Chiropractic in Noua Zeelanda - Engleza

Step by Step®
TREATMENT OF
OSTEOARTHRITIS KNEE
Step by Step®
TREATMENT OF
OSTEOARTHRITIS KNEE
Syed Musab Rahim Hashmi BPT

Chief Physiotherapist
Safe Hands Physiotherapy Clinic
Hyderabad, Andhra Pradesh, India
Lubna Fatima BPT
Associate Physiotherapist
Safe Hands Physiotherapy Clinic
Hyderabad, Andhra Pradesh, India
Foreword
Md Baseeruddin
JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

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Step by Step® Treatment of Osteoarthritis Knee
© 2011, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication and DVD-ROM should be reproduced, stored in a
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First Edition: 2011

ISBN 978-93-80704-83-8
Typeset at JPBMP typesetting unit
Printed at
To
My mother
late Dr Rukhsana Parveen,
Osmania University
Foreword ...........................
This book Step by Step Treatment of Osteoarthritis Knee is an

attempt to explain the disease and also to get rid of it
through physiotherapy. Osteoarthritis is a common
affliction among all age groups, though more common
among the elderly. The reasons for this are many.
According to many experts in the field of joint treatment
and medicine, it can be managed to a large extent. But
many agree that physiotherapy gives relief in a lot of cases.
The book is authored by practising physiotherapists
who have been in the field for a sizable time. The treatment
dealt with here is both by physical exercise and instruments
that can be operated very easily.
It is useful for physiotherapy practitioners, ortho-
pedicians and students. It will also help create awareness
among the general public about the disease. Tables and
diagrams have been extensively used to make it easily
understandable. Modern exercises have been included to
make it more relevant to the present day.
Md Baseeruddin BPT
Consultant Physiotherapist
Microsoft Corporation
Hyderabad, Andhra Pradesh
India
Preface ...............................
Step by Step Treatment of Osteoarthritis Knee can be aptly

described as the first book on this subject which includes
both medical and physiotherapy management.
This book is expected to fulfill the need of both the
practitioners and students of physiotherapy in better
understanding of osteoarthritis, particularly of the knee.
This book tries to give a more in-depth knowledge about
the subject.
This book is intended to further open the minds of
practitioners of physiotherapy on the issue of more diverse
exercises which can be done in cases of osteoarthritis knee.
However, one must understand that a few exercises
described here are difficult to be done during the acute
painful period of the disease process.
We do not claim this to be the ultimate book published
in the field of physiotherapy. It is just another small step
in the collective effort of all the practitioners and academia
in relieving the agony of our patients. Therefore, everybody
who feel that they are a part of the fraternity of those
intending to achieve maximum possible recovery of the
patients are welcome to bring out shortcomings in this
humble compilation. Suggestions, both from experts in the
field and also newcomers, are invited. Only if the
intellectuals work in symphony with each other, can we
achieve a wholesome and ethical environment, most
favorable for the pursuit of knowledge.
X Step by Step Treatment of Osteoarthritis Knee
Keeping in mind the practitioners’ need of under-

standing the management in a logical and practical
sequence, we have tried to explain matters in a step-wise
manner wherever required.
During the compilation of this book, practitioners’ needs
were kept in mind. Patients are requested not to implement
the regimens described herein without consultation with
a qualified expert.
We maintain two websites physiosafe.com and
physiohyderabad.com where contact can be established with
us and more information can be accessed.
Syed Musab Rahim Hashmi

Lubna Fatima
Acknowledgments............
I acknowledge the contribution of my ‘guru’, Dr K Aditya,

BPT, DSPT, Principal, DCMS College of Physiotherapy,
Hyderabad, Andhra Pradesh, India who has taught me
whatever I know about physiotherapy.
Further, I acknowledge the suggestions and valuable
feedback of the famous physiotherapist, Dr MY Sayani
DPT, CSP(UK), Director, Sayani Surgicals, Hyderabad,
Andhra Pradesh, India whose contribution to the field of
physiotherapy is incomparable. His efforts in popularizing
this kind of treatment are immense.
The following eminent personalities in the field
encouraged me with their opinions and suggestions in
completing this endeavor:
• Dr Phani Chander Reddy, BPT, former Principal,
Shadan College of Physiotherapy, Hyderabad, Andhra
Pradesh, India.
• Dr Imran B, MPT, former Faculty Memeber, DCMS
College of Physiotherapy, Hyderabad, Andhra Pradesh,
India.
• Dr Md Baseeruddin, BPT, Consultant Physiotherapist,
Microsoft Corporation, Hyderabad, Andhra Pradesh,
India.
Last but not least, I acknowledge the hardwork of the
management and staff of M/s Jaypee Brothers Medical
Publishers (P) Ltd., New Delhi, India who have been very
accommodating and supportive during the entire
endeavor.
Contents ............................
1. Understanding Osteoarthritis .................................. 1

2. Anatomy of the Knee-Joint or
Articulatio Genu ........................................................ 5
3. Causes of Osteoarthritis ......................................... 23
4. Risk Factors in Osteoarthritis ................................ 41
5. Signs and Symptoms of Osteoarthritis ................ 57
6. Preventive Measures for Osteoarthritis ............... 61
7. Common Knee Problems ........................................ 65
8. Diagnostic Methods of Osteoarthritis ................. 67
9. Medical Management of Osteoarthritis .............. 79
10. Surgical Management of Osteoarthritis .............. 85
11. Physiotherapeutic Modalities ................................ 91
12. Physiotherapeutic Exercises ................................. 115
13. Living with it (Practical Tips) .............................. 173
14. Alternate Medicine ................................................ 185
Index .......................................................................... 189

Understanding
1 Osteoarthritis
INTRODUCTION
Osteoarthritis (OA) is the most common type of arthritis.
It usually affects weight-bearing joints in the knees and
hips, along with hands and spine. It can cause stiffness,
joint pain and reduced movement. If OA is located in the
hips or knees, it can impair an individual’s ability to stand,
walk, climb and engage in other physical activities.
OA occurs in joints, where two or more bones meet.
The body has several types of joints. Some joints have
reduced movement, such as those in the skull, whereas
others allow wide range of motion, such as those in the
limbs.
OA primarily occurs in joints with the most movement,
such as hips, knees, feet and hands. These joints are known
as cartilaginous and synovial joints. A synovial joint capsule
is a space enclosed by the bones and adjoining ligaments.
The outer layer of the capsule is formed by a fibrous
membrane. The inside of the capsule is lined with synovial
membrane and filled with synovial fluid, which provides
lubrication. The ends of the bones encased in the capsule
are cushioned in soft cartilage. The cartilage and synovial
fluid permit the bones to move without rubbing against
each other. Figure 1.1 shows illustrations of healthy
cartilage and the damaged cartilage which has been
affected by osteoarthritis.
2 Step by Step Treatment of Osteoarthritis Knee
Fig. 1.1: Healthy cartilage and damaged cartilage affected by

osteoarthrities
Cartilaginous joints do not have a synovial cavity, but have
cartilage and fibrous disks between the bones to allow some
movement. The vertebrae in the spine have cartilaginous
joints.
Most OA damage is the result of cartilage degeneration.
Cartilage is made up of three substances:
• Collagen: A fibrous protein common in skin and
connective tissue.
• Proteoglycans: Strands of protein and sugar.
• Chondrocytes: Cells that usually help cartilage
development, but can release enzymes (proteins that
stimulate chemical reactions) that destroy collagen and
other proteins.
Understanding Osteoarthritis 3
Changes in the interaction of cartilage tissue lead to its

deterioration. Chondrocytes can produce enzymes that
destroy collagen and proteoglycans. Although the origin
of this enzyme disruption is unknown, outside factors, such
as years of stress on the joint, may be involved.
The disrupted interaction of chondrocytes, collagen and
proteoglycans eventually leads the cartilage to breakdown.
The smooth cartilage surface wears and frays. The bone
underlying the cartilage is exposed and may form bony
spurs called osteophytes. With less cartilage, more
exposure of bone and ragged surfaces, the joint cavity
becomes smaller and joint movement becomes painful or
stiff.
OA is usually defined by this degenerative process. It
was previously thought that the disease involved no
inflammation, despite the fact that the word arthritis means
inflammation in a joint. However, some recent studies have
indicated that joints severely degenerated by OA have, in
fact, shown some inflammation.
Joints commonly affected by OA include the fingers,
spine and the weight-bearing joints of the hips, knees and
feet. It is less common in the jaw, shoulders, elbows, wrists
and ankles, unless a separate injury occurs or stress in the
area, such as an athletic injury or trauma. Although many
forms of arthritis can affect other body systems, OA
remains confined to the joints.
The course of OA varies for each person. Some
individuals may experience a slight ache in one joint that
never worsens. Other people may have morning stiffness
or pain during exercise. In some cases, OA limits mobility
and restricts the abilities of joints such as the fingers and
knees. Most cases of OA are primary OA, which begin with

no known origin. Secondary OA occurs after injury or
overuse of a particular joint, such as the knee.
X-ray studies have shown the beginning of OA damage
to bones by age 45. However, pain from this damage may
not begin for many years. According to the American
College of Rheumatology, by age 70, X-rays show OA in
70 percent of the population, although not all of these
people experience pain from the condition.
It is important to note that OA is not the same as
rheumatoid arthritis (RA), a more severe, inflammatory
form of arthritis that occurs in younger people. Although
both forms of arthritis cause joint pain, there are several
major differences:
• OA involves degeneration of joint cartilage. RA, an
autoimmune disorder, involves inflammation of the
membranes lining joints.
• OA may occur on one side (e.g. in one knee). RA usually
occurs symmetrically, such as in both hands and both
knees.
• OA affects only the joints. RA can affect other systems
in the body, including the lungs, nerves or heart.
Anatomy of
2 the Knee-Joint
or Articulatio Genu
INTRODUCTION
The knee-joint was formerly described as a ginglymus or
hinge-joint. But it is really of a much more complicated
character. It must be regarded as consisting of three
articulations in one: two condyloid joints, one between each
condyle of the femur and the corresponding meniscus and
condyle of the tibia; and a third between the patella and
the femur, partly arthrodial, but not completely, since the
articular surfaces are not mutually adapted to each other,
so that the movement is not a simple gliding . This view of
the construction of the knee-joint receives confirmation
from the study of the joints of some of the lower mammals,
where, corresponding to these three subdivisions, three
synovial cavities are sometimes found, either entirely
distinct or only connected together by small
communications. This view is further made more probable
by the existence in the middle of the joint of the two cruciate
ligaments, which must be regarded as the collateral
ligaments of the medial and lateral joints. The existence of
the patellar fold of synovial membrane would further
indicate a tendency of the separation of the synovial cavity
into two minor sacs or cavities, one corresponding to the
lateral and the other, to the medial joint.
KNEE BONES AND LIGAMENTS

The knee bones are connected together by the following
ligaments (Figs 2.1 to 2.4):
• Articular capsule: Anterior Cruciate ligament.
• Ligamentum patellae: Posterior Cruciate ligament.
• Oblique popliteal ligament: Medial and Lateral Menisci.
• Tibial collateral ligament: Transverse ligament.
• Fibular collateral ligament: Coronary ligament.
The Articular Capsule (Capsula Articulari or

Capsular Ligament)
The articular capsule consists of a thin, but strong, fibrous
membrane which is strengthened in almost its entire extent
Fig. 2.1: Right knee-joint: Anterior view

Anatomy of the Knee-Joint or Articulatio Genu 7
Fig. 2.2: Right knee-joint, from the front, showing interior

ligaments
Fig. 2.3: Left knee-joint from behind,

showing interior ligaments
Fig. 2.4: Sagittal section of right knee-joint
by bands inseparably connected with it. Above and in

front, beneath the tendon of the Quadriceps femoris, it is
represented only by the synovial membrane.
Its chief strengthening bands are derived from the fascia
lata and from the tendons surrounding the joint.
In front, expansions from the Vasti and from the fascia
lata and its iliotibial band fill in the intervals between the
anterior and collateral ligaments, constituting the medial
and lateral patellar retinacula.
The back of the capsule consists of vertical fibers which

arise from the condyles and from the sides of the
intercondyloid fossa of the femur; the posterior part of the
capsule is therefore situated on the sides of and in front of
the cruciate ligaments, which are thus excluded from the
joint cavity. Behind the cruciate ligaments is the oblique
popliteal ligament which is augmented by fibers derived
from the tendon of the Semimembranosus. Laterally, a
prolongation from the iliotibial band fills in the interval
between the oblique popliteal and the fibular collateral
ligaments, and partly covers the latter. Medially,
expansions from the sartorius and semimembranosus pass
upward to the tibial collateral ligament and strengthen the
capsule.
The Ligamentum Patellae (Anterior Ligament)

The ligamentum patellae is the central portion of the
common tendon of the quadriceps femoris, which is
continued from the patella to the tuberosity of the tibia. It
is a strong, flat, ligamentous band, about 8 cm in length,
attached above the apex and adjoining margins of the
patella and the rough depression on its posterior surface;
below the tuberosity of the tibia;
• Its superficial fibers continue over the front of the patella
with those of the tendon of the quadriceps femoris.
• The medial and lateral portions of the tendon of the
Quadriceps pass down on either side of the patella, to
be inserted into the upper extremity of the tibia on either
sides of the tuberosity.
• These portions merge into the capsule, as stated above,
forming the medial and lateral patellar retinacula.
The posterior surface of the ligamentum patellae is

separated from the synovial membrane of the joint by a
large infrapatellar pad of fat, and from the tibia by a bursa.
The Oblique Popliteal Ligament (ligamentum

popliteum obliquum; posterior ligament)
This ligament is a broad, flat and fibrous band, formed of
fasciculi separated from one another by apertures for the
passage of vessels and nerves.
It is attached above the upper margin of the
intercondyloid fossa and posterior surface of the femur,
close to the articular margins of the condyles, and below
the posterior margin of the head of the tibia.
Superficial to the main part of the ligament is a strong
fasciculus, derived from the tendon of the semi-
membranosus and passing from the back part of the medial
condyle of the tibia obliquely upward and lateralward to
the back part of the lateral condyle of the femur.
The oblique popliteal ligament forms part of the floor
of the popliteal fossa, and the popliteal artery rests upon it.
The Tibial Collateral Ligament (ligamentum

collaterale tibiale; internal lateral ligament)
The tibial collateral is a broad, flat, membranous band,
situated nearer to the back than to the front of the joint.
It is attached, above the medial condyle of the femur,
immediately below the adductor tubercle; below the
medial condyle and medial surface of the body of the tibia.
The fibers of the posterior part of the ligament are short
and incline backward as they descend; they are inserted
into the tibia above the groove for the Semimembranosus.
The anterior part of the ligament is a flattened band,

about 10 cm long, which inclines forward as it descends.
It is inserted into the medial surface of the body of the
tibia about 2.5 cm below the level of the condyle.
It is crossed, at its lower part, by the tendons of the
Sartorius, Gracilis, and Semitendinosus, a bursa being
interposed.
Its deep surface covers the interior medial genicular
vessels and nerve and the anterior portion of the tendon
of the Semimembranosus, with which it is connected by a
few fibers; it is intimately adherent to the medial meniscus.
The Fibular Collateral Ligament (ligamentum

collaterale fibulare; external lateral or long
external lateral ligament)
The fibular collateral is a strong, rounded, fibrous cord,
attached, above, to the back part of the lateral condyle of
the femur, immediately above the groove for the tendon
of the popliteus; below the lateral side of the head of the
fibula, in front of the styloid process.
The greater part of its lateral surface is covered by the
tendon of the Biceps femoris; the tendon, however, divides
at its insertion into two parts, which are separated by the
ligament.
At the deep level of the ligament are found the tendon
of the Popliteus, and the inferior lateral genicular vessels
and nerve.
The ligament has no attachment to the lateral meniscus.
An inconstant bundle of fibers, the short fibular
collateral ligament, is placed behind and parallel with the
preceding, attached, above the lower and back part of the
lateral condyle of the femur and below the summit of the

styloid process of the fibula.
Further deep are the tendon of the Popliteus, and the
inferior lateral genicular vessels and nerve.
The Cruciate Ligaments (ligamenta cruciata genu;

crucial ligaments)
The cruciate ligaments are of considerable strength,
situated in the middle of the joint, nearer to its posterior
than to its anterior surface.
They are called cruciate because they cross each other
somewhat like the lines of the letter X; and are named
anterior and posterior, from the position of their
attachments to the tibia.
The anterior cruciate ligament (ligamentum cruciatum
anterius; external crucial ligament) is attached to the
depression in front of the intercondyloid eminence of the
tibia, being blended with the anterior extremity of the
lateral meniscus; it passes upward, backward, and
lateralward, and is fixed into the medial and back part of
the lateral condyle of the femur.
The Posterior Cruciate Ligament (ligamentum

cruciatum posterius; internal crucial ligament)
The Posterior Cruciate Ligament (ligamentum cruciatum
posterius; internal crucial ligament) is stronger, but shorter
and less oblique in its direction, than the anterior.
It is attached to the posterior intercondyloid fossa of
the tibia, and to the posterior extremity of the lateral
meniscus; and passes upward, forward, and medialward,
to be fixed into the lateral and front part of the medial
condyle of the femur.
The Menisci (semilunar fibrocartilages)

