of a cyst or tumor in the canal. In some cases, no cause can be identified.
What are the symptoms of CTS?
Waking in the night is the most common symptom for CTS. People with CTS report waking with painful, numb, tingling or shaking hands. Other common symptoms include: numbness or decreased sensation usually in the fingers; clumsiness with everyday tasks such as driving, clipping earrings or tying shoes; and occasionally poor distinction between hot and cold.
Who is at risk?
Women are more likely than men to develop CTS. The dominant hand is usually affected first and is the most painful. People with diabetes are more likely to develop CTS as well as people in repetitive strain jobs such as production line work, machinists etc. CTS almost always occurs exclusively in adults.
Treatment for CTS should start as early as possible under the direction of your GP or specialist.
Conservative treatment includes treating the underlying cause such as diabetes or arthritis; resting from aggravating activities; sometimes a night splint is used to avoid twisting or bending of the wrist during sleep; ice packs can help to reduce swelling; medication prescribed and managed by your Doctor; exercises from your Doctor or physiotherapist; alternative therapies such as acupuncture, dry needling and Yoga.
Surgery can be performed to release the carpal tunnel and is generally only performed if symptoms last for 6 months. Surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve. This is usually performed under local anaesthetic and does not require an overnight hospital stay. Physiotherapy is required post surgery to restore wrist and hand mobility and strength.
Carpal Tunnel Syndrome (CTS)
Carpal tunnel syndrome is the most common neuropathy (nerve pain) in Australia. It occurs in 1 in 1000 men and 4 in 1000 women.
What is the Carpal Tunnel?
The carpal tunnel is a passageway of rigid tube in your wrist made of bone and connective tissue. The median nerve runs from the forearm into the hand through the middle of this tube along with other tendons for the hand.
What is the cause of Carpal Tunnel Syndrome?
CTS results when the median nerve becomes pressed or squeezed at the wrist. This is usually because some people have a smaller carpal tunnel than others.
Other contributing factors include trauma or injury to the wrist that causes swelling (eg fracture or sprain), work stress, repetitive use of vibrating tools, fluid retention during pregnancy or menopause, overactivity of the pituitary gland, hypothyroidism, rheumatoid arthritis, or the development of a cyst or tumor in the canal. In some cases, no cause can be identified.
What are the symptoms of Carpal Tunnel Syndrome?
Waking in the night is the most common symptom for Carpal Tunnel Syndrome. People with Carpal Tunnel Syndrome report waking with painful, numb, tingling or shaking hands. Other common symptoms include: numbness or decreased sensation usually in the fingers; clumsiness with everyday tasks such as driving, clipping earrings or tying shoes; and occasionally poor distinction between hot and cold.
Who is at risk?
Women are more likely than men to develop CTS. The dominant hand is usually affected first and is the most painful. People with diabetes are more likely to develop CTS as well as people in repetitive strain jobs such as production line
work, machinists etc. CTS almost always occurs exclusively in adults.
Your physiotherapist or GP will take a thorough history and perform some basic tests in a physical examination to reach or exclude a diagnosis of CTS. Sometimes, it is necessary to be referred to a specialists for further tests to see how well the nerves are condutcting impulses.
Treatment for CTS should start as early as possible under the direction of your GP, physiotherapist or specialist.
Conservative treatment includes; resting from aggravating activities; use of a night splint to avoid twisting or bending of the wrist during sleep; ice packs can help to reduce swelling; medication prescribed and managed by your Doctor; exercises from your physiotherapist; alternative therapies such as acupuncture, dry needling and Yoga. For more information, please feel free to contact us and talk to a physiotherapist.