Hip & Knee Pain

Overview

Limb length discrepancy is a condition in which the lower extremity limbs have a noticeably unequal length. There are two different types of Limb Length Discrepancy: Anatomical/Structural and Functional.

Anatomical: 

This can occur from a physical shortening of on of the lower limbs compared to the other and can be found from congenital conditions such as mild developmental abnormalities throughout birth or childhood or from trauma, fractures, orthopedic degenerative diseases and joint replacements. These are detected by radiographic imaging.

Functional:

Non-structural shortening is a unilateral asymmetry of the lower limb without any structural abnormality which can be caused from an alteration of lower limb mechanics such as joint contracture, static of dynamic mechanical axis malalignment, muscle weakness and shortening. It can also develop due to abnormal ranges of motion through the hip, knee, ankle for foot in any plane of motion. This type of abnormality is impossible to detect with imaging but is assessed with clinical test.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Treatment is directed on if intervention is required or not, depending on the magnitude of the inequality and is the patient is symptomatic and treatment pathways can differ from heel raise wedges, in shoe orthotics to surgical intervention if required as well as physical therapy management with stretching and strengthening.

Overview

Osgood-Schlatter disease is a common cause of pain in the front of the knee in late childhood and early adolescence, found more commonly in boys however is starting to be seen frequently in girls too. The condition often appears in children who are highly active or involved in a lot of sports, especially ones that involve running and jumping such as AFL or soccer. In Osgood-Schlatter disease, the repeated running and jumping leads to a small injury where the thigh muscle attaches to the shin bone just below the knee caps and this can become a painful lump. The pain is usually worse during and just after activities and tends to improve with rest and activity modification. It is diagnose by clinical examination.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Treatment is aimed at relieving discomfort as continuing sport of physical activity is not harmful, though it may make the pain worse. With this in mind activity modification  to reduce pain in addition to taping or a protective sleeve worn over the area can be helpful. Icing the knee after sport with strengthening and stretching is recommended as well as shockwave therapy aimed at releasing the tight muscles. Pain associated with Osgood-Schlatter’s goes away when the growing is finished however the lump on the knee may remain prominent which can occasionally cause discomfort when kneeling.

Overview

Patellofemoral pain syndrome (PFPS) is pain at the front of your knee, around your kneecap (patella). Sometimes called “runner’s knee,” it’s more common in people who participate in sports that involve running and jumping.

The knee pain often increases when you run, walk up or down stairs, sit for long periods, or squat. Simple treatments — such as rest and ice — often help, but sometimes physical therapy is needed to ease patellofemoral pain.

It can be due to the following reasons:

• Overuse. Running or jumping sports puts repetitive stress on your knee joint, which can cause irritation under the kneecap.
• Muscle imbalances or weaknesses. Patellofemoral pain can occur when the muscles around your hip and knee don’t keep your kneecap properly aligned. Inward movement of the knee during a squat has been found to be associated with patellofemoral pain.
• Injury. Trauma to the kneecap, such as a dislocation or fracture, has been linked to patellofemoral pain syndrome.
• Surgery. Knee surgery, particularly repair to the anterior cruciate ligament using your own patellar tendon as a graft, increases the risk of patellofemoral pain.

Factors that can increase your risk include:

• Age. Patellofemoral pain syndrome typically affects adolescents and young adults. Knee problems in older populations are more commonly caused by arthritis.
• Sex. Women are twice as likely as men are to develop patellofemoral pain. This may be because a woman’s wider pelvis increases the angle at which the bones in the knee joint meet.
• Certain sports. Participation in running and jumping sports can put extra stress on your knees, especially when you increase your training level.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Treatment of patellofemoral pain often begins with simple measures. Rest your knee as much as possible. Avoid or modify activities that increase the pain, such as climbing stairs, kneeling or squatting.

If needed, take over-the-counter pain relievers however this should be done in conjunction with the following physical therapies:

• Rehabilitation exercises. Specific exercises can strengthen the muscles that support your knees and control limb alignment, such as your quadriceps, hamstrings and the muscles around your hips, especially hip abductors. Correcting inward movement of the knee during squatting is a primary goal.
• Supportive braces. Knee braces or arch supports may help improve pain.
• Taping. Your physical therapist may show you how to tape your knee to reduce pain and enhance your ability to exercise.
• Ice. Icing your knee after exercise might be helpful.
• Knee-friendly sports. During your recovery, you may want to restrict yourself to low-impact activities that are easier on the knees — such as bicycling and swimming or water running.