The menisci are two crescentic lamellae, which serve to
deepen the surfaces of the head of the tibia for articulation
with the condyles of the femur.
The peripheral border of each meniscus is thick, convex,
and attached to the inside of the capsule of the joint; the
opposite border is thin, concave, and free.
The upper surfaces of the menisci are concave, and in
contact with the condyles of the femur. Their lower surfaces
are flat, and rest upon the head of the tibia; both surfaces
are smooth, and invested by synovial membrane.
Each meniscus covers approximately the peripheral
two-thirds of the corresponding articular surface of the tibia.
The medial meniscus (meniscus medialis; internal
semilunar fibrocartilage) is nearly semicircular in form, a
little elongated from before backward, and broader behind
than in front. Its anterior end, thin and pointed, is attached
to the anterior intercondyloid fossa of the tibia, in front of
the anterior cruciate ligament. The posterior end is fixed
to the posterior intercondyloid fossa of the tibia, between
the attachments of the lateral meniscus and the posterior
cruciate ligament.
The lateral meniscus (meniscus lateralis; external
semilunar fibrocartilage) is nearly circular and covers a
larger portion of the articular surface than the medial one.
It is grooved laterally for the tendon of the Popliteus,
which separates it from the fibular collateral ligament.
Its anterior end is attached in front of the intercondyloid
eminence of the tibia, lateral to, and behind, the anterior
cruciate ligament, with which it blends. The posterior end
is attached behind the intercondyloid eminence of the tibia
and in front of the posterior end of the medial meniscus.
The anterior attachment of the lateral meniscus is

twisted on itself so that its free margin looks backward
and upward, its anterior end resting on a sloping shelf of
bone on the front of the lateral process of the intercondyloid
eminence.
Close to its posterior attachment it sends off a strong
fasciculus, the ligament of Wrisberg, which passes upward
and medialward, to be inserted into the medial condyle of
the femur, immediately behind the attachment of the
posterior cruciate ligament.
Occasionally a small fasciculus passes forward to be
inserted into the lateral part of the anterior cruciate ligament.
The lateral meniscus gives off from its anterior convex
margin a fasciculus which forms the transverse ligament.
The Transverse Ligament (ligamentum

transversum genu)
The transverse ligament connects the anterior convex
margin of the lateral meniscus to the anterior end of the
medial meniscus; its thickness varies considerably in
different subjects, and it is sometimes absent.
The coronary ligaments are merely portions of the
capsule, which connect the periphery of each meniscus
with the margin of the head of the tibia.
Synovial Membrane
The synovial membrane of the knee-joint is the largest and
most extensive in the body.
Commencing at the upper border of the patella, it forms
a large cul-de-sac beneath the Quadriceps femoris (on the
lower part of the front of the femur, and frequently
communicates with a bursa interposed between the tendon

and the front of the femur.
The pouch of synovial membrane between the
Quadriceps and front of the femur is supported, during
the movements of the knee, by a small muscle, the
Articularis genu, which is inserted into it.
On either side of the patella, the synovial membrane
extends beneath the aponeuroses of the Vasti, and more
especially beneath that of the Vastus medialis.
Below the patella it is separated from the ligamentum
patellae by a considerable quantity of fat, known as the
infrapatellar pad. From the medial and lateral borders of
the articular surface of the patella, reduplications of the
synovial membrane project into the interior of the joint.
These form two fringe-like folds termed the alar folds.
Below the folds converge it continues as a single band, the
patellar fold (ligamentum mucosum), to the front of the
intercondyloid fossa of the femur.
On either side of the joint, the synovial membrane passes
downward from the femur, lining the capsule to its point
of attachment to the menisci; it may then be traced over
the upper surfaces of these to their free borders, and thence
along their under surfaces to the tibia. At the back part of
the lateral meniscus it forms a cul-de-sac between the
groove on its surface and the tendon of the popliteus; it is
reflected across the front of the cruciate ligaments, which
are therefore situated outside the synovial cavity.
Bursae
The bursae near the knee-joint are the following:
In front there are four bursae: A large one is interposed
between the patella and the skin, a small one between the
upper part of the tibia and the ligamentum patellae, a third

between the lower part of the tuberosity of the tibia and
the skin, and a fourth between the anterior surface of the
lower part of the femur and the deep surface of the
Quadriceps femoris, usually communicating with the
knee-joint.
Laterally there are four bursae:
1. One (which sometimes communicates with the joint)
between the lateral head of the gastrocnemius and the
capsule.
2. Another between the fibular collateral ligament and the
tendon of the biceps.
3. Yet another between the fibular collateral ligament and
the tendon of the Popliteus (this is sometimes only an
expansion from the next bursa).
4. The last, between the tendon of the popliteus and the
lateral condyle of the femur, usually an extension from
the synovial membrane of the joint.
Medially, there are five bursae:
1. One between the medial head of the gastrocnemius and
the capsule. This sends a prolongation between the
tendon of the medial head of the gastrocnemius and
the tendon of the semimembranosus and often
communicates with the joint.
2. The other superficial to the tibial collateral ligament,
between it and the tendons of the sartorius, gracilis, and
semitendinosus.
3. Another is set deep to the tibial collateral ligament,
between it and the tendon of the Semimembranosus
(this is sometimes only an expansion from the next
bursa).
4. Yet another between the tendon of the semimem-

branosus and the head of the tibia and
5. Occasionally there is a bursa between the tendons of
the semimembranosus and semitendinosus.
STRUCTURES AROUND THE JOINT

In front, and at the sides, is the Quadriceps femoris;
laterally the tendons of the Biceps femoris and Popliteus
and the common peroneal nerve; medially, the Sartorius,
Gracilis, Semitendinosus, and Semimembranosus; behind,
the popliteal vessels and the tibial nerve, Popliteus,
Plantaris, and medial and lateral heads of the
Gastrocnemius, some lymph glands, and fat.
The arteries supplying the joint are the highest genicular
(anastomotica magna), a branch of the femoral, the
genicular branches of the popliteal, the recurrent branches
of the anterior tibial, and the descending branch from the
lateral femoral circumflex of the profunda femoris.
The nerves are derived from the obturator, femoral,
tibial, and common peroneal.
Movements
The movements that take place at the knee-joint are flexion
and extension, and, in certain positions of the joint,
internal and external rotation.
The movements of flexion and extension at this joint
differ from those in a typical hinge-joint, such as the elbow,
in that (a) the axis around which motion takes place is not
fixed, but shifts forward during extension and backward
during flexion; (b) the commencement of flexion and the
end of extension are accompanied by rotatory movements
associated with the fixation of the limb in a position of

great stability.
The movement from full flexion to full extension may,
therefore, be described in three phases:
1. In the fully flexed condition the posterior parts of the
femoral condyles rest on the corresponding portions of
the meniscotibial surfaces, and in this position a slight
amount of simple rolling movement is allowed.
2. During the passage of the limb from the flexed to the
extended position a gliding movement is superposed
on the rolling, so that the axis, which at the
commencement is represented by a line through the
inner and outer condyles of the femur, gradually shifts
forward.
In this part of the movement, the posterior two-thirds
of the tibial articular surfaces of the two femoral
condyles are involved, and as these have similar
curvatures and are parallel to one another, they move
forward equally.
3. The lateral condyle of the femur is brought almost to
rest by the tightening of the anterior cruciate ligament.
It moves, however, slightly forward and medialward,
pushing before it the anterior part of the lateral meniscus.
The tibial surface on the medial condyle is prolonged
farther forward than that on the lateral, and this
prolongation is directed lateralward. When, therefore, the
movement forward of the condyles is checked by the
anterior cruciate ligament, continued muscular action
causes the medial condyle, dragging with it the meniscus,
to travel backward and medialward, thus producing an
internal rotation of the thigh on the leg. When the position
of full extension is reached the lateral part of the groove
on the lateral condyle is pressed against the anterior part

of the corresponding meniscus, while the medial part of
the groove rests on the articular margin in front of the
lateral process of the tibial intercondyloid eminence. Into
the groove on the medial condyle is fitted the anterior part
of the medial meniscus, while the anterior cruciate
ligament and the articular margin in front of the medial
process of the tibial intercondyloid eminence are received
into the forepart of the intercondyloid fossa of the femur.
This third phase by which all these parts are brought
into accurate apposition is known as the “screwing home,”
or locking movement of the joint.
The complete movement of flexion is the converse of
that described above, and is therefore preceded by an
external rotation of the femur which unlocks the extended
joint.
The axes around which the movements of flexion and
extension take place are not precisely at right angles to
either bone; in flexion, the femur and tibia are in the same
plane, but in extension the one bone forms an angle,
opening lateralward with the other.
In addition to the rotatory movements associated with
the completion of extension and the initiation of flexion,
rotation inward or outward can be effected when the joint
is partially flexed. These movements take place mainly
between the tibia and the menisci, and are more free when
the leg is bent at right angles with the thigh.
Movements of Patella
The articular surface of the patella is indistinctly divided
into seven facets—upper, middle, and lower horizontal
pairs, and a medial perpendicular facet.
When the knee is forcibly flexed, the medial

perpendicular facet is in contact with the semilunar surface
on the lateral part of the medial condyle. This semilunar
surface is a prolongation backward of the medial part of
the patellar surface.
As the leg is carried from the flexed to the extended
position, first the highest pair, then the middle pair, and
lastly the lowest pair of horizontal facets, are successively
brought into contact with the patellar surface of the femur.
In the extended position, when the Quadriceps femoris
is relaxed, the patella lies loosely on the front of the lower
end of the femur.
During flexion, the ligamentum patellae is put upon the
stretch, and in extreme flexion, the posterior cruciate
ligament, the oblique popliteal, and collateral ligaments,
and, to a slight extent, the anterior cruciate ligament, are
relaxed.
Flexion is checked during life by the contact of the leg
with the thigh. When the knee-joint is fully extended the
oblique popliteal and collateral ligaments, the anterior
cruciate ligament, and the posterior cruciate ligament, are
rendered tense. While extending the knee, the ligamentum
patellae is tightened by the quadriceps femoris, but in full
extension with the heel supported it is relaxed.
Rotation inward is checked by the anterior cruciate
ligament;. rotation outward tends to uncross and relax the
cruciate ligaments, but is checked by the tibial collateral
ligament.
The main function of the cruciate ligament is to act as a
direct bond between the tibia and femur and to prevent
the former bone from being carried too far backward or
forward.
They also assist the collateral ligaments in resisting any

bending of the joint to either side.
The menisci are intended, as it seems, to adapt the
surfaces of the tibia to the shape of the femoral condyles
to a certain extent, so as to fill up the intervals which would
otherwise be left in the varying positions of the joint, and
to obviate the jarring which would be so frequently
transmitted up the limb in jumping or by falls on the feet.
They also permit the two varieties of motion, flexion and
extension, and rotation, as explained above.
The patella (Fig. 2.5) acts as a great defense against the
front of the knee-joint, and distributes upon a large and
tolerably even surface. While kneeling, the pressure, which
would otherwise fall upon the prominent ridges of the
condyles; it also affords leverage to the quadriceps femoris.
Fig. 2.5: Posterior surface of the right patella, showing

diagrammatically the areas of contact with the femur in different
positions of the knee
When standing erect in the attitude of “attention,” the

weight of the body falls in front of a line carried across the
centers of the knee-joints, and therefore tends to produce
overextension of the articulations. This, however, is
prevented by the tension of the anterior cruciate, oblique

popliteal, and collateral ligaments.
Extension of the leg on the thigh is performed by
quadriceps femoris.
Flexion is performed by:
1. Biceps femoris
2. Semitendinosus
3. Semimembranosus.
The process is assisted by:
1. Gracilis
2. Sartorius
3. Gastrocnemius
4. Popliteus
5. Plantaris.
Rotation outward is effected by the biceps femoris.
Inward rotation is helped by the popliteus,
semitendinosus, and, to a slight extent, the semimem-
branosus, the sartorius, and the gracilis.
The Popliteus comes into action especially at the
commencement of the movement of flexion of the knee.
By its contraction the leg is rotated inward, or, if the tibia
be fixed, the thigh is rotated laterally. Thus the knee-joint
is unlocked.
Causes of
3 Osteoarthritis
INTRODUCTION
Osteoarthritis’ exact cause remains unknown. Researchers
know aging does not appear to be its cause. Cartilage in
people with the disease show many destructive changes
not seen in older persons without the disease. However,
certain conditions do seem to trigger osteoarthritis or make
it worse.
Some families seem to have a lot of osteoarthritis,
pointing to a genetic factor. This is most commonly seen
in people who have osteoarthritis of the hands. Repeated
trauma can contribute to osteoarthritis, too. Athletes,
extremely active people, and individuals, who have
physically demanding jobs, often develop the disease.
Persons, who have certain bone disorders, are more prone
to osteoarthritis due to the continuous and uneven stress
in their hips and knees.
Obesity also is a risk factor for the disease. In overweight
women, osteoarthritis of the knee is fairly common. Excess
pounds also may have a direct metabolic effect on cartilage
beyond the effects of increased joint stress. Obese people
also often have more dense bones. Research has shown
dense bones may provide less shock-absorbing function
than thinner bones, allowing more direct trauma to the
cartilage.
Acute Macro-Traumatic Injury (Fig. 3.1)

An example of this type of injury is a rupture or tear of a
ligament, part of the passive restraint system of the knee.
Perhaps most common among these injuries is rupture of
the anterior cruciate ligament, a condition usually caused
by over-rotation of the joint. This type of injury can occur
in both sports and occupations where there is excessive
twisting.
Micro-Traumatic Injury (Fig. 3.2)

Micro-trauma due to overstress of normal tissue. Instead
of damage from one event, the knee suffers many repetitive
injuries over a period of time. Another name for this
condition is overuse syndrome.
Fig. 3.1: Macro-traumatic injuries: Front view

Causes of Osteoarthritis 25
Fig. 3.2: Micro-traumatic injuries: Side view
Micro-trauma often occurs with a sudden increase in

exercise level, such as when a runner increases distance or
a tennis player plays extra sets.
MAIN CAUSES
Most of the time, the cause of OA is unknown. It is mainly
related to aging, but metabolic, genetic, chemical, and
mechanical factors can also lead to OA.
Osteoarthritis of the knee usually occurs in knees that
have experienced trauma, infection, or injury. A smooth,
slippery, fibrous connective tissue, called articular
cartilage, acts as a protective cushion between bones.
Arthritis develops as the cartilage begins to deteriorate or
is lost. As the articular cartilage is lost, the joint space
between the bones narrows. This is an early symptom of

osteoarthritis of the knee and is easily seen through X-rays.
As the disease progresses, the cartilage thins, becoming
grooved and fragmented. The surrounding bones react by
becoming thicker. They start to grow outward and form
spurs. The synovium (a membrane that produces a thick
fluid that helps nourish the cartilage and keeps it slippery)
becomes inflamed and thickened. It may produce extra
fluid, often known as “water on the knee,” that causes
additional swelling.
Over a period of years, the joint slowly changes. In
severe cases, when the articular cartilage is gone, the
thickened bone ends rub against each other and wear
away. This results in a deformity of the joint. Normal
activity becomes painful and difficult.
Primary vs Secondary
Primary, or idiopathic, is the most common type of OA
and has no identifiable underlying etiology or predisposing
cause. Although secondary OA has an underlying cause,
pathologically it is indistinguishable from primary OA. In
some cases, the distinction between primary and secondary
disease is unclear because the clinical presentation and
symptoms of both classifications are often very similar.
However, clinically, it is generally not important to make
a distinction between the two forms.
Several disorders are well-recognized as causes of
secondary OA. They can be grouped into the four basic
categories as shown in Table 3.1.
PRIMARY OSTEOARTHRITIS
OA is classified as primary (idiopathic) OA or secondary
according to some known cause or disease. Although the
Table 3.1: Potential causes of secondary OA
Metabolic Calcium crystal deposition, hemochromatosis,
acromegaly
Anatomic Leg length inequality, congenital hip dislocation
Traumatic Major joint trauma, chronic joint injury
(occupational), joint surgery
Inflammatory Ankylosing spondylitis, septic arthritis
etiology of primary OA is not fully understood, systemic

factors such as sex, age and heredity have been proven to
contribute to its onset. In the knee, local factors such as
previous knee trauma, a person’s biomechanical
alignment, and obesity, also contribute to the degeneration
of cartilage, and consequently OA.
The osteoarthritic process involves a slow progression
of degenerative changes. In the knee, cartilage loss may
occur in the medial, lateral and/or patellofemoral
compartment. OA may be unicompartmental, occurring
in one compartment only, or bicompartmental, with
pathology occurring in both the medial and lateral
compartments of the knee. The most challenging brace
candidate is the patient that suffers from tricompartmental
OA, with disease pathology occurring in all three
compartments of the knee.
Criteria for the classification of primary OA of the knee
involves specific radiographic, and clinical evidence
(Table 3.2) as outlined by the American College of
Rheumatology (Altman et al 1986). Radiographic evidence
provides clues to the progression of OA, by depicting joint
space narrowing, and the presence of osteophytes (bony
outgrowths).
Table 3.2: Classification

