The Knee:
The knee joint, medically known as the tibiofemoral joint, is the largest joint in the body. Two bones make up this joint; the femur and tibia. This joint is dependent on the muscles and ligaments which surround it for strength.

The Ligaments:
Four ligaments are present in the knee joint, the medical collateral ligament, lateral collateral ligament, anterior cruciate ligament, and posterior cruciate ligament. These ligaments provide strength to the knee joint.
The medial collateral ligament is located at the inside of the knee joint. It extends from the medial femoral epicondyle to the tibia. This ligament prevents excessive abduction of the knee.

The lateral collateral ligament is located at the outside of the knee joint. It extends from the lateral femoral epicondyle to the head of the fibula. This ligament prevents excessive adduction of the knee.
The anterior cruciate ligament extends posterolaterally from the tibia and inserts on the lateral femoral condyle. This ligament prevents excessive posterior movement of the femur on the tibia.

The posterior cruciate ligament extends anteromedially from the tibia posterior to the medial femoral condyle. This ligament prevents excessive anterior movement of the femur on the tibia.

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Prophylactic Knee Braces
Prophylactic knee braces are used to prevent knee injuries. Prophylactic knee braces are worn by athletes who participate in some high-risk sports in an effort to minimize their risk of sustaining a knee injury.
Functional Knee Braces
Most patients who are concerned about knee braces already have a knee ligament injury. These patients would be interested in the functional knee braces. These functional knee braces are designed to compensate for a torn knee ligament.
Do the functional knee braces work as well as a normal ligament?
This is an easy question to answer: No. However, the functional knee braces may help in patients who have a knee ligament injury. There have been a number of studies to investigate the effectiveness of these knee braces. The summary of these studies is that functional knee braces provide some protection to the knee at low loads. This means that when a force is applied to a knee that is supported with a functional knee brace, it is more stable than without the brace.

So doesn’t that mean that functional knee braces work?
Not quite. The forces that are applied in these studies are thought to be much lower and more slowly applied than forces applied to the knee during competitive athletics. When a knee injury occurs during high-level sports, the knee is subjected to very high forces that occur very quickly. Unfortunately, testing these braces under these unique conditions is difficult. No one can prove that functional knee braces are of much help under these unique conditions.

Should I wear a functional knee brace if I have a ligament injury?
You should discuss this with your doctor, because it depends on several factors, including:

Which ligaments are injured
What sport you are participating in
What rehabilitation you have done or plan to do
What is known, it that physical therapy, including strengthening, is an important factor in returning to sports following a ligament injury. Therapy and rehabilitation are by far more important than a knee brace. Knee braces may help prevent re-injury to the knee, but it is likely a small factor, if any at all.
Prophylactic Knee Braces
Prophylactic knee braces are designed to prevent knee injuries in healthy athletes. These knee braces were popularized in the late 1970s when the use of prophylactic knee braces was tested in NFL players. Since that time, several studies have investigated the injury rates in athletes who wear prophylactic knee braces versus those who don’t wear a knee brace.
Do athletes who wear knee braces have fewer injuries?
Again, the evidence is cloudy, because the difference is very small. Studies do show that athletes in certain sports (football) have a lower rate of MCL injury when wearing a prophylactic knee brace. However, the effect of the prophylactic knee brace should be placed in perspective. Much more important factors in determining the likelihood of an injury include:

Sport played
Player position
Player conditioning
Player size
Is there any harm in wearing a prophylactic knee brace?
There was some concern that knee braces could alter the forces on the knee such that prophylactic knee braces could prove problematic. However, knee braces, when properly fitted and worn, have not been shown to increase injury rates. They are probably safe to wear, and have not been shown to increase rates of knee or ankle injuries.
Where should I obtain a knee brace?
The knee braces that are investigated in these studies are not simple knee sleeves or knee braces that can be purchased at a drug store. These knee braces need to be special ordered and prescribed by your physician. If you are interested in using a knee brace for competitive sports, you should contact your team doctor, or your orthopedic surgeon. Your doctor can prescribe the proper type of knee brace for you and your sport. Furthermore, any effective knee brace must fit properly. Once you have a knee brace, ensure that your doctor inspects the fit of the knee brace to ensure it is sized and placed properly.

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Knee replacement surgery can be performed as a partial or a total knee replacement. In general, the surgery consists of replacing the diseased or damaged joint surfaces of the knee with metal and plastic components shaped to allow continued motion of the knee.

