Physical therapy (also physiotherapy) is a health profession that assesses and provides treatment to individuals to develop, maintain and restore maximum movement and function throughout life. This includes providing treatment in circumstances where movement and function are threatened by aging, injury, disease or environmental factors.
Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention, habilitation and rehabilitation. This encompasses physical, psychological, emotional, and social well being. It involves the interaction between physical therapist (PT), patients/clients, other health professionals, families, care givers, and communities in a process where movement potential is assessed and goals are agreed upon, using knowledge and skills unique to physical therapists. Physical therapy is performed by either a physical therapist (PT) or an assistant (PTA) acting under their direction.
PTs use an individual’s history and physical examination to arrive at a diagnosis and establish a management plan and, when necessary, incorporate the results of laboratory and imaging studies. Electrodiagnostic testing (e.g., electromyograms and nerve conduction velocity testing) may also be of assistance.
Physical therapy has many specialties including cardiopulmonary, geriatrics, neurologic, orthopaedic and pediatrics, to name some of the more common areas. PTs practice in many settings, such as outpatient clinics or offices, inpatient rehabilitation facilities, skilled nursing facilities, extended care facilities, private homes, education and research centers, schools, hospices, industrial workplaces or other occupational environments, fitness centers and sports training facilities.
Education qualifications vary greatly by country. The span of education ranges from some countries having little formal education to others requiring masters or doctoral degrees.
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Chondromalacia patella is an abnormal softening of the cartilage of the patella. However it fits within a larger group problems with the knee cap and is known as patello-femoral syndrome. Chondromalacia patella is an older term and was used in rather a blanket fashion. So even now it sometimes gets overused when you just have signs of patellofemoral syndrome. However you can have all the symptoms with patellofemoral syndrome and not have chondromalacia patella. The physio for either condition is much the same but it may take longer with chondormalacia patella due to the changes in cartilage.
Chondromalacia patella should be diagnosed from loss of cartilage seen on xrays or CT and you need to have a specific sort of xray called a “sunrise view” which it sounds like you have had. Not just based on cracking noises when you passive glide the patella against the femoral bone
in Patellofemoral syndrome, including chondromalacia patella, you may have changes in the way the patella works in the joint such as
• it failing to track correctly in the joint when you move your knee joint with your quadriceps muscle
• small or misshaped patellae
• Increased Q angle
• Weakness of the part of the quariceps on the inner side (vastis medialis obliqus)
• tightening of the tissue ant the front of the join on the outer side (lateral patellar retinaculum)
• Tight/overactive hamstrings muscles.
It sounds to me the physio gave you rational exercise but your physio should also have checked out the above points. The issue with the increase in knee flexion angle while working the quadriceps the greater the force is placed on the joint. The purpose of the exercise is to increase the strength of the quadriceps muscle including and also cause the joint cartilage to remodel in a useful way that will make the joint and cartilage more functional and more healthy.
The exercise has to be balanced and incrementally increased so that on one hand you don’t flare up the inflammatory process (most likely reason why you feel the pain and swelling later is stirring up the inflammatory process with the disorder) but on the other hand challenging enough to increase the strength of the muscle and to stimulate remodelling of the cartilage
Gradual increase in the angle while strengthening sounds a good idea. Using the reduction in pain and inflammation later as a marker for increasing the challenge of the exercise sounds good. However there are a few things to consider:
• Ice packs or anti inflammatory gel can help if you apply them immediately after the exercise. Menthol cream may help the pain but isn’t really anti-inflammatory
• Have the knee cap assessed for poor tracking and having the knee taped may sometimes help reduce the abnormal force on the joint while exercising and thereby reduce the pain and inflammation so you can do more. As long as you don’t have any skin problems with sports taping this may be a good point to discuss with your physio
• Closed chain exercises may actually be more effective than open chain exercises. “Closed chain” means the weight is going through the foot as with squats whereas open chain is where the weight is not going through the foot as in leg extension machine. Probably a variety is good but if you are having problems the closed chain variety may be better.
I don’t think there is any golden rule for restricting the joint range for exercising – you should base it on how you go. However you can hit a ceiling where you just can’t increase the range without aggravating the joint and you have tried this gradual increase including trying taping, closed chain exs etc. then you may just have to accept that you can’t do much more. However the remodelling doesn’t happen within a few weeks. You do have to persist for a long time.
Increase in popping on bending may or may not be significant. If it is painful then that is concerning. You may be “overtraining” If not it may be due to changes in the force across the joint and it may settle down more in time. If the cartilage hs really worn away then the cracking can be due to bone rubbing against bone but that sounds unlikely since your xray was good. I would be more guided by getting stronger, able to do more such as squats without causing pain and inflammation than by cracking noises.
Physiotherapy for anterior knee pain: a randomised controlled trial
Abstract
OBJECTIVE To determine the efficacy of the individual components of physiotherapy in subjects with anterior knee pain.
METHODS An observer blind, prospective, factorial design randomised controlled trial. 81 young adults with anterior knee pain were randomly allocated to one of four treatment groups: (1) exercise, taping, and education; (2) exercise and education; (3) taping and education; and (4) education alone. Each group received six physiotherapist-led treatments over three months. Follow up took place at three months using the following outcome measures: patient satisfaction (discharge/refer for further treatment); a visual analogue pain score; the WOMAC lower limb function score; the Hospital Anxiety and Depression scale (HAD); and quadriceps strength. At 12 months the WOMAC and HAD were assessed by postal questionnaire.
RESULTS All groups showed significant improvements in WOMAC, visual analogue, and HAD scores; these improvements did not vary significantly between the four groups or between exercising/non-exercising and taped/non-taped patients at three and 12 months. However, patients who exercised were significantly more likely to be discharged at three months than non-exercising patients (χ2, p<0.001). Taping was not significantly associated with discharge. Significantly greater improvements in WOMAC, visual analogue, and the anxiety score (but not the depression score) were seen in patients who were discharged than in those who were referred.
CONCLUSIONS The proprioceptive muscle stretching and strengthening aspects of physiotherapy have a beneficial effect at three months sufficient to permit discharge from physiotherapy. These benefits are maintained at one year. Taping does not influence the outcome.