Stage Findings
0 Normal joint
I No skeletal abnormalities, soft-tissue swelling is present
II Osteoporosis and overgrowth of the epiphysis, no cysts, no
narrowing of the cartilage space
III Early subchondral bone cysts, squaring of the patella, widened
notch of the distal femur or humerus, preservation of the
cartilage space
IV Findings of stage III, but more advanced; narrowed cartilage
space
V Fibrous joint contracture, loss of the joint cartilage space,
extensive enlargement of the epiphysis, substantial
disorganization of the joint
To properly diagnosis OA, clinical evidence needs to

be gathered by a health care practitioner (HCP). A HCP
performs a physical examination to assess a person’s
biomechanical alignment, which helps determine which
compartment of the knee is effected. For example, a person
that has genu varum alignment, or is commonly referred
to as being bow-legged, suggests medial compartment
involvement. Genu valgum alignment predisposes a
person to lateral compartment osteoarthritis. In the early
stages of OA, pathology is not always synchronous with
clinical evidence of OA. As the osteoarthritic process
progresses, the surface of the knee joint becomes swollen,
resulting in sufferers displaying clinical signs of
inflammation. Other signs such as crepitus (cracking or
grinding) and tenderness at the joint line become more
prominent as bony changes occur and cartilage
degeneration continues.
As the cartilage loses its elasticity, range of motion in

the knee is lost, and sufferers of OA complain of stiffness
in the knee. Patients describe knee pain that is diffuse, or
specific to the compartment of the knee affected. The pain
is typically activity related, made worse with weight
bearing and improved with rest. The loss in motion, and
chronic pain, makes daily living tasks, such as walking
and climbing stairs, extremely difficult for people living
with OA. For these reasons, osteoarthritis of the knee
accounts for more dependency in daily living tasks, than
any other joint disease (Manek and Lane, 2000). The
prevalence of the disease, especially amongst the elderly,
creates a demand for a thorough medical management
plan. Ossur specializes in custom knee bracing, one
strategy that has been proven to improve the quality of
life for people with osteoarthritis.
SECONDARY OA
The causes of secondary osteoarthritis knee are as follows:
Dysplasia, Congenital or Acquired

Some people suffering from Congenital aplasia of the
anterior cruciate ligament may get osteoarthritis of knee.
Trauma (sports-induced)
Exercise-induced osteoarthrosis (OA), most commonly of
the hip and knee, is a significant and disabling condition
for many present and former athletes. The resulting pain
and loss of movement can limit function. And while former
athletes report symptoms at similar rates to the population
in general, they also have higher pain thresholds, which
may lead to a relative underestimation of their problems.
The mechanisms by which sportsmen may develop

exercise-induced osteoarthrosis (OA) is not yet properly
developed. Several models have been proposed. It is
known, for instance, that sporting activity increases the
chances of suffering minor trauma to the articular cartilage.
This will alter the way in which forces are transmitted
through the joint, risking further damage; and may also
alter the force transfer through adjacent joints, putting these
in jeopardy.
Sporting activity also increases the chances of damage
to intra-articular structures. Taking the knee as an example,
a meniscal tear can result in chondral (articular cartilage)
damage. Rupture of a knee ligament, such as the anterior
cruciate ligament, is also associated with a greater risk of
articular damage.
Osteonecrosis
Osteonecrosis is a disease characterized by a derangement
of osseous circulation leading to actual necrosis of osseous
tissue. Osteonecrosis of the knee has been divided into two
separate entities, spontaneous osteonecrosis of the knee
(SPONK) and secondary osteonecrosis.
Problem
In osteonecrosis, the lesion can extend to the subchondral
plate and result in collapse of the necrotic segment. This
can lead to disruption of the joint line, resulting in painful
secondary arthritis.
Frequency
The knee is the second most common site for osteonecrosis,
and it is affected much less often than the hip.
Osteonecrosis of the knee is believed to account for

approximately 10 percent of such cases.
Etiology
The etiology of SPONK is poorly understood. A possible
causative factor may be trauma. SPONK commonly is seen
in elderly women with osteoporotic bone. Osteoporotic
bone is more susceptible to microfracture with minor
trauma, which leads to fluid accumulation in the marrow
space. The intraosseous edema leads to increased pressure
within the marrow cavity and may lead to subsequent
ischemia and necrosis. Another possible cause may be
vascular compromise to the subchondral bone, resulting
in osseous ischemia and subsequent edema. Again, edema
leads to rise in intraosseous pressure that further
compromises blood flow, thus worsening ischemia and
necrosis.
The etiology of secondary osteonecrosis is unknown.
However, several risk factors are associated with this
disease. Use of corticosteroid is the most significant risk
factor. Other risk factors include alcohol consumption,
sickle-cell disease, systemic lupus erythematosus (SLE),
caisson disease, and Gaucher disease. The pathogenesis
for this condition is poorly understood. A possible
mechanism is microvascular disruption in the subchondral
bone, which causes infarction. This compromise of
circulation leads to bone marrow edema and resultant
ischemia and necrosis. The mechanism by which
corticosteroids contribute to osteonecrosis also is unclear.
A possible hypothesis is an increase in size of the marrow
fat cells, which leads to decreased circulation and ischemia.
Other possible contributing factors to the etiopathogenesis

are coagulopathies, fat emboli, and thrombi formation.
Chronic Inflammation
Chronic inflammation can also lead to secondary
Osteoarthritis knee:
Angiogenesis and inflammation are central players in the
osteoarthritis (OA) disease process, and inhibiting both
processes might alter OA progression, inflammation,
angiogenesis linked to pain, cartilage damage:
OA has traditionally been described as a noninflammatory
disease and distinguished from inflammatory arthro-
pathies such as rheumatoid arthritis (RA). But this
categorization is rapidly breaking down by new research
about the disease process.
Key Points
• Inflammation can stimulate angiogenesis.
• Angiogenesis can facilitate inflammation.
• Angiogenesis can promote chondrocyte hypertrophy
and endochondral ossification.
• Inflammation sensitizes nerves and decreases the pain
threshold.
• New innervation may accompany vascularization of the
articular cartilage.
• Hypoxia and compressive forces in the cartilage may
trigger these new nerves and cause pain, even after
inflammation has resolved.
Hemarthrosis, Specially Hemophilia

Joint hemorrhages are very common in patients with
severe hemophilia. Inhibitors in patients with hemophilia
are allo-antibodies that neutralize the activity of the clotting

factor. After total knee replacement, rare intra-articular
bleeding complications might occur that do not respond
to clotting factor replacement.
The Knee is the Classic Target Joint

The chronic joint effusions in hemophilia may be denser
than other effusions because of the presence of iron. Juxta-
articular osteoporosis develops, especially in children,
secondary to the hyperemic state. The irregular appearance
of the subchondral surface is secondary to either blood that
directly destroys bone or to synovial intrusion.
Deeper invasion of the synovium and joint fluid leads
to multiple subchondral cysts. Chronic hyperemia causes
overgrowth of the epiphysis and widening of the
intercondylar notch in the growing child. Squaring of the
inferior pole of the patella (seen in 20-30 percent of patients
with hemophilia) is another form of overgrowth. A similar
effect of overgrowth may be seen in children with juvenile
rheumatoid arthritis (JRA). A fixed flexion deformity and
painful limitation of motion are late findings on physical
examination.
Metabolic Disorders
Acromegaly
Acromegaly is an endocrine condition caused by the excess
production of growth hormone. People with acromegaly
may have an increased risk of OA.
OA often affects the knees and may substantially limit
the range of motion of these joints. Advanced OA of the
knee may be associated with changes in the alignment of
the knee, including a bow-legged or a knock-kneed
appearance. OA of the knee may also cause Baker’s cyst, a

collection of joint fluid in the hollow at the back of the
knee.
Hemochromatosis
About 1 in 200 persons in certain populations of northern
European descent has hereditary hemochromatosis. The
three most common symptoms are fatigue, arthralgia, and
libido loss. Radiographic findings look similar to those of
osteoarthritis (OA); however, OA in unusual sites, in large
non-weight-bearing joints, or in a patient younger than 50
years can be clues to hereditary hemochromatosis. Diabetes
develops in about 50 percent of affected patients, but the
well-known finding of “bronze diabetes” (skin
hyperpigmentation) occurs late in the disease.
Ochronosis
Ochronosis commonly affects all connective tissue.
Recognition of changes secondary to the deposition of
ochronotic pigments has increased with advances in
diagnostic technology, allowing both improved imaging
and early biochemical and genetics-based diagnosis of
alkaptonuria, the cause of ochronosis. Successful
symptomatic treatment of ochronotic arthropathy with
joint replacement has been documented, and a new
pharmacotherapeutic agent, nitisinone, is currently under
investigation for both prevention and treatment of
ochronosis.
Ochronotic arthropathy is a manifestation of long-
standing alkaptonuria resulting from deposition of ochro-
notic pigments within the articular cartilage.
The patients suffering from this disease are usually

asymptomatic until they present with arthritis of the main
joints or as low back pain and stiffness.
It also leads to stiff and painful shoulders. The tendency
for alkaptonuria to affect the shoulder joints further
distinguishes it from osteoarthritis.
The arthritis is usually so severe that the patient is
crippled with pain and cannot carry out routine activities.
The most common age for onset of ochronotic arthropathy
is in the fourth decade.
CPPD Arthropathy (calcium pyrophosphatedihydrate

deposition disease)
Chondrocalcinosis is the calcification of a hyaline
(articular) cartilage or fibrocartilage (menisci). It most
commonly is seen in CPPD. However, it can also occur in
other diseases including hemochromatosis and
hyperparathyroidism.
CPPD crystal deposition disease most commonly affects
patients who are middle-aged or older. It affects men and
women equally. CPPD arthropathy involves structural
damage to articular cartilage secondary to CPPD crystal
deposition in joints. Pseudogout syndrome refers to acute
pain similar to that seen in gouty arthritis without response
to the usual treatment for gout.
The radiographic findings of CPPD arthropathy are
similar to those seen in osteoarthritis: joint space
narrowing, subchondral sclerosis, and osteophytosis.
However, the wrist, elbow, shoulder, ankle, and
femoropatellar joint are also characteristically involved in
CPPD arthropathy. Also, chondrocalcinosis is witnessed,
and the tendons, ligaments, and joint capsule may calcify

as well.
Deposition of crystals in the joints may damage their
structure. Tophi eroding the juxta-articular bone or soft
tissues result in joint damage. Dissolution of tophi after
reduction of uricemia results in a peculiar arthropathy
which should be considered as a sequel. CPPD crystal
deposition damages the cartilage and may result in
osteoarthritis. Since the cartilage is often eroded away in
the process, and with it the crystal deposits which allow
radiographic recognition of the disease, the diagnosis may
easily pass unnoticed. In such cases SF analysis is necessary
to achieve the diagnosis. These patients with osteoarthritis
and CPPD crystals may have small episodes of
inflammation superimposed on the osteoarthritis
symptoms. They may benefit from a very small daily dose
of an NSAID, such as naproxen 250–500 mg or
indomethacin 25 mg. If CPPD crystals could be got rid of
as is done with MSU, it remains speculative whether the
associated osteoarthritis could be halted or even avoided
with early treatment. Being a frequent and invaliding
condition, research in this direction seems essential.
Joint Hypermobility
Doctors believe that joint hypermobility is linked to the
development of premature osteoarthritis. In a normal joint
the ends of the bones are covered by a layer of smooth,
slippery gristle called cartilage. This helps in spreading
the forces evenly when pressure is put on the joint, and
allowing the ends of the bones to move freely against each
other. Osteoarthritis causes the cartilage to roughen and
become thin, leading to pain and stiffness in the joint. If
hypermobility is due to abnormally shaped bone surfaces

or to an abnormal sense of joint position, then the patient
is more likely to develop osteoarthritis. However, in
general, the symptoms of osteoarthritis seem to be no worse
in people who are hypermobile than in those who are not.
Opinions vary on the benefits of glucosamine, though
trials conducted in the last two years look promising,
especially for the knee, and it seems to do no harm.
Mucopolysaccharidoses
The conditions to be described in this group of lesions are
generalized skeletal abnormalities characterized by
dwarfism affecting the spine and limbs, visceral
abnormalities and evidence of a lysosomal storage disorder
involving mucopolysaccharide or mucolipid.
Charcot Joint (Neuropathic)

Neuropathic osteoarthropathy can be defined as bone and
joint changes that occur secondary to loss of sensation and
that accompany a variety of disorders.
The radiographic changes include destruction of
articular surfaces, opaque subchondral bones, joint debris,
deformity, and dislocation. Neuropathic arthropathy poses
a special problem in imaging when it is associated with a
soft tissue infection.
Neuropathic osteoarthropathy can be classified into
hypertrophic and atrophic types. Hypertrophic changes
predominate in the upper motor neuron lesions, and
atrophic changes occur in peripheral nerve injuries. The
early stage of osteoarthritis simulates neuropathic
osteoarthropathy, both radiologically and pathologically.
Progressive joint effusion, fracture, fragmentation, and

subluxation should raise the suspicion of neuro-
arthropathy. In the advanced stage, abnormal findings on
radiographs include subchondral sclerosis, osteophytosis,
subluxation, and soft tissue swelling. Long-standing
neuroarthropathy is characterized by disorganization of
joints. The finding of considerable amounts of cartilaginous
and osseous debris within the synovial membrane (termed
detritic synovitis) should alert the pathologist that the
changes may represent a neuropathic joint. Other causes
of detritic synovitis include osteonecrosis, calcium
pyrophosphate dihydrate crystal deposition disease,
psoriatic arthritis, osteoarthritis, and osteolysis with detritic
synovitis.
Relation of Estrogen / Menopause and Osteoarthritis

Preclinical Studies
Ovariectomy (OVX)-induced acceleration of cartilage
degradation and erosion in rats indicate that estrogen
deficiency accelerates cartilage turnover and increases
cartilage surface erosion.
Estrogen supplementation may play an important role
in delaying the development of osteoarthritis in OVX-
induced osteoarthritis in female rats both biochemically
and histologically. Not only estrogen but even levor-
meloxifene, a SERM, can prevent the OVX-induced
changes in cartilage degradation in both rodents and
humans, suggesting potential therapeutic benefits in the
prevention of destructive joint diseases such as
osteoarthritis.
OVX may also have a detrimental effect on the intrinsic

material properties of the articular cartilage of the knee.
Treatment with estradiol implants ameliorates these
deleterious effects and helps maintain the tissue’s
structural integrity.
One recent study provides direct experimental proof
that long-term estrogen replacement therapy may be
beneficial in OA by increase insulin-like growth factor
binding protein (IGFBP-3) levels in articular cartilage
which appears to be synthesized by articular cartilage
chondrocytes in a well-characterized monkey model of
naturally occurring OA.
Other Causes of Knee Pain

• Arthritis red, hot, swollen knee; mostly Staph. aureus,
also streptococcal and septic gonococcal,
• Inflammatory arthritis, gout, osteoarthritis, RA, AS,
psoriatic,
• Knee trauma strain/sprain, meniscal tear, ACL tear,
ligamentous tear, bone/cartilage injury,
• Bursitis carpenter’s knee, Baker’s cyst, prepatellar
bursitis, Anserine bursitis.
• Growing pains in children during growth spurts,
• Osgood-Schlatter disease in athletically minded
adolescents.
• Avascular necrosis at medial compartment of knee in
elderly females congenital knee problems hyper-
mobility, congenital plicae.
• Alignment problems bowlegs, knock knees and
• Malignant bone tumors osteosarcoma and others.
Risk Factors in Osteoarthritis 41
Risk Factors in
4 Osteoarthritis
INTRODUCTION
Why some people remain free of osteoarthritis and others
develop the condition cannot be fully explained.
Osteoarthritis appears to depend on many contributing
factors and takes various forms in different individuals.
The contributions of risk factors differ from joint to joint.
Age
Of all factors contributing to osteoarthritis, age is the most
important. Exactly how the aging process contributes to
the risk of osteoarthritis is not known. By age 65, more
than 80 percent of Americans have some signs of
osteoarthritis on X-rays, but only about one-half of these
experience symptoms.
Gender
Overall, osteoarthritis is more common in women than in
men. Until about 55 years of age, the rate of developing
osteoarthritis is about equal in women and men. After 55,
many more women than men are affected by osteoarthritis.
This same trend is apparent for knee osteoarthritis,
osteoarthritis that affects several joints at the same time,
and especially osteoarthritis of the hand.
Women have a considerably higher risk of osteoarthritis

of the knee, a difference that may be due to wearing high-
heeled shoes. Men have more frequent osteoarthritis of
the hip joint.
Overweight and Obesity