The operation involves substantial postoperative pain, and includes vigorous physical rehabilitation. The recovery period is 6 weeks or longer and involves use of a walker and then a cane.

What is a total knee replacement?

A total knee replacement is a surgical procedure whereby the diseased knee joint is replaced with artificial material. The knee is a hinge joint which provides motion at the point where the thigh meets the lower leg. The thigh bone (or femur) abuts the large bone of the lower leg (tibia) at the knee joint. During a total knee replacement, the end of the femur bone is removed and replaced with a metal shell. The end of the lower leg bone (tibia) is also removed and replaced with a channeled plastic piece with a metal stem. Depending on the condition of the kneecap portion of the knee joint, a plastic “button” may also be added under the kneecap surface.

The posterior cruciate ligament is a tissue that normally stabilizes each side of the knee joint so that the lower leg cannot slide backward in relation to the thigh bone. In total knee replacement surgery, this ligament is either retained, sacrificed, or substituted by a polyethylene post. Each of these various designs of total knee replacement has its benefits and risks.

Total Knee Replacement

Total knee replacement (arthroplasty) has proven to be a very effective surgical treatment of osteoarthritis of the knee for many years. Relatively recently, however, partial knee replacement (also known as unicondylar knee replacement) has emerged as a possible – and viable – option for certain patients.

For the treatment of end stage arthritis of the knee, total knee replacement is a very predictable surgery with an excellent outcome. It promises a return to activities of daily living, walking, and a life with no (or minimal) pain. The results for total knee arthroplasty over the last 20 years have shown continuous improvement in knee function as well as durability of the surgery, and most patients today can expect a ten year implant survival rate in the range of 95% and a 20 year survival rate in the range of 85% – 90%. This means that 20 years after surgery, nine out of ten patients will still have a functioning implant and will not need another surgery. These promising outcomes have resulted in the widespread use of total knee arthroplasty for the treatment of osteoarthritis of the knee.

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kneepict-copy-Knee-Anatomy.gif

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Quadriceps Strengthening
Quad Strengthening Contractions:
Sit in chair. Extend legs, heels to floor. Keep knees straight (or as straight as possible if you have arthritis.) Tighten thigh muscles. Hold for count of 10. Relax for count of 3. Do 10 repetitions. You can do this several times throughout the day. You can build up to 2 or 3 sets of 10 repetitions at a time.

Quad Strengthening Leg lifts:
Lie flat on back. Bend left knee at 90-degree angle, keeping foot flat on floor. Keeping the right leg straight, slowly lift it to the height of the left knee. Hold for a count of 3. Repeat 10 times. Switch sides. Work up to 10 sets of 10 over several weeks.

Safety Tip:
Leg lifts: Lifting both legs at the same time causes excessive stress on your lower back so
only lift one leg at a time; the opposite leg should be kept slightly bent with foot on floor.

Quad Strengthening Short-Arc Leg Extensions:
Sit or lie on floor. Place a rolled up towel under your thigh for support. Keep you leg straight and raise your foot about six inches off the floor. Hold for 5 seconds. Slowly lower your foot, bending your knee. Do 10 repetitions. Switch sides.

Quad Strengthening Knee Dips:
Stand with knees slightly flexed. Point your toes straight ahead.
Make sure your kneecaps are also pointed straight ahead.
Lift one leg up and balance on the other leg. Slowly lower yourself up and down ONLY a few inches. Keep the knee of the leg you are balancing on slightly flexed. Your knees must remain pointing straight forward. Do not let them turn inward. Stand straight, do not lean you body to one side. Do 10 dips. Switch sides.
If you feel pain in your knees, start with fewer dips.

Quad Strengthening Partial Squats:
Double leg partial squat: Stand. Keep Back Upright. Knees pointing straight ahead – inline with feet and hips. Slowly lower yourself. Don’t bend your knees beyond a 90-degree angle, if 90 degrees is too difficult bend even less.

Safety Tip: Make sure your knees do not extend beyond your toes when doing partial squats. Keeping your weight behind your knees reduces the pressure on the knee joint during the squat. Bending the knees beyond 90 degrees (a right angle) places excessive strain on the knee.

