Imagine a 65-year old patient walks into your clinic with medial sided knee pain. He reports an insidious onset of pain that increases after rest and decreases with movement. Assuming he does not present with any red flags, this patient likely has knee osteoarthritis. Osteoarthritis is a breakdown of the protective cartilage surrounding synovial joints. The knee joint contains fibrocartilaginous meniscus and the articular cartilage surrounding the joint surfaces. In osteoarthritis, there will be a breakdown of both types of cartilage. As a clinician it is important to understand that a patient with OA will also have degenerative meniscal tears. This individual likely does not need a meniscal surgery, they need lower quadrant strengthening and mobility exercises.
Conservative management of cartilage defects is challenging. Cartilage has poor vascular supply which does not aid the healing process. Movement is the ideal method of healing for cartilage. As the PT, our job is to gradually reintroduce joint loading to the injured tissue. This can be done through muscle contractions and gradual weightbearing. Individuals with cartilage defects should be performing 1,000's of repetitions at ~15% of their 1RM. In other words, low resistance/high repetition interventions are the best. Examples of low resistance/high intensity include the bicycle, total gym (vigor gym), unloaded treadmill, and seated tailgaters (passive knee swings). Early in the patient's plan of care, you want to train in the pain free region as much as possible. The patient should not leave the clinic in more pain than when they come in.
Recommendation for Treatment for someone with Degenerative Knee Meniscal Pathology:
1) Manual therapy to address joint hypomobility
2) Corrective exercises to address any positional faults
3) Strengthening the hip and ankle musculature
4) Education on cartilage damage and how to rehabilitate the tissue*
5) Aerobic machines for high repetition, low resistance exercise- Thousands of repetitions at 15% 1 RM.
6) Retraining poor functional movement patterns (squat, lunge, SL balance)
*Education includes the necessity to perform these repetitions throughout the day also. If able, the patient should be going to the gym an riding a stationary bike for long periods. As always, let pain and the patient's response to treatment be your guide before progression.
James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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