Excess body weight that is not due to muscle is a modifiable
risk factor that appears to increase the risk of osteoarthritis
through mechanical stress and metabolic changes
associated with excess fat. The exact nature of the metabolic
changes is still being investigated.
• Overweight men and women increase the risk of
developing osteoarthritis of the knee—often of both
knees. Being overweight also increases the risk of
osteoarthritis of the knee increasing in severity, once it
has developed.
• Excess weight may increase the risk of osteoarthritis of
the hand joints.
Muscle Strength
The strength of the quadriceps (the large, frontal thigh
muscle) is a strong predictor of the risk of the development
and progression of knee osteoarthritis, even if no weakness
is visible from the outside.
Physical Activity
Heavy physical activity has been found to increase the risk
of osteoarthritis of the knee. This risk was greater in
overweight and obese people.
But the normal use of muscles, tendons, and joints is
important to keep joints healthy. This includes doing light-
to-moderate physical work and exercise or even

recreational, long-distance running. Light and moderate
activities, such as walking or climbing stairs, do not
increase the risk of getting osteoarthritis. People who
exercise regularly develop impairments of muscle and joint
function less often and experience less muscle and joint
pain as they age than those who exercise less.
Occupation
Frequent or very heavy exercise or physical activity at work
increases the risk of osteoarthritis in the knee and possibly
the hip. For example, activities that require frequent
bending of the knee can increase the risk of osteoarthritis
in the knee. This increase in risk appears mostly in people
who are over the age of 50 or obese.
Certain jobs, such as farm or shipyard work, increase
the risk of osteoarthritis of the hip, and jobs that require
much knee-bending increase the risk of osteoarthritis of
the knee.
Mechanical Stress
Injury to a joint or repeated use of the joint in a way that
stresses it beyond its capacity to heal may start a chain of
events that leads to osteoarthritis.
Genetics
People with a family history of osteoarthritis are a bit more
likely to develop osteoarthritis themselves. This may be
because of heritable abnormalities of the joints that make
them more vulnerable. Osteoarthritis of the hand, knee,
and possibly of other joints tends to run in families through,
it is believed, genetic transmission. For example,

osteoarthritis of the joints at the fingertips occurs about
three times more often among sisters than in the general
population, and mutations of a gene that is associated with
a severe form of osteoarthritis run in families.
Injuries and Diseases

A major injury or operation on a joint increases the risk of
developing osteoarthritis at that joint. While normal
physical activity and exercise are good for joints, hard,
repetitive activity may injure joints.
Diseases that involve abnormalities of joints also can
lead to osteoarthritis in later life. For example, Perthes’
disease of the hips is an abnormality with which some
people are born and which greatly increases their risk of
osteoarthritis.
Women who have a high risk of osteoporosis have a
lower risk of getting osteoarthritis. And, women who have
a low risk of osteoarthritis tend to have lower bone density
and, therefore, a higher risk of problems related to
osteoporosis.
Race and Ethnicity

Ethnic and racial groups have patterns of risk of
osteoarthritis that vary depending on the joint. For
example, Asians generally have a lower risk of
osteoarthritis of most joints, except for knee joints, than
do Caucasians. Asians have a higher risk of osteoarthritis
of the knee joint than do Caucasians.
INDIVIDUAL AND OCCUPATIONAL RISK

FACTORS FOR KNEE OSTEOARTHRITIS—STUDY
PROTOCOL OF A CASE CONTROL STUDY
Background
Knee osteoarthritis (OA) is one of the frequent and
functionally impairing disorders of the musculoskeletal
system. A number of occupational risk factors are identified
as being related to the development and progress of knee
joint diseases, e.g. working in kneeling or squatting
posture, lifting and carrying of heavy weights.
The importance of the single risk factors and the
possibility of prevention are currently under study. Besides
the occupational factors, a number of individual risk factors
are important, too.
The distinction between work-related factors and
individual factors is crucial in assessing the risk and in
deriving preventive measures in occupational health. In
existing studies, the occupational stress is determined
mainly by surveys in employees and/or by making
assumptions about individual occupations.
Direct evaluation of occupational exposure has been
performed only exceptionally. The aim of the research
project ArGon is the assessment of different occupational
factors in relation to individual factors (e.g. constitutional
factors, leisure time activities, sports), which might influence
the development and/or progression of knee (OA).
The project is designed as a case control study.
Methods
To collect valid data about the physical stress associated
with occupational and leisure time activities, patients with
and without knee OA are questioned by means of a
standardized questionnaire and an interview.
The required sample size was estimated to 800 cases
and an equal number of controls. The degree and
localization of the knee cartilage or joint damages in the
cases are documented on the basis of radiological,
arthroscopic and/or operative findings in a patient record.
Discussion
In this research project, specific information on the
correlation of occupational and individual factors on the
one hand and the current state of knee OA on the other
will be analyzed in order to describe preventive measures.
In addition, information regarding a better evaluation of
various forms of physical stress in different occupations
will be available. This might lead to more effective
prevention strategies.
Risk Factors for Cartilage Loss in Knee Osteoarthritis

Researchers from North America have investigated the risk
factors associated with progression of knee osteoarthritis
(OA) by using MRI to quantitatively assess the progressive
loss of cartilage volume in different areas of the knee and
studying the correlation of these changes with demographic,
clinical, radiological, and structural variables.
This longitudinal study included a subset of 107 patients
with symptomatic knee OA selected from a larger trial
assessing the effects of bisphosphonate therapy. Patients
were evaluated at baseline and at 24 months with X-ray

and MRI investigations of the knee.
Osteoarthritis Risk Factors

• What increases the risk of developing osteoarthritis?
• Age is an osteoarthritis risk factor.
Osteoarthritis is the most common joint disease in the
United States and worldwide. Osteoarthritis is also among
the most common causes of pain and disability in older
people. Consider these quick statistics:
• One-third of people over 65-year-old have knee
osteoarthritis which can be seen on X-ray.
• Seventy percent of people over 70-year-old have X-ray
evidence of osteoarthritis.
• Before 50-year-old, osteoarthritis is more prevalent
among men than women.
• After 50-year-old, women are more likely affected by
osteoarthritis than men.
Not all people who have osteoarthritis evident on X-ray
develop symptomatic osteoarthritis. This fact has made
defining osteoarthritis risk factors more difficult.
Osteoarthritis risk factors include:
• Excess weight or obesity: Obese women are four to five
times more likely to have knee osteoarthritis than people
of normal weight.
• Injury: Acute knee injuries are recognized as common
causes of knee osteoarthritis.
• Certain occupations: Farmers, jackhammer operators, and
mill workers have high rates of osteoarthritis.
• Congenital or developmental deformities: Abnormalities of
the hip and knee can lead to premature osteoarthritis.
• Hormones: Women who take estrogen replacement

therapy are not as likely to develop osteoarthritis as
women who do not take estrogen.
• Weak thigh muscles: Weak quadriceps can lead to
osteoarthritis of the knees.
• Genetic factors: Genetics may impact the incidence of
osteoarthritis. For example, heritability of hand
osteoarthritis is about 65 percent.
• Race: Some reports suggest that African-Americans have
higher rate of osteoarthritis than Caucasians.
• Other diseases which change cartilage structure: Rheumatoid
arthritis, gout, pseudogout, and hemochromatosis may
increase the risk of developing osteoarthritis.
• Low intake of vitamin C and D: Has been associated with
increased risk of knee osteoarthritis.
Risk Factors and Causes of Osteoarthritis

In most instances, the cause of osteoarthritis (OA) is
unknown. Some people consider it a normal part of aging.
Mechanical stress on joints over time may affect the
enzymes (proteins that stimulate chemical reactions) in
cartilage, but the exact relationship is unclear. Figure 4.1
shows the pathophysiological cascade for the development
of osteoarthritis, while the pathological features occurring
in the knee joint due to osteoarthritis are shown in Figure 4.2.
Some risk factors for OA have been identified. Risk factors
make an individual more likely to develop a condition but
do not mean the person will get the disease. In addition,
people with no risk factors can still develop the disease.
The most common risk factors associated with OA include
(Table 4.1 and Fig. 4.3):
Fig. 4.1: The OA/vascular disease pathophysiological cascade
• Age: OA usually develops after age 45, and by age 65,

more than half the population shows X-ray evidence
of osteoarthritis in at least one joint, according to the
National Institutes of Health (NIH).
• Weight: Overweight or obese people are more likely to
develop OA.
• Heredity: People with a family member with OA are
more likely to develop the disease. Inherited bone
Fig. 4.2: Pathological features in the knee joint due to

osteoarthritis
Fig. 4.3: Factors which worsen knee osteoarthritis

Table 4.1: Risk factors for incidence and progression of osteoarthritis
of the knees, hips and hands
Degree of evidence for association
Strong Intermediate Suggested
Incidence
Knee Age Vitamin D Quadriceps strength
Female sex Smoking (protective)
Physical activity (protective) Intensive sport activities
High bone mass index Alignment
Bone density
Previous injury
Hormone replacement
therapy (protective)
Hip Age Physical activity Injury
High bone mass index Intensive sport activities
Hand Age Grip strength Occupation
High bone mass index Intensive sport activities
Progression
Knee Age Vitamin D Intensive sport activiites
Hormone replacement
therapy Alignment
Hip Age Physical activity High bone mass index
Intensive sport activities
abnormalities, such as a malformed joint or defective

cartilage, may also increase the likelihood of developing
OA. Recent research indicates that even a minor
difference in leg lengths, a common condition, may
increase the risk of knee and hip OA.
• Sex: Although OA is less common before age 55, it occurs
equally in both sexes in this age group. After age 55, it
is more common in women than men.
• Lifestyle factors: People are more likely to develop OA
when they have repetitive motion or stress on a joint
from exercise or work conditions. Repetitive strain
disorders include carpal tunnel syndrome, tennis elbow
and shin splints. Also, individuals who have long
periods of immobilization are at risk for OA.
Knee Malalignment
Knee malalignment is a key risk factor for the progression
of knee osteoarthritis (OA). Today, an estimated 4 million
patients in the US are progressing towards advanced knee
OA with no apparent solution to interrupt the degenerative
cascade.
Risk Factors
• Obesity: Excess weight increases stress on the knee joints.
It increases risk of accelerated osteoarthritis
(degenerative collapse of the joint).
• Overuse: Can lead to muscle fatigue and excessive
loading stresses across the joint. This causes an
inflammatory response (increased blood flow and cell
response) that damages tissues.
• Age
• Instability: Tight or weak muscles offer less joint support.
• Mechanical problems: Structural abnormalities, such as
having one leg shorter than the other, abnormal
alignment of the bones or flat feet can increase risk of
knee problems.
• Athletic activities
• Previous injuries.
Smoking Worsens Knee Osteoarthritis

Rheumatologist indicate that men with knee osteoarthritis
who smoke experience greater cartilage loss and more
severe pain than men who do not smoke.
The association between smoking and cartilage loss in
knee osteoarthritis could be explained by one or more of
the following theories, according to researchers:
• Smoking may disorder the cells and inhibit cell
proliferation in the knee cartilage.
• Smoking may increase oxidant stress, which contributes

to cartilage loss.
• Smoking may raise carbon monoxide levels in arterial
blood, contributing to tissue hypoxia (insufficient blood
oxygenation), which could impair cartilage repair.
Risk Factors for Arthritis

The most common type of risk factor for arthritis, include
obesity, sports injuries and repetitive motion.
Obesity is defined as body mass index (BMI) greater
than or equal to 30.
BMI = multiply weight in pounds by 704.5; divide result
by height in inches squared according to the NIH clinical
guidelines on the identification, evaluation and treatment
of overweight and obesity in adults.
Regular exercise was defined as at least five days per
week for 30 minutes per session. Relationship between the
excercise and weight is illustrated in Figure 4.4.
Reducing Your Arthritis Risk

Many factors can affect chances of developing osteoporosis.
The good news is that some of them can be controlled.
Even though genes cannot be changed one can still lower
the risk with attention to certain lifestyle changes that will
help build and maintain bone mass. The younger one start,
and the longer one keep it up, the better.
Here’s what can be done:
• Be sure to get enough calcium and vitamin D. Engage
in regular physical activity, such as walking. Do not
smoke
• If one drinks alcohol, it should be done in moderation.
Fig. 4.4: Relationship of exercise and weight
A sedentary lifestyle, smoking, excessive drinking, and

low calcium intake all increase risk. Other factors are
beyond a human’s control. Being aware of them can
provide extra motivation and can help the man and his
doctor to make health-care decisions.
These risk factors are:
• Being female: Women are at five times greater risk than
men; thin, small-boned frame; broken bones or stooped
posture in older family members, especially women,
which suggest a family history of osteoporosis; early
estrogen deficiency in women who experience
menopause before age 45, either naturally or resulting
from surgical removal of the ovaries; estrogen deficiency
due to abnormal absence of menstruation (as may
accompany eating disorders).
• Ethnic heritage: White and Asian women are at highest
risk; African-American and Hispanic women are at
lower, but significant, risk, advanced age; prolonged use
of some medications, such as excessive thyroid
hormone, some antiseizure medications, glucocorticoids

(certain anti-inflammatory medications, such as
prednisone, used to treat conditions such as asthma,
arthritis and some cancers), certain cancer treatments,
some treatments for endometriosis, excessive use of
aluminum-containing antacids, and excessive thyroid
hormone.
It is important to discuss the use of these drugs with
a physician, and not to stop or alter the medication dose
on his/her own.
• Growth hormone deficiency in children and youth.
Signs and Symptoms of Osteoarthritis 57
Signs and Symptoms of

5 Osteoarthritis
INTRODUCTION
Most people who experience symptoms of osteoarthritis
(OA) have joint pain, limited mobility and stiffness. Many
experience stiffness when they wake up in the morning,
which usually lasts no more than 30 minutes. Stiffness that
lasts an hour may be a symptom of rheumatoid arthritis
(RA). Joints may become sore when used after periods of
inactivity or after exercise. Pain that occurs during activity
or exercise usually is relieved by rest.
Symptoms of OA vary, depending on the joints affected.
Some of the main symptoms, grouped according to joints,
include the following:
Fingers
This may include pain, swelling or enlargement of finger
joints. Bone spurs called Heberden’s nodes (end joints) and
Bouchard’s nodes (middle joints) may also appear. People
may experience difficulty with fine motor movements such
as picking up items or gripping a pen.
Spine
In the spine, growths on or around the intervertebral disks
may cause pain or pressure on nerves. This may be
experienced as pain or stiffness in the neck, arms, lower

back or legs. Pinched nerves may produce numbness in
the arms or legs. As OA affects the spine, it may lead to
other complications such as spinal stenosis, a narrowing
of spinal canal.
Hips
It may cause pain in the groin, buttocks or thighs. Hip pain
may also cause limping. OA in the hip may cause referred
pain, which originates in the hip but is felt in the knee,
thigh or lower back.
Knees
Pain affects the knee while moving, walking, using stairs or
rising from a chair. OA in the knee may produce a slipping
sensation, as if there is no support in the leg. It can also
produce creaking or grating sounds when the knee moves.
Feet and Ankles

There is pain and swelling in the feet, especially the joint
at the base of the big toe. It may also cause foot pain while
wearing high heel or tight shoes that was not previously
experienced with those types of shoes.
For thousands of years, people have perceived a
connection between the onset of arthritic pain and changes
in weather (usually approaching rain). Such changes were
noted as early as 400 BC by the ancient Greek physician
Hippocrates.
Although many people acknowledge a connection, the
studies conducted on the phenomenon have not yielded
definitive results. These studies may not be representative
Signs and Symptoms of Osteoarthritis 59
because they had small groups of subjects and relied on

self-reporting methods. Still, many individuals with OA
report an increased amount of pain and stiffness before or
during a change in weather.
EARLY SYMPTOMS
Early arthritis symptoms can be vague and confusing, but
they are important to recognize. Newly diagnosed patients
quickly realize that early symptoms are just the first layer
to be uncovered before a definitive diagnosis and treatment
plan for arthritis can be established.
Joint Pain—Arthritic Joints

Arthritis can affect any joint. Certain types of arthritis are
associated with a specific pattern of joint disease. For
example, rheumatoid arthritis is usually symmetric —
affecting the same joint on both sides of the body. Other
types of arthritis typically affect a single joint. It is
important to tell the doctor about all the symptoms and
every joint that hurts.
SIGNS AND SYMPTOMS