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Knee Arthritis Symptoms:

Symptoms of arthritis of the knee depend on the type of arthritis a person develops. The most common types of arthritis of the knee include osteoarthritis, which causes the bone and cartilage in the knee to deteriorate and change, and rheumatoid arthritis, which causes inflammation and swelling of the knee joint. Other rheumatic diseases such as infectious arthritis, psoriatic arthritis and gout can also cause knee arthritis symptoms.
Osteoarthritis
Arthritis in the knee caused by osteoarthritis leads to pain and stiffness, especially after a person has been sitting or lying down for long periods of time. Osteoarthritis in the knee also causes tenderness, swelling and problems with joint mobility.
Rheumatoid Arthritis
Arthritis in the knee caused by rheumatoid arthritis can cause the knee to swell, turn red and become hot to the touch. These symptoms are caused by the inflammation characteristic of rheumatoid arthritis.
Infectious Arthritis
People who have infectious (or septic) arthritis in the knee may find that they suddenly develop severe pain, swelling, chills, fever and sometimes nausea or vomiting. The knee joint may also be sore and hurt to touch.
Psoriatic Arthritis
People with psoriatic arthritis, a type of arthritis that affects people with the skin disease psoriasis, may develop arthritis in the knee that causes painful, swollen joints that feel hot to the touch. Psoriatic arthritis can cause symptoms in one knee or both knees.

knee arthritis treatment and exercises:

Knee Osteoarthritis Treatment

The knees are among the joints most commonly affected by arthritis. Early, aggressive knee osteoarthritis treatment can relieve pain and protect the joint from further damage. Find out about common treatments and alternative therapies for knee osteoarthritis.

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Exercises Can Prevent Injury

Strengthening the muscles that support the knee with knee exercises is most important in protecting your knees from injury and knee pain.

Weak or fatigued muscles cannot adequately support the knee joint or absorb shock before it gets to the knee and the extra stress placed upon the knee can cause injury to the structures of the knee. Strengthening exercises can make the muscles tight, so follow strength exercises with stretching exercises.

Stretching the muscles that support the knee with knee exercises is also important in preventing injury. Flexible muscles are not as easily injured as tight muscles. Tightness of muscles connected to the knee can also pull the knee out of alignment.

When doing stretching knee exercises, be careful to go slowly and not to overstretch. You do not want to tear a muscle.

You need to increase the duration of your knee exercises gradually to avoid overuse injuries and knee pain. Be patient. You will see results.

Strength must be built up gradually. When muscles, tendons or ligaments are stressed slightly beyond their limits, microscopic tears occur. This is normal, and as these tears heal the muscles actually become bigger, firmer and stronger. These microscopic tears must be given adequate time to heal or chronic problems can develop. Try not to exercise the same muscle groups two days in a row to give your body a chance to recover. Doing strengthening knee exercises three or four times a week is enough. Stretching knee exercises can be done more often.

The goal is to prevent injury and knee pain, not cause it.
Don’t ignore pain. Pain is your body’s way of protecting you from hurting yourself further. It is not unusual to experience mild stiffness and aching of the muscles that lasts up to a day after exercising. But hardly being able to move for a few days after exercising means you have overdone it. It’s difficult to know when to quit when you doing knee exercises. Often, the pain doesn’t’ set in until a day or two later. It happens. If it does, you will have a greater understanding of your body’s limitations.

When you have overdone your knee exercises.
Rest is important for inflamed muscles/tendons. Applying ice wrapped in a cloth can help reduce inflammation and pain and speed up healing. See Treatment for Overuse Injuries. Knee pain should be completely gone before fully resuming your knee exercises program, however, lightly exercising the sore muscle may help decrease muscle soreness.

If you are currently experiencing knee pain and/or have a very limited range of motion, or are not sure which knee exercises are safe for you to do, see a physical therapist (physiotherapist). A doctor or physical therapist can assess your condition and give you a customized treatment / exercise plan.

Main Muscle Groups Affecting Knee Stability

Several muscle groups support the knee. The two main muscle groups that control knee movement and stability are the quadriceps and the hamstrings.

THE QUADRICEPS is a four-part powerful muscle that run along the front of the thigh and attach to the front of the shinbone, just below the knee. The quadriceps control the straightening of the knees and movement of the kneecap. The quadriceps is used to extend the leg, and is essential for standing up, walking upstairs, walking uphill, and running.

THE HAMSTRINGS are muscles that run make up the back of the thigh, and attach to the back of the shinbone, just below the knee. The hamstrings are used to bend the knee and are also needed when you are pushing against something.

Other Muscles Affecting Knee Stability
Other muscles that affect knee stability, to a lesser degree than the quadriceps and hamstrings are the calf muscles, the hip abductors located on the outer thigh, and the hip adductors located on the inner thigh. The body functions as a unit (remember – the hip bone’s connected to the knee bone) and even muscles not near the knee can contribute to knee stability.