If nonsurgical treatments aren’t effective, your doctor might suggest:

• Arthroscopy. During this procedure, the doctor inserts a pencil-thin device equipped with a camera lens and light (arthroscope) into your knee through a tiny incision. Surgical instruments are passed through the arthroscope to remove fragments of damaged cartilage.
• Realignment. In more-severe cases, a surgeon may need to operate on your knee to realign the angle of the kneecap or relieve pressure on the cartilage.

The following steps may help prevent the pain in future:

• Maintain strength. Strong quadriceps and hip abductor muscles help keep the knee balanced during activity, but avoid deep squatting during your weight training.
• Think alignment and technique. Ask your doctor or physical therapist about flexibility and strength exercises to optimize your technique for jumping, running and pivoting — and to help the patella track properly in its groove. Especially important is exercise for your outer hip muscles to prevent your knee from caving inward when you squat, land from a jump or step down from a step.
• Lose excess pounds. If you’re overweight, losing weight relieves stress on your knees.
• Warm up. Before running or other exercise, warm up with five minutes or so of light activity.
• Stretch. Promote flexibility with gentle stretching exercises.
• Increase intensity gradually. Avoid sudden changes in the intensity of your workouts.
• Practice shoe smarts. Make sure your shoes fit well and provide good shock absorption. If you have flat feet, consider shoe inserts.

Overview

Patellar tendinopathy is  when there is pain in the front of the knee localised at the inferior pole of the patella which increases when the knee is loaded. It occurs in younger people (15-30 years old) who are athletic and involved in sports which involve jumping such as basketball, volleyball, jumping athletics events, tennis, AFL and soccer. This is because these sports repetitively load the patellar tendon however gender, weight and BMI also increase the risk factor. Pain may also occur when there is prolonged sitting, squatting and stairs however this complaint is more consistent with patellofemoral pain syndrome (see above). Pain usually only is experience with loading instantly and will almost always cease immediately when the load is removed or when resting. In addition to this, the pain may actually improve with repeated loading as the tendon ‘warms up’.  Aggravating activities are predominantly loading activities, such as walking down stairs or when performing a decline squat.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

The use of non-steroidal anti-inflammatory drugs (NSAID’s) in the treatment of tendinopathy remains controversial as they can sometimes impede soft tissue healing, however they do assist with tendon swelling and pain relief. In addition to this, corticosteroids are also used to decrease pain. Surgery is considered a reasonable option in those who have failed all conservative interventions.

Overview

Piriformis syndrome (PS) is a painful musculoskeletal condition, characterised by a combination of symptoms including hip or buttock pain occurring more frequently in women then men. Primary piriformis syndrome has an anatomical cause, with variations such as a split piriformis muscle, split sciatic nerve, or an anomalous sciatic nerve path. Patients with piriformis syndrome have many symptoms that typically consist of persistent and radiating low back pain, (chronic) buttock pain, numbness, paraesthesia, difficulty with walking and other functional activities such as pain with sitting, squatting, standing, with bowel movements and dyspareunia in women. Other characteristics include the following:

• They can also have pressure pain in the buttock on the same side as the piriformis lesion and point tenderness over the sciatic notch in almost all instances. The buttock pain can radiate into the hip, the posterior aspect of the thigh and the proximal portion of the lower leg.

• Swelling in the legs and disturbances of sexual functions have also been observed in patients with PS.

• There may be an aggravation of pain with activity, prolonged sitting or walking, squatting, hip adduction and internal rotation and manoeuvers that increase the tension of the piriformis muscle.

• Depending on the patient, the pain can lessen when lying down, bending the knee or when walking. However, some patients cannot tolerate the pain in any position and can only find relief when they’re walking.

• Piriformis syndrome is not characterized by neurological deficits typical of a radicular syndrome, such as declined deep tendon reflexes and myotomal weakness.
  

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Conservative treatment for piriformis syndrome includes pharmacological agents [non-steroidal anti-inflammatory agents (NSAIDs), muscle relaxants and neuropathic pain medication], physical therapy, lifestyle modifications and psychotherapy. Piriformis syndrome often becomes chronic and pharmacological treatment is recommended for a short time period.

The non-invasive treatments include physical therapy, (osteopathic) manipulative treatment and lifestyle modification. The most commonly reported physical therapy interventions include ultrasound, soft tissue mobilization, piriformis stretching, hot packs or cold spray, shockwave therapy and various lumbar spine treatments. There is also recommendations for functional exercises aimed at strengthening the hip extensors, abductors and external rotators, as well as correction of faulty movement patterns. 