Signs and symptoms associated with osteoarthritis may
include the following:
• Joint soreness after inactivity or periods of overuse of a
joint.
• Stiffness after rest that disappears quickly as activity
begins again.
• Morning stiffness lasting no longer than 30 minutes.
• Joint pain which is less in the morning and stronger at
the end of the day following activity.
• Muscle atrophy around joints caused by inactivity can

increase pain.
• Pain and stiffness can affect posture, coordination and
ability to walk.
• Joints of the knees, hips, fingers, lower spine, and neck
are most commonly affected by osteoarthritis. The
knuckles, wrists, elbows, shoulders and ankles are rarely
affected by osteoarthritis except when there is an injury
or overuse the joint.
• Signs of hip osteoarthritis may include pain in the groin,
inner thigh, or buttocks and a pronounced limp.
• Signs of knee osteoarthritis may include pain
exacerbated by moving the knee, knee locking or
catching, pain when standing up from a chair, pain
when going up and down stairs, and weakening thigh
muscles.
• Signs of osteoarthritis of the fingers may include pain
and swelling of the finger joints, the presence of
Heberden’s nodes or Bouchard’s nodes, enlarged joints,
and problems with manual dexterity.
• Signs of osteoarthritis of the feet may first be revealed
by pain and tenderness in the large joint of the big toe.
Certain shoes, such as high heels, can provoke pain in
osteoarthritic feet too.
• Osteoarthritis of the spine occurs when there is
deterioration of spinal disks. The breakdown can cause
osteophytes (bone spurs) to develop. The neck and lower
back are stiff and painful. Pressure on nerves in the
spinal cord can cause pain radiating to the neck,
shoulder, arm, lower back, and legs or numbness in
arms and legs.
Preventive Measures for Osteoarthritis 61
Preventive Measures
6 for Osteoarthritis
INTRODUCTION
Weight control and regular exercise as approved by a
physician may help prevent osteoarthritis (OA). Practicing
good posture and ergonomics and reducing the risk of
trauma with safety precautions such as seat belts and
athletic equipment may also help.
Some evidence suggests that diet can play a preventive
role in OA. In North Carolina, the Johnson County
Osteoarthritis Project, described as the largest and longest-
term investigation of its kind, found that participants with
high amounts of the mineral selenium had less knee OA
than people lacking selenium. Selenium is found naturally
in soil and in foods grown in soil but varies widely by
location. It is also found in seafood, chicken and other
meats and is available in supplements.
A deficiency of vitamin K has also been found in people
suffering from OA. Sources of vitamin K include leafy
green vegetables, canola oil, soybean oil and olive oil.
It may also help not to use tobacco. Recent research links
smoking to increased severity of OA.
PREVENTION
Although it’s not always possible to prevent knee pain,
the following suggestions may help forestall injuries and
joint deterioration:
• Keep extra pounds off. Maintaining a healthy weight

is one of the best things one can do for the knees—
every extra pound puts additional strain on the joints,
increasing the risk of ligament and tendon injuries and
even osteoarthritis.
• Get strong, stay limber. Because weak muscles are a
leading cause of knee injuries, people can benefit from
building up their quadriceps and hamstrings, which
support the knees. Try knee extensions, hamstring curls
and leg presses to strengthen these muscles. Balance and
stability training helps the muscles around the knees
work together more effectively. Since tight muscles also
can lead to injury, stretching is important. One should
include flexibility exercises in his/her workouts.
• Be smart about exercise. If somebody has osteoarthritis,
chronic knee pain or recurring injuries, he/she may
need to change the way they exercise. It means being
smart about when and how one works out. If the knees
ache after jogging or playing basketball or other sports
that give joints a real pounding, consider switching to
swimming, water aerobics or other low-impact
activities—at least for a few days a week. Sometimes
simply limiting high-impact activities will provide
relief.
• Make sure shoes fit well. This will prove to be a lot
safer. Choose footwear that’s appropriate for sport.
Running shoes are not designed for pivots and turns,
for instance, but tennis and racquetball shoes are.
• Baby the knees. Wearing proper gear for knee-sensitive
activities can help prevent injuries. Use kneepads when
playing volleyball or laying carpet and buckle seat belt
Preventive Measures for Osteoarthritis 63
while driving. Most shattered kneecaps occur in car

accidents.
• Listen to the body. If the knees hurt, or one feels
fatigued, do not be a hero—take a break. There are more
chances of injury when tired.
SIX STEPS TO HELP THE KNEES

1. Stay active: This is said so often it’s almost a mantra, but
it is particularly true when it comes to the knees. The
knee was made to bear weight, but wasn’t designed to
go it alone. Strong, flexible leg muscles—especially the
quadriceps, the group of four muscles that forms the
front of your thigh—take a great deal of pressure off it.
And there’s a bonus—exercising your knee causes the
synovial (pronounced si-NO-vee-al) tissue in the joint
to produce synovial fluid, which lubricates the knee and
nourishes cartilage.
2. Easy does it: When starting to exercise, take it slowly.
Too many people try to reform overnight, only to injure
themselves or get discouraged when the exercise seems
too difficult or boring. They stop and are right back
where they started—sitting around getting creaky.
3. Simple is the solution: Plenty of people want to make
money off people’s desire to exercise. But nobody need
buying expensive treadmills or the contraptions sold
on cable television. A lot of that equipment follows a
predictable path from the den to the basement to the
yard sale. To get started, all that most people need is a
good pair of walking shoes, a level surface (the mall, a
high school track, a well-maintained sidewalk), and, the
hardest part of all, some willpower.
4. Walk in water: For those suffering from osteoarthritis,

walking in water is a great way to exercise the knee
without putting too much weight on it. Chest-high water
reduces the weight on the knee by about 75 percent.
Biking also exercises knees - and the quadriceps -
without putting weight on them.
5. PRICE is right: The traditional recipe for treating a knee
that swells up and gets sore is RICE: rest, ice,
compression (wrapping it in an elastic bandage, but not
too tightly), and elevation (which drains away fluid and
blood). Physical therapists like Shillue have added
protection as a first step, so RICE becomes PRICE. By
protection, they mean avoiding (if possible) the activity
that caused the problem, taking steps to avoid injuries
in the future, or both.
6. Do the homework: Needless to say, a physical therapist
can be a big help. Some physical therapy facilities
resemble mini-health clubs, with stationary bikes,
weights, and even small pools. One may get ultrasound
treatments to loosen up muscles and joints. He or she
will probably be put on an exercise program and get
friendly coaching.
But Shillue says that physical therapy works best if the
patient follows through by learning the exercises and doing
them at home. PT is not a spa. It helps best those who are
most willing to help themselves.
Common Knee Problems 65
Common Knee
7 Problems
BURSITIS
Bursae are thin sacs that pad the joints and bony
outcroppings, reducing friction between the movable parts.
Bursae prone to inflammation include the prepatellar bursa
on the front of your kneecap (patella); the infrapatellar bursae
below it; and the pesanserine, which is on the inside of the
knee just below the knee joint, tucked in behind the
tendons attached to the shinbone (tibia) (Figs 7.1 and 7.2).
Fig. 7.1: Longitudinal section of the knee joint showing

different bursae
Fig. 7.2: Longitudinal section of the knee joint
The suprapatellar pouch contains fluid and, similar to a

bursa, cushions and lubricates the knee. People can get
bursitis from banging their knee or putting pressure on it.
Kneeling can cause prepatellar bursitis, which is why it’s
nicknamed “housemaid’s knee.” Bursitis is best treated
with PRICE (see tip 5 chapter 6) and pain relievers.
Tendonitis
Tendons attach muscle to bone. Like muscle, they are
designed to move and stretch, but if they are overused or
stretched too far, they get inflamed. One tendon that is
often affected is the patellar tendon (Fig. 7.3), which runs
vertically from kneecap to shinbone (it’s a continuation of
the tendon that connects the quadriceps to the kneecap).
Fig. 7.3: Affect on the patellar tendon in tendonitis
Bursitis and tendonitis feel much the same. But the

location of the discomfort is different and bursitis, unlike
tendonitis, hurts even when you aren’t moving your knee.
The treatment, however, for the flare-ups is the same -
PRICE (see tip 5 chapter 6).
OSTEOARTHRITIS
Cartilage covers the end of the thighbone (the femur) and
the back of the kneecap. The two crescent-shaped menisci
(pronounced meh-NISK-i) that provide the padding
between the femur and shinbone (tibia) are made of
fibrocartilage, which is tougher and more rubbery than the
hyaline cartilage that covers the ends of bones.When that
cartilage gets soft, the condition is called chondromalacia.
When it starts to breakdown, pit, or decay, the result is

osteoarthritis. If pain from osteoarthritis flares up, follow
the standard PRICE advice. In the long run, exercising to
strengthen quadriceps and hamstring muscles will help,
but not cure, the condition.
Can Osteoarthritis be Prevented?

While there is currently no sure way to prevent
osteoarthritis or slow its progression, some lifestyle
changes may reduce or delay symptoms.
The Arthritis Foundation states that maintaining a
healthy weight, losing weight if needed, and regular
exercise are effective osteoarthritis prevention measures.
Optimal calcium intake in younger years is vital to
ensure a healthy aging skeletal system. Vitamins A, C, D,
and E have been studied for their role in osteoarthritis
prevention. These vitamins also have shown benefit in
individuals who have osteoarthritis.
PREVENTING KNEE INJURY

Knee’s tolerance for stressful activities will decrease with
age and loss of conditioning. So, stresses that would not
have caused injury last year could hurt the knee today. A
decrease in level of activity over a period of time will also
contribute to its vulnerability.
But there are things one can do to help prevent injury
so he/she can continue to enjoy sports and exercise.
Pursuing an exercise program designed by physical
therapist, and applying some good common sense, can be
the best protection from injury.
The first step in designing exercise program is an

evaluation by a physical therapist. He or she can identify
the predisposing factors, those body traits that may make
one more or less vulnerable to a knee injury.
Based on this assessment, the physical therapist can
design a program that will help people gain their optimum
levels of strength and conditioning.
PREVENTION
Although it is not always possible to prevent knee pain,
the suggestions made in Chapter 6 may help forestall
injuries and joint deterioration.
Diagnostic Methods of Osteoarthritis 71
Diagnostic Methods of
8 Osteoarthritis
INTRODUCTION
Diagnosis of osteoarthritis (OA) begins with a review of
the patient’s medical history. Focus will be placed on any
familial arthritic conditions, previous injuries or surgeries
and general use of the joints. A pain assessment may also
be used to help identify the nature and severity of the
condition. A physical examination that concentrates on the
areas of complaint may be completed by a rheumatologist
(physician who specializes in arthritis and other inflam-
matory diseases).
The physician will examine the joints and surrounding
areas for:
• Pain and/or tenderness
• Swelling and/or stiffness
• Reduced range of motion and/or flexibility
• Instability and/or difficulty bearing weight
• Bony lumps, nodes or growths.
Most diagnostic examinations where OA is suspected will
include imaging studies, such as X-rays, MRI (magnetic
resonance imaging) or a bone scan. Although X-rays and
MRI are good indicators of damage to joints, the degree of
damage may be unrelated to the intensity of a patient’s
symptoms. Physicians use the studies to look for:
• Bony outgrowths (osteophytes)
• Narrowing of the joint capsule

• Hardening or formation of cysts.
Laboratory tests cannot diagnose OA. However, several
blood tests are often used to rule out other forms of arthritis
and diseases. These tests may include:
• Rheumatoid factor (RF) test: This may indicate rheuma-
toid arthritis (RA) or other autoimmune conditions.
• Erythrocyte sedimentation rate (ESR): An elevated
level of this blood test indicates inflammation, but can
be caused by many forms of inflammation or infection.
It may be combined with the physician’s clinical
findings to confirm polymyalgia rheumatica.
• C reactive protein test: An elevated level of this protein
produced by the liver suggests an inflammatory disease,
such as RA.
Other blood tests may indicate the presence of uric acid,
a symptom of gout, or the presence of a genetic marker
that is seen with some other forms of arthritis.
In some cases, a biopsy or synovial fluid analysis may
be done. These tests may identify or rule out other
conditions but cannot diagnose OA.
The combination of findings from lab tests, X-rays and
a physical examination may provide a physician with
PWV in OA
Methods
K-L grading:
• grade 1, doubtful OA: doubtful narrowing of joint space and possible
osteophytic lipping
• grade 2, minimal OA: definite osteophytes and possible narrowing
of joint space
• grade 3 moderate OA: moderate multiple osteophytes, definite
narrowing of joints space,some sclerosis and possible deformity of
bone contour
• grade 4, severe OA: large osteophytes, marked narrowing of joint
space, severe sclerosis and definite deformity of bone contour
enough information to diagnose OA (According to this

grading system of 1 to 4, grade 1 is scored as doubtful OA;
there is doubtful narrowing of the joint space and possible
osteophytic lipping. Grade 4 is rated as severe OA, where
there are large osteophytes, marked narrowing at the joint
space, severe sclerosis, and definite deformity of the bone
contour). Twenty joints across the three joint groups (10
DIPs, 8 PIPs, and 2 first CMC joints) were assigned a K-L
grade. OA was defined in the following manner:
• OA was present in any of the joints if their K-L was 2 or
higher.
• OA of the joint group was present if at least 1 of the
joints in that group had OA.
• OA of the hand was present if at least 2 of the 3 anatomic
hand sites (DIP, PIP, or CMC) had OA.
• Other parameters that the doctor looked at for hand OA
were the total number of joints with K-L grade 2 or
higher and the total of all K-L grades across the 3 joint
groups.
DIAGNOSIS OF ARTHRITIS
An accurate diagnosis is required for proper treatment of arthritis.
An accurate diagnosis precedes appropriate treatment
of arthritis. With over 100 types of arthritis, early symptoms
can overlap and diagnosis can be difficult.
When diagnosing, your doctor will look for very specific
signs, symptoms, and disease characteristics. The doctor
will also consider the patient’s medical history, physical
examination, blood tests, and imaging studies.
Medical History and Clinical Symptoms

The patients’s medical history consolidates information
about past medical conditions and his current medical
condition. To obtain medical history, the patient will likely

be asked to fill out a written questionnaire at his/her first
appointment.
The sufferer should be ready for medical history by
having a list of current medications, medication allergies,
past and present medical conditions he/she are being
treated for, and the name of their primary doctor and other
specialists, along with their contact information.
Keep a symptom diary. A symptom diary can help keep
track of pertinent facts about condition and also help track
changes that may occur. With the diary, the patient are
more inclined to give the doctor a good overall picture of
the symptoms.
Physical Examination
The doctor will perform a physical examination to try to
see any visible signs and symptoms that point to arthritis:
• Redness/warmth around a joint (inflammation)
• Joint stiffness or tenderness
• Joint fluid or swelling
• Bumps or nodules
• Pattern of affected joints (e.g. symmetric or asymmetric)
• Limited range of motion
• Fever
• Fatigue.
Laboratory Tests
After a medical history and physical examination have
been completed, the doctor will likely need more
information. Blood tests can provide more specific
information and often serve to confirm what the doctor
suspects is the diagnosis. Blood tests are also used to

monitor disease activity and treatment effectiveness after
a diagnosis has been established. On the initial visit, the
doctor will most likely order only a few of these tests, based
on medical history and examination.
Rheumatoid Factor
Rheumatoid factor is an antibody or immunoglobulin
which is present in about 70 to 80 percent of adults who
have rheumatoid arthritis.
Erythrocyte Sedimentation Rate

The erythrocyte sedimentation rate (ESR) is also known
as sedimentation rate or sedrate. The test is an indicator of
the presence of nonspecific inflammation.
C-reactive Protein (CRP)

C-reactive protein is a protein which is produced by the
liver following tissue injury. Plasma levels of CRP increase
quickly following periods of acute inflammation or
infection, making this test a better indicator of disease
activity than the sedrate which changes more gradually.
Anti-cyclic Citrullinated Peptide

Antibody Test (anti-CCP)
Anti-CCP is a blood test which has become more
commonly used and is ordered if rheumatoid arthritis is
suspected. Moderate to high levels of anti-CCP in a
patient’s blood confirm the diagnosis in someone who is
felt clinically to have rheumatoid arthritis. The test is more
specific than rheumatoid factor.
Antinuclear Antibodies (ANA)

Antinuclear antibodies (ANA) are abnormal auto-
antibodies (immunoglobulins against nuclear components
of the human cell). The test is based on indirect
immunofluorescence. Moderate to high antinuclear
antibody levels are suggestive of autoimmune disease.
Positive antinuclear antibody tests are seen in more than
95 percent of systemic lupus erythematosus patients, 60 to
80 percent of scleroderma patients, 40 to 70 percent of
patients with Sjögren’s syndrome, and 30 to 50 percent of
rheumatoid arthritis patients, among others.
Complete Blood Count

The complete blood count determines the WBC (white
blood cell count), RBC (red blood cell count), hemoglobin,
hematocrit, several red blood cell indices and the platelet
count. Elevated white blood cell counts suggest the
possibility of an active infection. Patients taking
corticosteroids may have an elevated WBC due to the
medication. Chronic inflammation can cause a low red
blood cell count. Low hemoglobin and hematocrit may be
indicative of anemia associated with chronic diseases or
possible bleeding caused by medications. The platelet
count is often high in rheumatoid arthritis patients, while
some potent arthritis medications can cause platelets to be
low.
HLA Tissue Typing

