Young or old, athletes or sedentary workers – most people get knee pain at some time or other. An old lady went crying to the doctor: ‘I cannot walk, even walking in the house hurts me. I do not want to be crippled and dependent for little things on my children.’ Old age and knee pain are almost synonymous.

A young footballer trying to kick the ball, fell down, but rose up and collecting all his courage, continued with the game. The next day, he had a big swelling over the knee and a lot of pain. He hobbled to the clinic with the help of a friend, was treated and asked to spend a few days in bed. For several weeks he limped in great discomfort. The pain and swelling gradually subsided. A few months later he complained of pain in the knee whenever he exerted it. It would swell up for a day or two after the strain and the swelling would subside completely a few days later. If the legs were stretched to their full, they hurt, and sometimes he found it difficult to bend the knee joints. Rotational movements at the knee also hurt. All this indicated that the ligaments had been strained during the injury and adhesions had formed during recovery. Due to the pain, the knee was not being used to its full extent, and following this, wasting of the thigh muscles had started, further aggravating the pain.

Weak muscles are not able to give full support to the knee and all the strain falls upon the ligaments. What is the treatment for such a knee? The answer lies in breaking the adhesions by manipulative reduction: this will bring back free and painless movement. The patient should be advised to do exercises for the quadriceps and rebuild his thigh muscles to give the knee full support. Strong thigh muscles take off the strain from the ligaments and the pain disappears completely. If the ligaments undergo a long stress and are stretched for long, they start aching. Muscles can remain contracted for any length of time and they will not ache.

The knee is the largest joint in the body, and has the function of supporting the entire body weight. One of the disadvantages of the knee joint is that it does not heal quickly. For faster healing any joint should be given proper rest. This is not possible for the knee joint. As you get up, stand and walk, you put all the weight of the body on your knees and irritate the healing joint.

However the knee is a joint where a more exact diagnosis can be made than in any other joint because the greater part of the joint and its ligaments and tendons can be felt by the hands. Sometimes when diagnosis is not possible in a middle-aged person, the cause of pain may be a cartilagenous loose body inside the joint. Cartilage cannot be seen in an X-ray picture. Sometimes bone margins can flake off as loose bodies and be seen in the X-ray, but most of the time they are not the cause of pain as they remain attached to the synovial membrane of the joint capsule and do not cause any interference in movement.

The pain is often localised in the joint itself. An impacted loose body in the joint may cause pain, thus complicating an existent case of osteoarthritis. The pain may be up in the thigh and down in the leg but the patient quite clearly indicates that the symptoms originate from the knee. Pain in front of the knee can also be caused by a lesion in the lower back. Any mechanical disturbance at the third lumbar nerve may cause pain in the knee. In such cases a patient complaints of vague pain in the whole knee and cannot pin-point the exact spot. He may complain of pain above the knee cap or in front, or in the inner aspect of the thigh upto the groin. The hip joint, when at fault, can also cause pain in the knee. Examination of the knee in such cases helps in establishing the diagnosis.

Pain is common among bow-legged persons due to the strain on certain ligaments rather than because of osteoarthritis. A few cases of the knee relate to hypertrophy of the joint wherein the knee is swollen with limitation of movement in all directions, and more so on flexion than extension. Extension may be limited top 5-10 , whereas flexion may be limited to 60-90 .

Diagnosis

A detailed history of the patient must be taken including his age, occupation, how the pain, whether he suffered an injury, and if so, in what position. Enquiries must be made about how he was standing, how he twisted his knee, whether there was any injury at all. Did the knee give way? Did it lock, and if so, at that time, was the leg straight or bent? If it was locked, how did he unlock it? Was the pain located all over? Did the pain shift from one place to another? Did the knee swell, and if so, how quickly? For how long was the patient disabled? Was he still experiencing sudden twinges, feeling clicks or hearing grating sounds in the knee?

The diagnosis has to be clear before treatment is started, the X-rays and laboratory tests confirming the diagnosis. However, the following conditions must also be excluded before manipulating a joint: a tubercular knee, gonorrheal or septic arthritis, gout, rheumatoid arthritis, active infective arthritis and other possible ailments.

Treatment

Manipulative reduction helps in complete recovery in the shortest period. Manipulation helps to achieve full movement at the knee joint. Realignment of the joint bones takes off all the strain from the ligaments, and they recover completely. Manipulation can be done on the young and the old. Techniques and manoeuvres are selected according to the needs of the patient. All cases of advanced osteoarthritis, chronic ligamentous injury and post-traumatic adhesion can be manipulated. A gradual improvement in the range of movement and reduction in the pain is seen.