Surgical interventions should be considered only when nonsurgical treatment has failed and the symptoms are becoming intractable and disabling.

Overview

Iliotibial band syndrome (ITB Syndrome) is a common knee injury where there is pain and tenderness on the outside of the knee above the joint area. It is a non-traumatic overuse injury seen in runners or cyclists which is often due to underlying weakness of the hip abductor muscles. The ITB is a band of fascia that runs on the lateral (outside) side of the thigh from the hip to the knee. The etiology of ITB syndrome is often dependent on a number of factors. Long distance running is a very common cause, especially when running on a slightly banked ground. In addition to this, sudden increase in activities can lead to ITB syndrome. The main complaint with ITB syndrome is a sharp pain on the outside of knee especially when the heel strikes the floor when walking, and it can radiate through the outer thigh or calf. The pain is often worse when running or coming down stairs and there may be an audible snapping sensation when the knee bends. There can also be swelling to the outside of the knee.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

The first recommendation of treatment is activity modification, targeting activities in which the pain is exacerbated. Periods of active rest and substantial decrease in the intensity of activities is recommended as well as participation in activities which do not aggravate the pain which as swimming are strongly encouraged. In addition to this ice therapy, heat therapy, taping and stretching along with shockwave therapy are assistant in rehabilitation.

Shockwave Therapy is considered safe as it results in minor adverse effects including worsening of symptoms over a short period of time, reversible local swelling, redness and hematoma. It is believed to stimulate healing of soft tissue and to inhibit nociceptors. Thus, it increases the diffusion of cytokines across vessel walls into the painful area and stimulates the tendon healing response. Shockwaves also reduce the non-myelinated sensory nerve fibers and significantly reduce calcitonin gene related peptide (CGRP), and substance-P release. Finally shockwave treatment may stimulate neo-vascularization in the tendon-bone and bone junction, thus promoting healing.

In rare cases surgical intervention may be recommended. Surgical intervention is not indicated for ITBS except in rare cases in which prolonged conservative treatment has failed to either alleviate the patient’s symptoms or resolve the ITBS.

Overview

One of the most common injuries affecting the knee joint is meniscal tears or injuries. The meniscus are ‘C’ shaped discs made from tough cartilage called fibrocartilage  and are positioned on the tibial plateau, which is the top of the shin bone. They sit in-between the tibia (shin bone) and the femur (thigh bone) and are responsible to shock absorption and distributing weight at the knee joint. In each knee there are two menisci, medial and lateral. Injury to the meniscus can occur in isolation or in combination with a ligamentous injury and usually occurs as a result of a twisting injury with the knee slightly flexed and the foot remaining planted. Injury to the meniscus can also occur with prolonged or repeated squatting and can be either degenerative or traumatic in nature. Degenerative tears occur as a part of progressive wear and tear in the while joint, or as a result of habitual and prolonged squatting. Traumatic injury is common however among athletes and occurs commonly on the lateral (outside edge of the knee) meniscus.

When the meniscus is injured, pain is usually experienced, especially when trying to straighten, bend or twist the knee. Dependent on the size of the tear, the meniscus can stay connected to the front and the back with a smaller tear, however the meniscus may only be left slightly intact with a larger tear. Intermittent sharp pain may occur on the affected side of the joint which results from the part of the tear catching between the articular joint surfaces of the tibia and femur blocking the knee from extending fully and straightening, causing a locking sensation. The area may swell directly after the injury or several hours later as a result of inflammation. After the injury there can often also be clicking, popping or locking of the knee and after the initial swelling and pain settles, normal activities can sometimes be resumed. When this occurs, it may be because the tear in the meniscus is small or the flap doesn’t affect the joint mechanics.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Immediately after the injury, treatment should be the same as any soft tissue injury, following the RICER protocol- Rest, Ice, Compression, Elevation and Referral. This should be following for the first 48-72 hours post injury to reduce the bleeding, inflammation and damage within the joint. Following this, a sports medicine professional, whether that be a podiatrist, physio or sports doctor, should be seen as soon as possible to assess the extent of the injury and provide advice on the treatment required.