Human Leukocyte Antigens (HLA) are proteins on the
surface of cells. Specific HLA proteins are genetic markers
for some of the rheumatic diseases. Patients may be tested
to see if they have the genetic markers. HLA-B27 has been

associated with ankylosing spondylitis and other
spondyloarthropathies. Rheumatoid arthritis is associated
with HLA-DR4.
Uric Acid
High levels of uric acid in the blood (known as hyperuri-
cemia) can cause crystals to form which are deposited in
the joints and tissues, causing painful gout attacks. Uric
acid is the final product of purine metabolism in humans.
For certain types of systemic rheumatic diseases,
biopsies of certain organs can provide important diagnostic
information. Also, joint fluid analysis can provide a doctor
with many details about the health of a person’s joint.
Medical Imaging
The doctor may order X-rays (radiographs), which are
pictures of bones and joints; they do not show cartilage,
muscles, and ligaments. X-rays can reveal deformities and
abnormalities.
MRIs, or Magnetic Resonance Imaging scans, produce
cross-sectional images of the body by using a magnetic
field and radiowaves. Precise information about bones,
joints and soft tissues is provided. Very small changes in
the body can be detected using MRI.
Medical Management of Osteoarthritis 79
Medical Management
9 of Osteoarthritis
INTRODUCTION
Doctors prescribe medicines to eliminate or reduce pain
and to improve functioning. Doctors consider a number
of factors when choosing medicines for their patients with
osteoarthritis. Two important factors are the intensity of
the pain and the potential side effects of the medicine.
Patients must use medicines carefully and tell their doctors
about any changes that occur.
COMMON MEDICINES
The following types of medicines are commonly used in
treating osteoarthritis:
Acetaminophen
Acetaminophen is a pain reliever that does not reduce
swelling. Acetaminophen does not irritate the stomach and
is less likely than nonsteroidal anti-inflammatory drugs
(NSAIDs) to cause long-term side effects. Research has
shown that acetaminophen relieves pain as effectively as
NSAIDs for many patients with osteoarthritis.
Warning
People with liver disease, people who drink alcohol
heavily, and those taking blood-thinning medicines or
NSAIDs should use acetaminophen with caution.
NSAIDs (nonsteroidal anti-inflammatory drugs)

Many NSAIDs are used to treat osteoarthritis. Patients can
buy some over the counter (for example, aspirin, Advil,
Motrin IB, Aleve, ketoprofen). Others require a
prescription. All NSAIDs work similarly: they fight
inflammation and relieve pain. However, each NSAID is
a different chemical, and each has a slightly different effect
on the body.
Side Effects
NSAIDs can cause stomach irritation or, less often, they
can affect kidney function. The longer a person uses
NSAIDs, the more likely he or she is to have side effects,
ranging from mild to serious. Many other drugs cannot be
taken when a patient is being treated with NSAIDs because
NSAIDs alter the way the body uses or eliminates these
other drugs. Check with the health care provider or
pharmacist before taking NSAIDs in addition to another
medication. Also, NSAIDs sometimes are associated with
serious gastrointestinal problems, including ulcers,
bleeding, and perforation of the stomach or intestine.
People over age 65 and those with any history of ulcers or
gastrointestinal bleeding should use NSAIDs with caution.
COX-2 inhibitors: Several new NSAIDs—valdecoxib
(Bextra) and celecoxib (Celebrex)—from a class of drugs
known as COX-2 inhibitors are now being used to treat
osteoarthritis. These medicines reduce inflammation
similarly to traditional NSAIDs, but they cause fewer
gastrointestinal side effects. However, these medications
occasionally are associated with harmful reactions ranging
from mild to severe.
Other Medications
Doctors may prescribe several other medicines for
osteoarthritis, including the following:
1. Topical pain-relieving creams, rubs, and sprays which are
applied directly to the skin.
2. Mild narcotic painkillers, which—although very effective—
may be addictive and are not commonly used.
3. Corticosteroids, powerful anti-inflammatory hormones
made naturally in the body or manmade for use as
medicine. Corticosteroids may be injected into the
affected joints to temporarily relieve pain. This is a short-
term measure, generally not recommended for more
than two or three treatments per year. Oral
corticosteroids should not be used to treat osteoarthritis.
4. Hyaluronic acid, a medicine for joint injection, used to
treat osteoarthritis of the knee. This substance is a
normal component of the joint, involved in joint
lubrication and nutrition.
Most medicines used to treat osteoarthritis have side
effects, so it is important for people to learn about the
medicines they take. Even nonprescription drugs should
be checked. Several groups of patients are at high risk for
side effects from NSAIDs, such as people with a history of
peptic ulcers or digestive tract bleeding, people taking oral
corticosteroids or anticoagulants (blood thinners), smokers,
and people who consume alcohol.
Some patients may be able to help reduce side effects by
taking some medicines with food. Others should avoid
stomach irritants such as alcohol, tobacco, and caffeine.
Some patients try to protect their stomachs by taking other
medicines that coat the stomach or block stomach acids.
These measures help, but they are not always completely

effective.
Using NSAIDs
Many people who have osteoarthritis have persistent pain
despite taking simple pain relievers such as acetaminophen.
Some of these patients take NSAIDs instead. Health care
providers are concerned about long-term NSAID use
because it can lead to an upset stomach, heartburn, nausea,
and more dangerous side effects, such as ulcers.
Scientists are working to design and test new, safer
NSAIDs. One example currently available is a class of
selective NSAIDs called COX-2 inhibitors. Traditional
NSAIDs prevent inflammation by blocking two related
enzymes in the body called COX-1 and COX-2. The
gastrointestinal side effects associated with traditional
NSAIDs seems to be associated mainly with blocking the
COX-1 enzyme, which helps protect the stomach lining.
The new selective COX-2 inhibitors, however, primarily
block the COX-2 enzyme, which helps control inflam-
mation in the body. As a result, COX-2 inhibitors reduce
pain and inflammation but are less likely than traditional
NSAIDs to cause gastrointestinal ulcers and bleeding.
However, research shows that some COX-2 inhibitors may
not protect against heart disease as well as traditional
NSAIDs.
Drugs to Prevent Joint Damage

No treatment actually prevents osteoarthritis or reverses
or blocks the disease process once it begins. Present
treatments just relieve the symptoms. Researchers are
looking for drugs that would prevent, slow down, or

reverse joint damage. One experimental antibiotic drug,
doxycycline, may stop certain enzymes from damaging
cartilage. The drug has shown some promise in clinical
studies, but more studies are needed. Researchers also are
studying growth factors and other natural chemical
messengers. These potential medicines may be able to
stimulate cartilage growth or repair.
ANTI-INFLAMMATORY MEDICATIONS
Nonsteroidal anti-inflammatory drugs (NSAIDs),
including aspirin, ibuprofen (Advil, Motrin, others) and
naproxen sodium (Aleve, Naprosyn), can help relieve pain.
But if taken immediately after an injury, they may actually
increase swelling. What’s more, NSAIDs can have side
effects, especially if you take them for long periods or in
amounts greater than the recommended dosage. Even
small doses may cause nausea, stomach pain, stomach
bleeding or ulcers; and large doses can lead to kidney
problems and fluid retention.
NSAIDs also have a ceiling effect, which means there is
a limit to how much pain they can control. If you have
moderate to severe pain, exceeding the dosage limit
probably will not relieve symptoms. Taking two different
NSAIDs at the same time also will not provide more relief
and may increase the risk of side effects.
When self-care measures are not enough to control pain
and swelling and promote healing in an injured knee, the
doctor may recommend other options, including:
• Medication: Many prescription and nonprescription
medications are used for OA pain. Some of these include:
• Nonsteroidal anti-inflammatory drugs (NSAIDs): These

drugs are used to reduce pain and inflammation.
They come in prescription and nonprescription forms
and include gels that have demonstrated
effectiveness in relieving OA pain in the knees.
• Acetaminophen: This over-the-counter analgesic may
relieve mild pain associated with OA.
• Injections of hyaluronic acid: These injections use a
synthetic version of the fluid in the joint capsule. They
may be injected into joints of people who do not
receive pain relief from NSAIDs.
• Corticosteroid injections: These anti-inflammatory
injections are used in cases where OA is confined to
a few joints and pain cannot be relieved with
NSAIDs. The use of corticosteroid injections for OA
is somewhat controversial. Physicians recommend
no more than three or four injections a year for
weight-bearing joints.
• Topical analgesics: Capsaicin cream, which has the
same active substance as hot chili pepper, can lessen
the pain for OA patients.
Surgical Management of Osteoarthritis 85
Surgical Management
10 of Osteoarthritis
INTRODUCTION
There is no single best way to treat most knee injuries.
Whether surgical treatment is right for it depends on many
factors, including:
• The type of injury and amount of damage to the knee
• The risk of future injury or damage if there is no surgery
• Patient’s lifestyle, including which sports he/she plays
• Willingness to modify activities and sports
• Motivation to work through rehabilitation to strengthen
the knee after surgery.
If there is an injury that may require surgery, it is usually
not necessary to have the operation immediately. In most
cases, it will be better if one waits until the swelling goes
down and regain strength and full range of motion in the
knee.
Before making any decision, consider the pros and
cons of both nonsurgical rehabilitation and surgical
reconstruction in relation to what is most important.
Nonsurgical treatment is not an option if there is cartilage
damage that interferes with the range of motion (locked
knee) or if the blood supply to the knee is severely
compromised.
INDICATIONS OF SURGERY
For many people, surgery helps relieve the pain and
disability of osteoarthritis.
Surgery may be performed to:
• Remove loose pieces of bone and cartilage from the joint
if they are causing mechanical symptoms of buckling
or locking
• Resurface (smooth out) bones
• Reposition bones
• Replace joints.
Surgeons may replace affected joints with artificial joints
called prostheses. These joints can be made from metal
alloys, high-density plastic, and ceramic material. They can
be joined to bone surfaces by special cements. Artificial
joints can last 10 to 15 years or longer. About 10 percent of
artificial joints may need revision. Surgeons choose the
design and components of prostheses according to their
patient’s weight, sex, age, activity level, and other medical
conditions.
The decision to use surgery depends on several things.
Both the surgeon and the patient consider the patient’s level
of disability, the intensity of pain, the interference with the
patient’s lifestyle, the patient’s age, and occupation.
Currently, more than 80 percent of osteoarthritis surgery
cases involve replacing the hip or knee joint. After surgery
and rehabilitation, the patient usually feels less pain and
swelling, and can move more easily.
NONTRADITIONAL APPROACHES
Among the alternative therapies used to treat osteoarthritis
are the following:
Acupuncture
Some people have found pain relief using acupuncture (the
use of fine needles inserted at specific points on the skin).
Preliminary research shows that acupuncture may be a
useful component in an osteoarthritis treatment plan for
some patients.
Folk Remedies
Some patients seek alternative therapies for their pain and
disability. Some of these alternative therapies have
included wearing copper bracelets, drinking herbal teas,
and taking mud baths. While these practices are not
harmful, some can be expensive. They also cause delays
in seeking medical treatment.
Nutritional Supplements
Nutrients such as glucosamine and chondroitin sulfate
have been reported to improve the symptoms of people
with osteoarthritis, as have certain vitamins. Additional
studies are being carried out to further evaluate these
claims.
SURGICAL OPTIONS
Surgical options may include:
Arthroscopic Surgery
Depending on the nature of the injury, the doctor may be
able to examine and repair joint damage using an arthro-
scopic technique (arthroscopy) that requires just a few
small incisions. Arthroscopy may be used to remove loose
bodies from the knee joint, repair torn or damaged
cartilage, reconstruct torn ligaments and occasionally

correct damage from degenerative joint diseases such as
arthritis.
The advantage of the procedure is that the patient likely
to recover more quickly and with less discomfort than with
open surgery. Even so, recovery from ligament and
meniscus surgery is often slow and requires a strong
commitment to physical therapy.
Partial Knee Replacement Surgery

If there is considerable knee damage from degenerative
arthritis but still retain some healthy cartilage, and
conservative measures such as lifestyle changes, medication
and physical therapy fail to help your symptoms, the right
choice will be partial knee replacement.
In this procedure (unicompartmental arthroplasty), the
surgeon replaces only the most damaged portion of the
knee with a prosthesis made of metal and plastic. The
surgery can usually be performed with a small incision.
Healing is also likely to be quick. Unfortunately, many
people who opt for knee replacement surgery have damage
too extensive for unicompartmental arthroplasty. In
addition, long-term results may not be as good as they are
with a total knee replacement.
Total Knee Replacement

In this procedure (total knee arthroplasty), the surgeon cuts
away damaged bone and cartilage from the thighbone,
shinbone and kneecap, and replaces it with an artificial
joint (prostheses) made of metal alloys, high-grade plastics
and polymers. Total knee arthroplasty can improve knee
problems associated with osteoarthritis, rheumatoid

arthritis and other degenerative conditions such as
osteonecrosis—a condition in which obstructed blood flow
causes your bone tissue to die.
Total knee replacement if there is a severely damaged,
arthritic knee that limits the patient’s mobility and function,
he/she is older than 55 and in generally good health, and
conservative measures fail to improve the symptoms.
Surgery
Several types of surgery can correct OA damage. Surgery
is usually reserved for the most debilitating cases of OA.
Types of surgery include:
Arthroscopy: A flexible lighted tube is inserted in a joint to
remove fragments of bone or cartilage from the joint
capsule. It may also be used to remove the lining of the
joint capsule (synovectomy). Arthroscopy may not provide
much pain relief to OA patients.
Corrective surgery: May be used on deformed joints and to
realign bones (osteotomy).
Fusion (arthrodesis): Surgeons may fuse bones, usually in
the spine or in other areas where the joints are damaged
but joint replacement is not an option (fingers, toes or
ankle). A fused joint can bear weight but is no longer
flexible.
Joint replacement surgery (arthroplasty): Damaged joints may
be partially or completely replaced. When a joint is comp-
letely degenerated, surgeons can replace the entire joint.
This is most commonly performed for the knees and hips.
Researchers are studying many potential treatments to

slow the progression of OA or reduce pain and disability.
These include bioengineered implants of a patient’s own
cartilage, osteoporosis treatments such as bisphosphonates
and the hormone calcitonin, and injections of botulinum
toxin type A (Botox).
Physiotherapeutic Modalities 91
Physiotherapeutic
11 Modalities
In earlier chapters common knee problems were discussed.