The iliotibial band (fibrous tissue on the outer thigh, extending front the hip to below the knee) also affects knee stability. The glutes (back of hip muscles / buttocks) inserts into the thigh bone and iliotibial band and also help stabilize the knee.

*It is important to do strengthening exercises for all the muscles that support the knee. For example, if you concentrate on strengthening exercises for the quads, and neglect strengthening exercises for the hamstrings a muscle imbalance can be created.

Imbalances in Muscles Supporting the Knee
A physical therapist (physiotherapist) can help determine if you have a muscle imbalance in the muscles supporting the knee and create a personalized exercise program.

Imbalance of the quadriceps is common, especially in women – The quadriceps is divided into 4 divisions. If the inner division if weak, the stronger outer division tends to pull the kneecap toward the outer side of the leg. Tightness of the quads can also pull the knee towards one side so stretching as well as strengthening of muscles that support the knee is important.

In some cases, the quadriceps is significantly stronger than the hamstrings. (The quadriceps should only be about 25% stronger than the hamstrings). This can cause weakness of the knee. If this is the case, concentrating on strengthening exercises for the hamstrings, and stretching exercises for the quadriceps are very helpful.

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Knee Exercises
*NOTE: Only do one exercise per muscle group on the same day. There are several exercises to choose from for some muscles.

Strengthening Knee Exercises
Warming up with 5 minutes of low-impact aerobics, such as walking or riding a stationary exercise bike, increases blood supply to the muscles to help prevent injury and stiffness.

Quadriceps Strengthening
Quad Strengthening Contractions:
Sit in chair. Extend legs, heels to floor. Keep knees straight (or as straight as possible if you have arthritis.) Tighten thigh muscles. Hold for count of 10. Relax for count of 3. Do 10 repetitions. You can do this several times throughout the day. You can build up to 2 or 3 sets of 10 repetitions at a time.

Quad Strengthening Leg lifts:
Lie flat on back. Bend left knee at 90-degree angle, keeping foot flat on floor. Keeping the right leg straight, slowly lift it to the height of the left knee. Hold for a count of 3. Repeat 10 times. Switch sides. Work up to 10 sets of 10 over several weeks.

Safety Tip:
Leg lifts: Lifting both legs at the same time causes excessive stress on your lower back so
only lift one leg at a time; the opposite leg should be kept slightly bent with foot on floor.

Quad Strengthening Short-Arc Leg Extensions:
Sit or lie on floor. Place a rolled up towel under your thigh for support. Keep you leg straight and raise your foot about six inches off the floor. Hold for 5 seconds. Slowly lower your foot, bending your knee. Do 10 repetitions. Switch sides.

Quad Strengthening Knee Dips:
Stand with knees slightly flexed. Point your toes straight ahead.
Make sure your kneecaps are also pointed straight ahead.
Lift one leg up and balance on the other leg. Slowly lower yourself up and down ONLY a few inches. Keep the knee of the leg you are balancing on slightly flexed. Your knees must remain pointing straight forward. Do not let them turn inward. Stand straight, do not lean you body to one side. Do 10 dips. Switch sides.
If you feel pain in your knees, start with fewer dips.

Quad Strengthening Partial Squats:
Double leg partial squat: Stand. Keep Back Upright. Knees pointing straight ahead – inline with feet and hips. Slowly lower yourself. Don’t bend your knees beyond a 90-degree angle, if 90 degrees is too difficult bend even less.

Safety Tip: Make sure your knees do not extend beyond your toes when doing partial squats. Keeping your weight behind your knees reduces the pressure on the knee joint during the squat. Bending the knees beyond 90 degrees (a right angle) places excessive strain on the knee.

Hamstring Strengthening
Hamstring Strengthening Contractions:
Sit in chair, heels on floor. Don’t move heels but pull back on them. You will feel tension in you hamstrings. Hold for count of 10. Relax for count of 3. Do 10 repetitions.

Hamstring Strengthening Curls:
Lie on stomach. Place left foot onto the back of the right heel. Slowly pull your right heel toward your buttocks – resisting with the left leg. This contracts the hamstrings. Hold for a count of 10. (Keep pressing your left foot and right heel against each other) Hold for a count of ten and relax for count of 3. Do 10 repetitions.

Walking backwards helps to develop the hamstrings. When walking backwards, your weight is distributed more evenly, resulting in less strain on your knees.

Other Strengthening Exercises for Knee Stability

Hip Adductors (Inner Thigh) / groin muscle and inner quad muscle (VMO) Strengthening:
Sit in chair, put fist between knees, squeeze together knees. Hold for count of 10. Relax for count of 3. Do 10 repetitions.