Overview

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To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

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Overview

Click Here

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

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Overview

Hip bursitis is inflammation at the site of the hip bursae most commonly found in middle-aged and elderly women especially in low distance runners. It is where there is pain in the lateral hip region radiating to the outer region of the thigh and worse at night time. It is an overuse injury due to repetitive loading and poor trunk and pelvic stability and you are at a higher risk if you have previously had surgery at these regions. It is also found commonly in those who have Rheumatoid arthritis and people who have biomechanical issues such as a limb length discrepancy, poor core muscles or have significant overpronation through their feet which causes internal rotation of the lower limb and hip adduction.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

-Relative rest.
-Avoiding any aggravating activities.
-Strengthening of glute medius and stretching IT band as these structures run over the bursa.
-Possible orthotic intervention if indicated.
-Ultrasound guided cortisone injection.

Overview

A hip strain, or a hip flexor strain is where one of the supporting muscles in the hip joint is over stretched or torn. These can range from mild to severe depending on the extent of the injury and severe strains can limit the ability to move ones hip. Whilst a hip strain can occur at any time with mundane tasks, they are more likely to occur when doing sporting activities and whilst minor injuries improve with simple home treatments, more severe strains often require physical therapy or other medical treatment.

The hip is made up of the long thigh bone (femur) and the pelvis which are anchors for several muscles, and ligaments. In a hip strain the muscles or tendinous attachments are injured and they can be an over-stretch of the tendon or a partial or complete tear of the muscle fibers or the muscle tendon junction.

A hip stain can either be an acute injury or from overuse where the muscle or tendon becomes weakened over time with repetitive movements. There can be an increased risk of strain when there is a prior injury in the same area, muscle tightness, failure to warm up properly before exercising, attempting to do too much, too quickly, or exhaustion or deconditioning.

Signs of a hip strain can include pain or tenderness at the injured area, increased pain when the muscle is in use, swelling, limited range of motion or muscle weakness.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Many hip strains will improve with home treatment with the RICE protocol (rest, ice, compression, and elevation). Additionally, nonsteroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen and naproxen, can help reduce swelling and relieve pain. If the pain persists or it becomes more difficult to move your hip and leg, contact your podiatrist, physio or doctor.

When attending medical professionals they will do testing to ensure a correct diagnosis is completed and they will build a treatment pathway specilised to you which can include the following things:

Overview

Ankylosing spondylitis (AS) is a condition that mainly affects the spine in the sacroiliac joints which connects your base of your spine (sacrum) to your pelvis. It is where the joints of the neck, back and pelvis become inflamed, causing pain and stiffness and other joints, such as the hips and shoulders, can also be involved. AS can also affect other parts of the body, such as the eyes, skin, bowel and lungs. The symptoms of AS usually begin between the ages of 15 and 45 years and can be initially identified in the feet or ankles.

The symptoms of AS will vary vastly however will most commonly be pain and stiffness in the back, buttocks or next which is worse after rest or in early mornings and are releaved with exercise or moving. It can also appear with pain in tendons (which connect muscles to bones) and ligaments (which connect bones to each other), often felt as pain at the front of the chest, back of the heel or underneath the foot.

The cause of AS is unknown however there is increased risk with a family history and recently there are genes which are associated with increased risk of developing AS.

Whist commonly passing as ‘common back pain’, AS is often missed or patients with it are slow to seek assistance however it is important to seek diagnosis as early as possible as there are several effective treatments available and once diagnosed it is important to be referred on to a Rheumatologist.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

With treatment of medications and exercises most people who have AS can lead full and active lives with times where the symptoms worsen and flare. However, some people with AS have severe long lasting pain as a result of chronic inflammation in the spine and new bone growing around the joints leading to permanent stiffness in the back or neck. In severe cases this extra bone can fuse the cones in the spine together, stopping the spine from mobbing, leading to, at times, a bent or forward stooped posture. With early and effective treatments this can be prevented.

Rheumatologist’s will guide a treatment pathway and they will tailor treatment to symptoms and the severity of the condition as there is no way of predicting exactly which treatment will work best and multiple treatment pathways can be trialed to find one tailored to each individual. Each treatment has its own benefits and risks. Treatment usually involves:

• physiotherapy exercises (such as hydrotherapy or exercises in water), to keep the spine flexible and improve posture
• Medication such as:
  • analgesics (pain relievers, such as paracetamol)
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • corticosteroid medicines or injections
  • disease-modifying anti-rheumatic drugs (DMARDs)
  • biological DMARDs.

More information is available through the ARTHRITIS AUSTRALIA website which is a valuable resource: https://arthritisaustralia.com.au/types-of-arthritis/ankylosing-spondylitis/

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