Among these Osteoarthritis and its signs and symptoms
were highlighted. Light was thrown on the condition’s
diagnostic methods, its medical and surgical management.
Here its physiotherapeutic modalities are being discussed.
TRANSCUTANEOUS ELECTRICAL NERVE

STIMULATION (TENS)
Definition
The application of pulse rectangular wave current through
surface electrode on skin is known as TENS.
Parameters
Pulse shape : Rectangular
Pulse width : 50-300 microsecond
Frequency : 2-600 Hz
Intensity : 0 – 60 milliamperes
Classification
High Frequency TENS (Low Intensity TENS)
• Frequency = > 50 Hz
• USE: Acute pain
Low Frequency TENS (High Intensity TENS)

• Frequency: < 50 Hz
• USE: Chronic pain
Burst TENS
• Frequency = 1-10 Hz
Conventional Tens
• Frequency : 10-100 Hz
Mechanism of Analgesia
Endorphin Theory
TENS causes stimulation and circulation of endorphins.
Gate Control Theory

Painful impulses can be prevented from reaching brain
by stimulating large diameter sensory nerve fibers (A beta
fibers and substantia gelatinosa cells).
Method of Application
TENS is applied through Rubber electroconductive
electrodes (Fig. 11.1).
Electrodes
• Carbon impregnated electrode
• Silicon rubber electrode
• Pad electrode.
Placement
• Over spinal cord segment
• Acupuncture point
• Over painful dermatome
Fig. 11.1: Patient undergoing TENS therapy

for knee osteoarthritis
• Painful area
• Over nerve trunk
• Over trigger points.
Indications
Joint Pain
• Rheumatoid arthritis
• Osteoarthritis
• Intra-articular hemorrhage.
Muscle Pain
• Muscle spasm
• Torticollis (Wryneck syndrome)
• Myositis
• Myalgia
• Muscle strain.
Contraindications
• Anesthesia
• Cardiac pacemaker
• Carotid sinus
• Epileptic patients.
Dosage
• Acute pain: High frequency TENS for 20 mins
• Chronic pain: Low frequency TENS for 30 mins.
Benefits
• Due to reduced pain exercise program can be improved
• ADL can be improved
• Early return to work
• Early ambulation in postoperative cases.
SHORT WAVE DIATHERMY

Definition
Diathermy—The meaning of diathermy is heat given
through an object.
It is used for deep heating.
Parameters
• Frequency: 27.12 MHz
• Wavelength: 11 meters
Electrodes: The conductors through which current is applied
to the body.
Types
1. Electrodes used in olden days: Cable, axillary, rectal and
vaginal.
2. Nowadays electrodes used are: Pad, disk, monode, minode,

drum, sinus, butterfly.
Arrangement
Monopolar
Only one electrode is placed over treatment area and other
electrode is placed at a distance site or is not used at all.
Co-planar
Electrodes are placed side by side on the same aspect of
part of the body.
Example: Treatment of back.
Contraplanar
Electrodes are placed over opposite aspects of limb or joint
that is medial and lateral aspect or anterior and posterior
aspect.
Example: Hip joint, shoulder joint.
Cross Fire Technique

In this technique half of the treatment is given with the
placement of electrode in one direction that is medial and
lateral aspect and another half is used with the placement
of electrode in other direction that is anterior and posterior
aspect.
Example: Knee joint, sinuses (maxillary, frontal,
ethmoidal).
Physiological Effects
1. Temperature: Increase in local temperature may occur
due to production of heat. The heat is dissipated to other
parts of the body through blood.
2. Metabolism: Increased metabolism due to increased heat

(vont Hoff). Vont Hoff has stated that any chemical
change capable of being accelerated by heat is
accelerated by rise in temperature
3. Blood supply: The heat has a direct effect on blood vessels.
It causes vasodilatation of the vessels in the area of
treating. This results in increase local blood supply in
the treatment area.
4. Effects on nerves: SWD decreases excitability of nerves,
especially sensory nerves. It produces sense of sedation.
Perception of pain is reduced as it enhances pain
threshold.
5. Effects on muscular tissue: Rise in temperature induces
muscle relaxation.
6. Effects on sweat glands: Heat stimulates the centers for the
regulation of the sweat. The production of sweat is
increased, thus increasing elimination of waste products.
Therapeutic Effects
Pain Relief
• Decreases muscle spasm
• Decreases joint stiffness
• Enhances healing.
Indications
1. Orthopedic conditions:
• Low back ache
• Osteoarthritis
• Sprains
• Strains
• Muscle tear
• Capsulitis
• Myalgia
• Frozen shoulder
• Bursitis
• Hematoma
• Fibrositis
• Ankylosing spondylitis
• Neuralgia.
2. Sports injuries
• Rectus femoris strain
• Hamstring strain
• Contusions to thorax.
CRYOTHERAPY
The application of cold for various therapeutic purposes
is known as cryotherapy.
Techniques of Administering Cold

Ice Massage
Ice cube is taken in a polythene bag and massaged in a
circular manner over treatment area.
Indications: Bedsores.
Duration: 10-20 minutes.
Ice Towels
Prepare the ice solution by filling a bucket with two parts
of flaked or crushed ice to one part water in which two
terry towels are immersed, the excess water is wrung from
towel and applied over part to be treated.
Immersion in Cold (Cold Whirlpool)

The part of the body is immersed in cold water in which
temperature of water is lowered up to 0 to 10°C.
Duration: 10 minutes.
Cold Packs
These cold pack contain a special material which retains
cold like silicate gel.
These are available in different sizes and shapes.
Advantage: Reusable and mould according to part.
Vapocoolant Sprays (Evaporative Cooling)

Indications: Sports injuries.
The commonly used sprays are fluoromethane or ethyl
chloride. The jet of spray is usually applied from a distance
of about 1 feet. Gentle stretch is applied to tissue after
application of vapocoolant spray.
Excitatory Cold
The sensory stimulus of ice on skin can be used to facilitate
contraction of inhibited muscle.
Site of stroking: Myotome, dermatome.
The ice is stroked 3 times over dermatome and skin is
then dried. It increases the level of excitation around
anterior horn cells.
Effects on circulatory system: Lewis hunting reaction—
alternate periods of vasoconstriction and vasodilation.
The initial phase of vasoconstriction helps to limit

swelling and the extent of tissue damage.
The alternate phases of vasoconstriction and vaso-
dilatation helps in removing the waste products of
metabolism (lactic acid) and delays fatigue.
Effects on nervous system: The rate of conduction of nerve
fibers is reduced by cold. The major effects of ice
application are due to decrease pain.
Mechanism: The stimulation of cold receptors will send back
impulses which have to pass into the spinal cord via
posterior root.
Cold impulses are carried by large diameter nerve which
effectively blocks the pain impulses to spinal cord (pain
gate is closed).
The cold stimulus is itself noxious one and can stimulate
mid brain (PAG) which may release endorphins and
enkephalins into posterior horn and decrease pain.
Circulation: Cold increases circulation. Therefore chemical
substances which are stimulating nociceptors (substance
P, Prostaglandin, Interleukin, and Histamine) are washed
off and thus decrease pain.
Muscle: The short, brisk application of cold is thought to
increase muscle tone (excitatory cold). Therefore it is useful
in flaccidity.
The prolonged use of cold (immersion) reduces muscle
tone, therefore useful in spasticity.
Indications
• Pain
• Muscle spasm
• Trauma
• Spasticity.
Contraindications
Peripheral Vascular Disease
• Raynaud’s
• Burger’s
• Deep vein thrombosis
• Varicose veins.
Cardiovascular Insufficiency
• Myocardial infarction
• Coronary artery disease
• Loss of sensation
• Tumors
• Icing on posterior rami of spinal trunk
• Hypersensitive patients
• Carotid sinus
• Throat.
PARAFFIN WAX BATH THERAPY (PWBT)

PWBT is the application of molten paraffin wax on body
parts (Fig. 11.2).
Temperature
40-44°C.
(Melting point of paraffin wax is 52°C, addition of liquid
paraffin oil decreases melting point).
Mode of Transmission
Mode of transmission of heat from paraffin to patient skin
is by conduction.
The part to be treated must be cleaned by soap and
moisture to be soaked by towel.
Fig. 11.2: Application of molten wax on the body part
Position
Part to be treated must be brought closer to wax bath
container.
Techniques of Application
Direct Pouring Method
The molten wax is poured by a mug on the part to be
treated and wrapped by a towel. Allow to solidify for 10-
12 minutes and 4-5 layers.
Brushing Method
A brush is used for application of molten wax over the
affected part several coats/layers (4-6) are applied.
Direct Immersion / Dipping Method

The body part to be treated is directly immersed into
container repeatedly to make layers of wax.
Toweling /Bandaging Method

A towel is immersed in molten wax and then wrapped
around the body part. Several layers can be made around
the body part.
Effects
• Superficial heating of tissue
• Increases local circulation
• Increases pliability of skin
• Decreases stiffness
• Analgesic effect
• Stretching effect.
Indications
• Osteoarthritis
• Adhesions
• Joint stiffness
• Immobilization
• Scar.
Contraindications
• Open wounds
• Skin rashes
• Allergy
• Impaired sensation
• Defective circulation
• Tumors
INFRARED RADIATION (IRR)

IRR are electromagnetic waves.
Wavelength: 750 to 4 lakh nm.
Frequency: 4 × 10, 000, 000, 000, 000, 00 Hz and 7.5 ×
10, 000,000,000, 00 Hz.
Classification based on wavelength
Short wave infrared radiation: (near IRR)
Wavelength 750 to 1500 nm
Long wave infrared radiation: (far IRR)
Wavelength > 1500 nm
Technique of treatment:
Choice of apparatus:
• Nonluminous generator in acute inflammation and
injury.
• Luminous generator in chronic lesions.
Preparation of patient (Fig. 11.3):
Fig. 11.3: Clothes must be removed from treatment area and

skin checked for sensation
Positioning of patient: Suitable, comfortable.

Instructions: If there is increased heat it should be informed.
Lamp arrangement: The lamp is positioned so that it is
opposite the center of area to be treated and rays strike
skin at right angles, thus ensuring maximum absorption.
Distance between patient and lamp: 50 to 70 cm.
Application of IRR: At the start of treatment exposure
intensity should be low but after ten minutes when
vasodilatation has taken place intensity of radiation can
be increased.
The therapist should be near the patient. .
Duration:
– Acute conditions: 10 to 15 minutes
– Chronic conditions: 20 to 30 minutes.
Physiological effects: IRR produces heating effect in superficial
epidermis, thus resulting in vasodilatation which increases
blood circulation in that area. This will lead to more oxygen
supply and nutrition in that area leading to draining of waste
products resulting in relief of pain.
The sedative effects on nerve endings leads to reduction
in muscle spasm.
Therapeutic effects
– Pain relief
– Muscle relaxation.
Dangers of IRR
– Burns
– Shock
– Syncope
– Gangrene.
Indications
– Pain
– Muscle spasm
– Arthritis
– Inflammation
– Postimmobilization stiffness
– Infections.
Contraindications
IRR should not be applied to areas of:
– Defective arterial blood supply
– Defective skin sensation
– Areas where there is danger of hemorrhage
– Directly over the eyes
– Known cases of tumors.
ULTRASOUND
The treatment of diseases by using sound waves is known
as ultrasound therapy.
Ultrasound refers to mechanical vibrations which are
essentially the sound waves but of higher frequency.
Uses
Diagnosis: Imaging fetus during pregnancy.
Destructive: To produce extreme tissue hypothermia for
tumoricidal effect.
Therapeutic use: Used in rehabilitation of
Injuries
Decrease pain
Frequency= 1 to 3 MHz
1 MHz penetration= 3 to 5 cm
Indication: Individuals with high percentage of cutaneous

fat.
3 MHz penetration = 1 to 2 cm.
Coupling Media (Couplant)

The medium which is interposed between the treatment
head and patients’ skin for ensuring maximum
transmission of ultrasonic waves.
Example
Aquasonic gel = 72.6 percent
Glycerol = 67 percent
Distilled water = 59 percent
Liquid paraffin = 19 percent
Air = 0 percent
Petroleum jelly = 0 percent
Characteristics of Couplant
– Acquistic impedence similar to tissue
– High transmission for ultrasonic waves
– High velocity
– Low susceptibility to bubble formation
– Hypoallergic
– Chemically inactive
– Cheap
– As lubricant to allow smooth movement.
Treatment Parameters
Modes
Continuous mode: Treatment head continuously produces
ultrasound.
Pulsed mode: The periods of ultrasound are separated by

periods of silence.
Intensity
Space averaged intensity: The average intensity over a
specified area is given.
Example: w/cm2
Time (space) average intensity: It can be used when
ultrasound is applied in a pulsed mode. It gives average
intensity over whole treatment time for a specified area.
Example: 0.5 w/cm2 is applied pulsed 1:4 then in 1 sec
average intensity would be 0.1 w/cm2.
Pulsed mark space ratio: The ratio of time on to time off is
known as mark: Space ratio
Mark = time ultrasound on
Space = being silence
Ranges: M: S = 1:2, 1:4, 1:7, 2:8
Testing the Apparatus

This is done by placing the treatment head just below under
water surface and observing the disturbance (ripples).
Preparation of patient: Skin should be washed and hairs
should be removed.
Examination: Skin surface to be treated should be inspected.
Positioning: Suitable, comfortable position should be chosen.
Instructions: The patient is asked to keep the part still and
relaxed and to report if any increase of pain.
Application: The treatment head is moved continuously
over surfaces area.
The emitting surface must be kept parallel to skin

surface to decrease reflection.
Methods
– Concentric circles
– Overlapping circles
– Figure of 8
– Transverse strokes.
Techniques of Application
Direct contact method: If the surface is regular then a coupling
medium is applied to the skin in order to eliminate air
between the skin and treatment head. The treatment head
is moved in small concentric circles over the skin (Fig. 11.4).
Waterbath method: The part to be treated is immersed in
water; a waterbath is filled with degassed water.
Fig. 11.4: Technique of application of ultrasound waves over

the knee
Indications
Hand, ankle, foot.
The treatment head is placed in water and held 1cm
from skin and moved in small circles.
Water Bag Method

In this method a rubber bag filled with water forms a
cushion between treatment head and skin.
A coupling medium has to be placed both between
rubber bag and skin and rubber bag and treatment head.
The treatment head is moved over bag.
Dosage: Based on—
– Size of treatment area
– Depth of lesion
– Nature of lesion.
Thermal effect: As ultrasound is absorbed by tissue it is

converted into heat.
Uses: Increased heat accelerates healing process
Increases collagen extensibility
Stretching of scar tissue
Decrease pain.
Cavitation: This is the oscillatory activity of highly compres-
sible bodies within tissue such as gas.
Types: Stable cavitation occur when bubbles oscillate to and
fro within ultrasound pressure waves. This causes micro-
streaming. Microstreaming results in increased permeability
of cell membrane.
Unstable cavitations: (transient) occurs when volume of

bubbles changes rapidly and collapse. It is dangerous to
tissue.
Micromassage: This occurs where the long compression
waves of ultrasound beam produces compression and
rarefaction of cells.
Advantages: Decreases edema.
Increases extensibility of scar and adhesions.
Biological Effect
Inflammatory: Ultrasound increases fragility of lysosome
membrane and release of enzymes. These enzymes clear
area of debris.
Proliferative: Fibroblasts and myofibroblasts may have
calcium ions driven into them. This increases production
of collagen from fibroblasts.
Remodeling: Ultrasound has been shown to increase tensile
strength of scar by affecting elasticity of fibers.
Therapeutic Effects and Uses of Ultrasound

Scar tissue: Increases pliability (capable of bend and twist).
Chronic indurated edema: Mechanical effect decreases edema.
Varicose veins: Increases healing of varicose veins and
pressure sores.
Bone injuries: Ultrasound in first and second week after
bone injury enhances bone union.
Placebo effect: Ultrasound has psychological effect.
Plantar warts: Seen in athletic population on weight bearing

areas of feet. These can be cured by ultrasound.
HYDROCOLLATOR (HOT) PACK

Hot packs are the packs which are immersed in an
apparatus called hydrocollator.
They provide superficial moist heat.
They contain substance like silica/gel which absorbs
heat.
Temperature in hydrocollator pack: 65-80°C.
Aim of Hydrocollator Pack

To raise body temperature at 40-45°C, hydrocollator packs
are available in various shapes and sizes.
Sizes
Small—Elbow, ankle joint
Large—Hip joint and back
Contoured—Cervical spine.
Before treatment hydrocollator packs should be
wrapped in a six to eight layered towel.
Effects
Muscle: It relieves muscle spasm.

Increases local temperature: The rise in local body
temperature occurs following hot packs application.
Increases local temperature and decreases muscle spasm
and pain.
Circulation
It increases local circulation around area under
temperature.
It provides fresh blood supply and nutrition.
Skin: Skin becomes supple and increases elasticity.
Connective tissue: Increases elasticity of connective tissue
when combined with stretching.
Pain Relief
Pain relief following hot pack application may occur due
to decrease in:
– Nerve conduction velocity/ elevated pain threshold
– Sedative/counter irritation effect by heat.
Indications
• Pain
• Muscle spasm
• Joint stiffness
• Impaired circulation
• Decreased range of motion
• Poor muscle contraction.
Advantages
• Easily carried out
• Good sedative effect
• Saves time
• Gives uniform temperature.
CONTRAST BATH
The alternate method of applying heat and cold with a
certain amount of control to aid normal temperature of
body is known as contrast bath.
There is alternate immersion of part in hot and cold

water.
Method: Fill two baths of suitable size depending on limb
to be treated.
Hot waterbath = 40 to 45°C
Cold waterbath = 15 to 20°C
The treatment should begin and end with hot water.
Placement: Place the limb in:
Hot water for 3 minutes
Cold water for 1 minute.
Repetition: 4 to 5 times
Duration of treatment: The whole procedure should take 15
to 20 minutes.
Physiological effects
• Vasodilatation
• Increases skin temperature
• Increases circulation
• Sedative effect.
Indications
• Post-traumatic swelling
• Pain
• Edema
• Chronic inflammation.
Contraindications
• Peripheral vascular disease
• Arterial insufficiency
• Diabetes
• Open wounds.
Physiotherapeutic Exercises 115
Physiotherapeutic
12 Exercises
INTRODUCTION
Exercise therapy is one of the most important and effective
treatments for reducing and preventing pain. Exercise causes
the body to release chemicals such as endorphins and
enkephalins, which block pain signals from reaching the
brain. Exercise also offers general health benefits for people,
regardless of whether or not they are suffering from pain.
Patient’s who exercise strengthen muscles and increase
the range of motion in joints. Exercise programs can have
special benefits for those suffering from various types of
pain, such as back pain, neck pain, arthritis, fibromyalgia
and lupus.
Most exercises fit into one of three categories:
• Flexibility: These include range-of-motion and stretching
exercises that help ease movement in the joints.
• Aerobic capacity: Exercise that helps strengthen the heart,
lungs and muscles associated with the cardiovascular
system.
• Strength: Exercises that help build strong muscles.
Regular exercise can also:
• Promote weight loss, which can reduce stress in joints
and help prevent osteoarthritis.
• Improve sleeping and energy levels while awake.
• Increase bone mass, which reduces the risk of injury

and osteoporosis.
• Help prevent heart conditions, diabetes and other
diseases.
• Enhance healing of wounds.
People are advised not to begin an exercise program
without first consulting a physician or other expert, such
as a physical therapist, occupational therapist or certified
exercise therapist.
Exercises to do:
1. Rack Pulls (or partial deadlifts). Start from knee height
to groove the pattern. Once the patient masters that,
one can move on to other deadlift variations.
2. Pull-Throughs (the perfect cure for anyone who suffers
from flat tush syndrome).
3. SHELC (Supine Hip Extension w/ Leg Curl) on a SWISS
ball.
4. Glute Ham Raises.
5. Reverse Lunges/Walking Lunges (long stride). Key
Point: the longer the stride, the more emphasis you place
on the hamstrings.
6. Work on squat technique. 99 out of 100 times, if
someone says that squatting hurts them, they are
performing it wrong. Everyone uses a toilet with no
pain……that’s squatting. The patient should be taught
to squat with hips/hamstrings and NOT quads. They
should break with hips on the descent and not knees.
Have them squat down to a 14-16 inch box and see
what happens. The important thing is to have them
do it in a pain-free ROM. From there one can have them
do bodyweight squats and gradually load them (goblet
squats, front squats, etc.). Additionally, isometric holds

can be added.
7. As far as conditioning, if one has access to a sled that
would be perfect since it’s pretty much ALL concentric
action (no eccentric). So there should be no pain what-
so-ever doing those. Something along the lines of the
elliptical would be a better option for the time being.
In a nutshell, the therapist can still train the lower
body.
LOWER BODY STRETCH