Quadriceps Drill

This is an important exercise to be undertaken by patients suffering from pain in the knees. Though this exercise is very commonly advocated to patients by medical practitioners, necessary stress is not laid on its usefulness and importance. Also, it should not be done so strenuously so as to tire the patient before it can be effective.

The girth of the thigh should be measured and the patient should be educated about the wasting and weakness of his muscles. This can be measured by making a mark three or four inches above the upper margin of the knee cap and girth of both the thighs measured and compared in both legs.

The patient must be told that he has to regain the normal girth and strength and that this will take time. It cannot be achieved in a week or a month; it will take a couple of months or even a year. At each visit the girth of the thigh must be measured and noted so as to make the patient more conscious of this. The quadriceps drill must be done in the following manner: The patient is asked to lie on his back keeping his leg straight. He is asked to contract and tighten the thigh muscles without bending the knee. As he contracts his thigh muscles, the knee cap is seen moving up and down. This has to be done for 2-3 minutes at a time and repeated during the day as often as possible, preferably 20 times day. This simple exercise can be done while standing or sitting. To do this while sitting, one has to place oneself on the edge of the chair, straighten the leg and keep the back of the heel on the ground. It can then be done comfortably. The patient gets into the habit of doing this exercise without any effort in seven to ten days’ time. It becomes as effortless as cycling or driving. It is so convenient that it can be done in the office, at home, or even while waiting for the bus. This exercise starts showing results in three to four weeks.

Weight Reduction

All the body weight has to be carried by the knee joint. A reduction in weight relieves it of the pressure to some extent. The medical practitioner asks the patients to walk as much as they can and keep their joints mobile, so that they do not get jammed. In my opinion, movement is desirable, but not the strain of walking when the pain is severe. As the pain decreases, the patient can undertake further activity.

The strain of standing can be taken off from the knee if the patient is asked to bend the painful knee and out it on a chair or stool and stand on the painless leg, for instance, while washing at the basin or cleaning utensils. This will protect the painful knee from excessive strain and give it rest so as to hasten the recovery period.

Case Histories

• A forty-year-old man in the tea business was involved in a car accident and had pain in his left knee. It subsided after taking shortwave diathermy and doing knee exercises for about a month. However the pain in the knee continued to come and go, and gradually increased. For one and a half months it became almost continuous. It was painful for the patient to get up after sitting on the ground. The pain became worse and reached the thigh. Due to this and lack of activity, he began gaining weight and added six kilograms to his weight. The X-ray of the damaged knee showed osteoarthritis. Manipulative treatment of the left knee was started. The knee was strapped following manipulation. The patient was asked to do the quadriceps drill for forty minutes a day. He began showing signs of improvement following the first treatment and the pain became much less by the end of the third week. He recovered in two months, and was advised to continue the exercise for another month.
  
  
  
• A 65-year-old lady had pain in the left knee for three years. Later on the pain started in the right knee too, and was accompanied by pain in the lower back with numbness and tingling. She consulted an orthopaedic surgeon and five injections of hydrocortisone were given inside the knee joint. These helped her and she felt better. After two months however, the pain started all over again and she went to her village and underwent massage for two and a half months. She did get relief but the pain persisted.
  
  
  
• When she came to me, the X-rays of her lumbar spine and both knees indicated that she suffered from osteoarthritis. The lumbo-sacral spine showed a slipped disc with osteoarthritic changes.
  
  
  
• After manipulative treatment for the lumbar spine and both knee joints, she was advised to do the quadriceps exercise at home every day. She started showing improvement from the second week. The pain in her lower back and the tingling sensation in the left leg subsided in six weeks and her knees showed considerable improvement. She made complete recovery in three months.
  
  
  
• A fifty-seven-year-old lady, obese but tall, had a job which compelled her to walk long distances. She began experiencing pain in the left knee though she had not suffered any injury. She felt more pain and stiffness when she tried to get up after sitting for a while. The pain became severe for ten days. She took anti-inflammatory drugs but these did not help. Local application of ointments and heat from an infrared lamp did not help either.
  
  
  
• The X-ray showed osteoarthritis. Manipulative treatment of the left knee was done followed by strapping and the quadriceps exercise. She started feeling better after the third visit. By the end of seven weeks she got rid of her symptoms.