Lie on floor on your right side, shoulder and hips aligned. Use your right hand to prop up your head. Place the left hand on floor in front of you to help balance yourself. Bend left leg and bring it to the floor in front of you. Slowly raise your right leg about 10 inches off the floor then, hold for a second, then slowly lower leg to ground. Lift 10 times on each side.

Hip Abductors (Outer Thigh) strengthening:
Lie on floor on your right side, shoulder and hips aligned.
Bend right leg (leg on floor) to 90 degrees.
Slowly raise you left leg about 18 inches, hold for a second, then slowly lower leg.
Do 10 repetitions. Repeat on other side.

Glutes Strengthening Backward leg swing:
Hold onto back of chair for support. Swing leg back at a diagonal until you feel your buttocks tighten. Tense muscles as much as you can and swing leg back a couple more inches. Return leg to floor. Repeat 10 times.
Switch sides.Do 10 repetitions. Repeat on other side.

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Balancing Knee Exercises
(helps in knee stability)
Hold onto back of chair or counter top for support. Stand on one leg for one minute. Switch sides.

As your balance improves, use one hand only for support. Next use one finger only for support, then progress to letting go, but keeping your hands within a couple of inches above chair in case you lose your balance. Do not lean your trunk to one side.

To increase difficulty, shift weight onto the ball of the foot.

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Stretching Knee Exercises
No bouncing, slow & controlled fashion, 5-10 minutes aerobics warm up first (e.g. walking, stationary bike) Muscles warmed up are more responsive to stretches and less likely to tear.

Calf Muscles Stretch:
Step back with left, forward with right, lean forward with hips. Do not roll foot out to side. Keep heel flat, foot forward. Bend knees for alternate stretch. Hold 30 – 60 seconds.

Quad Muscle Stretch:
Bring heel to hip with hand. Keep knees together. Do not arch back. Do not leg go to side.
Hold for 30 seconds. Repeat on other side.

Hamstring Stretch:
Standing position
Keep one leg on ground; put one foot on chair with leg straight. Bend forward at the hip. Do not attempt to touch your toes as this will stretch your back, and the goal of this exercise is to isolate your hamstring muscles in the leg that is being supported by the chair.

Sitting in chair hamstring: Straighten one leg, keeping heel on floor. Lean forward at hips, keeping back straight. Don’t try to touch your toes. Hold for 30 seconds. Repeat on other side.

Iliotibial Band Stretch:

Standing position:
Stand up. Cross right leg behind left leg moving crossing knee beyond the midline of the body. Lean from the hips to the left, the stretch being felt on your right hip, side of the leg and knee. Hold for 30 seconds. Repeat on other side.

Sitting position: Sit in chair: Bring right foot to outside of left leg, bringing knee towards opposite shoulder so that the knee crosses the midline of the body. Hold for 30 seconds. Repeat on other side.

Hip Adductors (Inner Thigh) Stretch:
Standing: Step off to the side with the right leg. Then lean away from the leg (bending your left knee)

Sitting position: Sit on floor, spread legs into a v position. Slowly lean forward from your hips, keeping your back straight, until you feel the stretch. Do not bounce. Then lean towards the right, foot then left foot. Hold each position for 30 seconds.

Hip Abductors (Outer Thigh) Stretch:
Sit on the floor,legs extended in front of you.
Bend right leg and place right foot on floor on outside the left knee.
Twist upper body to right and use left elbow to gently push against outside of right nee until you feel a gentle stretch in the right hips, buttocks, and lower back.
Hold for 30 seconds. Repeat on other side.

Hip flexors (front of hips) Stretch:
Tightness in these muscles can affect the alignment of the knee bones.
Standing Exercise: Step forward with the right leg, bending right knee. Keep back upright. This stretches the front of the hip on the left side. Keep left knee slightly bent also.
Hold for 30 seconds. Repeat on other side.

Gluteal Stretch (back of hips / buttocks):
Stand in front of chair, about two feet away from chair. Place left foot on chair, leg bent. Bring your chest towards your knee, keeping back straight. Hold for 30 seconds. Repeat on other side.

*Of all the above knee exercises, the quadriceps strengthening contraction is probably the easiest, safest and most important exercise you can do to prevent knee pain and injury. Those who have trouble fitting in exercises into their schedule can always do this exercise while watching television.

Knee-Safe Aerobics. Low-impact exercises with minimal risk to the knee joint.

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