Stretching is an important part of any workout routine. It
helps increase flexibility and reduce chances of injury. It’s
best to stretch the muscles used after cool down although,
if the patients have any chronically tight muscles, they may
want to stretch those after warm up as well. Below are
some common stretches for lower body including quads,
hamstrings, glutes, calves and hips. Do each stretch at least
once and hold for at least 15 seconds (more if there is time).
Each stretch should feel good. If the patients feel any pain,
ease up and go slower.
INSTRUCTIONS
Hip/Glute Stretch
Cross left foot over right knee. Clasp hands behind right
thigh and gently pull the leg in towards the patient,
keeping upper body relaxed. Switch legs.
Hamstring Stretch (Fig. 12.1)

Lie on floor with knees bent. Straighten one leg and slowly
pull it towards the body, clasping the thigh, calf or ankle.
Keep knee slightly bent. Switch legs.
Fig. 12.1: Hamstring stretch posture
Inner Thigh Stretch (Fig. 12.2)

Make the patient sit on floor with feet pressed together.
Keeping abs in, lean forward until he/she feels a gentle
stretch in their inner thighs.
Fig. 12.2: Inner thigh stretch posture

Lunge Stretch (Fig. 12.3)

In lunge position, rest back knee on the floor, with front
knee at 90 degree angle, abs in. Gently press forward until
he/she feels a stretch in the front of the leg/hip. Switch
legs.
Fig. 12.3: Lunge stretch posture
Kneeling Hamstring Stretch (Fig. 12.4)

From above lunge position, slowly move backward until
leg is slightly bent. Bend forward at the hip, keeping back
flat until he/she feel gentle pull in the back of the leg.
Switch legs.
Fig. 12.4: Kneeling hamstring stretch posture

Piriformis Stretch (Fig. 12.5)

Begin on the hands and knees and bring the left knee in,
resting it on the floor between the hands (the patient should
be on the outside of the knee). Straighten the right leg out
behind and, bend forward and rest the forearms on the
floor.
Fig. 12.5: Piriformis stretch posture
Knees to Chest (Both knees) (Fig. 12.6)

Lying on the floor, pull the knees into the patient’s chest
and clasp the hands under the knees. Gently press the hips
to the floor.
Fig. 12.6: Knees to chest position using both knees

Knee to Chest (Single Knee) (Fig. 12.7)

From above position, straighten one leg and pull the other
knee into the chest until he/she feels a stretch in the hip.
Switch legs.
Fig. 12.7: Knee to chest position using single knee
Calf Stretch (Fig. 12.8)

On hands and knees, straighten the legs, but keep them
slightly bent. Gently press one or both feet towards the
floor, keeping back flat and abs in.
Fig. 12.8: Calf stretch posture

Kneeling Calf Stretch (Fig. 12.9)

On hands and knees, bring the left foot in between the
hands and gently press the knee forward while pressing
the heel towards the floor.
Fig. 12.9: Kneeling calf stretch posture
Spine Twist (Fig. 12.10)

Lying on the floor, place right foot on the left knee. Using
the left hand, gently pull the right knee towards the floor,
twisting spine and keeping left arm straight out, hips and
shoulders on the floor. Switch sides.
Fig. 12.10: Spine twist posture

Quad Stretch (Fig. 12.11)

Lie down on the side using elbow for balance. Using
other arm, slowly pull the foot towards the glutes, keeping
both knees together and bent knee pointing down. Switch
legs.
Fig. 12.11: Quad stretch posture
Squats
Squats are one of the best lower body exercises one can
do. Why? One reason is that squats are multijoint exercises
which target all the muscles of the hips, glutes and thighs.
This version, which requires no weights or equipment
(other than a chair) is great for beginners, for anyone with
knee problems or for those who are overweight and need
a bit more support.
It is also great for anyone wanting to add more
functionality into their lives because it mimics the
movements we do each time we sit down or stand up.
1. Place a chair just behind and stand in front of it with
feet about hip- or shoulder-width apart.
2. Contract the abs and keep them tight as he/she bends

the knees and slowly squat towards the chair.
3. Keep the knees behind the toes as he/she sits down on
the chair for a few seconds.
4. Contract the glutes and hamstrings to lift up out of the
chair and begin extending the legs.
5. Fully extend the legs until the patient is back to standing
position.
6. Repeat this for 1-3 sets of 10-16 repetitions.
7. To progress, squat down until he/she just hovering over
the chair, but not sitting all the way down.
8. Always keep the knees in line with the toes.
Knee Exercises
Rehabilitating a damaged knee can be difficult. Many times
exercises can aggravate or irritate the knee cap and increase
pain. In an effort to deal with this problem the following
knee exercises are advised. The exercises are into three
groups. The patient should begin with group one. When
group one can be done easily and without pain he/she
can proceed to group two. When group one and two can
be done easily they can proceed to group three.
Group 1 Exercises
1. Isometric quadriceps contraction
2. Straight leg raise without weights
3. Hip abduction strengthening
4. Hip adductor strengthening.
Isometric Quadriceps (Quads) Contraction (Fig. 12.12)
Fig. 12.12: Isometric quadriceps contraction posture
Position: Initially the exercise should be done lying down

or sitting comfortably. Once it can be done comfortably it
can be done while standing.
Repetitions: It should start by doing ten contractions at a
time. Increase the number by one repetition per day as
tolerated. The exercise can be done many times during the
day. If knee pain occurs decrease the number of repetitions
per day.
Exercise: Contract the quadriceps muscles in the front of
the knee attempting to maximally straighten out the knee.
While tightening the quadriceps muscle, pull toes and foot
toward the face. Push the heel down against the surface
upon which the leg rests. Hold the contraction for a count
of 5, then relax.
Counting should be:
One thousand - Two thousand - Three thousand - Four
thousand - Five thousand. Repeat the exercise after a rest
period of two counts.
Straight Leg Raise Without Weights (Figs 12.13 A and B)
Figs 12.13A and B: Straight leg raise without weights
Position: Initially the exercise should be done while lying

down. Once the exercise can be done comfortably lying
down, it can be done sitting. The opposite leg may be bent
to a position of comfort but not more than 30°.
Repetitions: Start with ten repetitions. Do the exercise very
slowly. Increase the number of repetitions by one per day
for the first week. After the first week increase the number
of repetitions by 20 percent per week.
Exercise: Contract the muscle by isometrically by contracting
the quadriceps muscle (was done in the first exercise). After
a two count (one thousand, two thousand) begin slowly
lifting the leg. Do not bend the knee more than 30°. Lift the
leg to at least 45°. Going higher than 45° will stretch the
back of the leg but will not add to quadriceps strengthening.
Hip Abductor Strengthening (Fig. 12.14)
Fig. 12.14: Hip abductor strengthening exercise posture

Position: Lying on the side. Leg straight or the leg may be
bent to the position of comfort.
Repetitions: Start with five repetitions. Increase by one per
day for the first week. Then increase by 10 percent per
week after the first week.
Exercise: Slowly lift the leg sideways raising the leg. Obtain
an angle of at least 30°. Hold the leg in that position for a
count of two (one thousand, two thousand). Ankle weights
can be added when it can be done at least 25 repetitions
with ease. Start with a one pound weight. Add weight in

one pound increments.
Hip Adductor Strengthening (Fig. 12.15)
Fig. 12.15: Hip adductor strengthening posture
Position: Sitting.
Repetitions: This exercise can be done many times. It has
no potential to increase knee pain.
Exercises: Sitting with the knees touching and feet slightly
apart. Push the knees together tightly. Hold for a count of
5 then relax. Repeat as tolerated.
Group Two Exercises

1. Straight leg raise with weights
2. Leg extension
3. Isometric quadriceps strengthening
4. Hamstring strengthening- quadriceps stretching.
Straight Leg Raise with Ankle Weights (Figs 12.16A and B)
Fig. 12.16A and B: Straight leg raise exercise with ankle

weights
Position: Same as straight leg raise without weights.

Exercise may be done sitting or lying down. Opposite leg
may be bent or straight.
Repetitions: Start with five repetitions. Increase as with
straight leg raise without weights.
Exercise: This exercise is done exactly the same as the straight

leg raise without weights except that one adds ankle
weights. Start with a two pound weight. When the patient
can comfortably do 25 repetitions increase to three pounds.
Remember that increasing two to three pounds represents
a 50 percent increase in weight. From three pounds go to
five pound by using the two and three pound weights
together. From five pounds go to seven and then to ten
pounds.
Weight recommendation: Use a 2 lb., 3 lb. and 5 lb. ankle
weight None—2 lb.—3 lb.—5 lb.— 7 lb.—10 lb.
Leg Extension Exercises (Figs 12.17A to C)
B
Fig. 12.17A to C: Leg extension exercise postures
Position: Sitting. A stool or bench may be used to rest the

leg at the bottom of the bent position.
Repetitions: Start with ten repetitions with no weight.
Increase repetitions until you reach 25. Then add ankle
weights as follows:
2 lb.—3 lb.—5 lb.—7 lb.— 10 lb.—15 lb.—20 lb..—25 lb.
Increase the weight after 25 repetitions.
Exercise: The starting position is sitting with the leg straight
out in front. Slowly bend the leg to 45°. The knee should
not bend beyond 45° because this may cause increased
kneecap pain. After 45° is reached reverse directions and
begin straightening the knee. When full extension is
reached hold the leg straight for a count of two. Then start
the exercise over again.
Isometric Quadriceps Strengthening (Figs 12.18A and B)
A B
Figs 12.18A and B: Isometric quadriceps strengthening

exercise postures
Position: Sitting. One leg on top of the other.

Repetitions: Start with ten repetitions. Increase the number
of repetitions as your strength increases.
Exercise:
Part 1: Start with the right leg straight. Put the left leg and
foot over the top of the right leg. Push down with the left
leg and up with the right leg. Hold the contraction for a
count of three. Relax for a count of two, then repeat the
exercise.
Part 2: Repeat the same exercise with the knee bent.
Part 3: Repeat the same exercise with the knee bent.
Part 4: Repeat the exercise with the left leg on the bottom
and the right leg on top.
Hamstring Strengthening - Quadriceps Stretching

(Figs 12.19 and B)
Position: Lying face down.
A
Figs 12.19A and B: Hamstring strengthening-quadriceps

stretching exercise posture
Repetitions: Start with ten repetitions. Increase the number

of repetitions one per day until you reach 25. Then add
weights as follows:
3 lb.—5 lb.—7 lb.—10 lb.—15 lb. —20 lb..—25 lb.
Exercise: Lying face down start bending the affected knee.
Slowly bend the knee until the patient feels pain or a
pulling sensation. Hold that position for a count of 3. From
that position try to increase the amount of bend in the knee
by contracting the hamstring muscles. The hamstring
muscles are the muscles on the back of the leg. Pull as hard
as he/she can tolerate then relax.
Repeat the exercise again. Both legs should be exercised.
Group Three Exercises

1. Hip abductor stretching
2. Hamstring stretching
3. Standing press
4. Quadriceps stretching.
Hip Abductor Stretching (Fig. 12.20)
Fig. 12.20: Hip abductor stretching posture
Position: Lying on the side at the edge of a bed or exercise

table with the back toward the edge of the table.
Repetition: Start with ten repetitions. Increase as tolerated.
Beware: This exercise will cause stiffness the day after the
exercise.
Exercise: Position the patient at the edge of a bed or table.
The back should be facing the edge of the table. Drop the
upper leg behind him/her and let the leg drop down as
far as it will go. Let the leg hang down over the edge of the
table or bed. Let the leg hang down as long as it is
comfortable. (From this position raising the leg strengthens
the hip abductor muscles).
Hamstring Stretching (Fig. 12.21)

Position: Sitting at the side of a bed, chair or table, the left
leg is placed on the bed, the right leg is bent over the edge
Fig. 12.21: Hamstring stretching posture
of the bed. The leg being stretched is straight. The leg not
being stretched is bent. This position will avoid stressing
the back.
Repetition: Repeat the exercise at least ten times. Increase
the force and number of repetitions of the exercise as
tolerated. Do no more than 25 such stretches at a time.
Exercise: Sit on the side of a bed, one leg over the edge of
the bed the other straight in front of you. Lean toward the
outstretched leg attempting to touch the toes. Keep the back
straight. Do not bend the head forward. If toes can be
touched then one can go beyond. When pulling is felt at
the back of knee slow the stretch down and hold that
position for a count of three. Then increase the stretch by
leaning farther toward the toes. Go as far as the patient
can and hold for a count of two. Release the stretch slightly
for a count of three and then lean back into the stretch. Try
not to let the tension completely off of the hamstring during
the rest periods. In that way the hamstring will be under

stretch throughout the exercise.
Standing Press (Figs 12.22A and B)
A B
Figs 12.22A and B: Standing press posture
Position: Stand leaning against a wall.

Repetition: Start out with ten repetitions. Increase both the
length of time that maintains the position and number of
repetitions as tolerated. Increase one repetition per day
for the first week then by 10 percent per week later.
Exercise: Start by leaning against a wall. Bend the knees
allowing the body to slide down the wall. Initially slide
down the wall until the knees are bent 15°. This may not
seem like a lot but this exercise can be very irritating to the
patella and one must proceed with caution. Once at 15°
hold that position for a count of 5, then slide back up the

wall to the standing position. There are two parts of this
exercise that can be increased. The first is the length of
time that one hold the position at the bottom of the press.
The second is the distance. Both should be increased
slowly. Increasing the amount of knee bend is more likely
to increase knee pain.The patient should not bend the knees
greater than 45°. Further flexion (bend in the knees) can
cause increased patellar pain.
Quadriceps Stretching (Fig. 12.23)
Fig. 12.23: Quadriceps stretching posture
Position: Lying face down.

Repetition: Do no more than ten of these stretches. This
exercise puts a lot of stress on the patella.
Exercise: Lying face down grab the ankle by reaching
behind the patient. Pull the ankle toward the buttocks.
Increase the pull for a count of 3. Relax for a count of 2
then repeat the excercise.
Osteoarthritis knee exercises can be an effective
treatment for knee joint pain. Exercise can help:
• Keep joints flexible
• Increase muscle strength

• Control weight
• Strengthen bones and ligaments
• Improve mood and overall outlook.
Before You Start
Talk to health care provider before beginning any exercise
program. It is important to learn which osteoarthritis knee
exercises are best for the patients, how to warm up safely,
and if there are any joints they should not exercise.
SITTING EXERCISES (FIGS 12.24A TO D)

Sit up on the chair straight. Lift one leg 3 inch from the
ground. Hold for 10 seconds and then leave. Repeat five
times then do it on the other leg (Fig. 12.24A).
Bend right knee so that it moves below the chair. Hold
for 10 seconds. Repeat 5 times. Do the same with opposite
leg.
Sit on the edge of the chair and extend the left leg as far
as possible keeping it as close to the floor as possible. Then
hold for 10 seconds. Repeat 5 times then do the same with
the opposite leg (Fig. 12.24B).
Sit comfortably on the chair and extend the right leg
from knee. Then hold for 10 seconds. Repeat for 5 times
then do the same with the left knee (Fig. 12.24C).
Sit comfortably on the chair without back supported. See
to it that the knee is extended for about 30°. Then extend
the knee and hold for 10 seconds . Repeat for 5 times and do
the same in opposite leg. Note: This will strengthen MO
since we are concentrating on the mid and end range of
motion (Fig. 12.24D).
B
Fig. 12.24A to D: Various types of sitting exercises
STANDING EXERCISES (FIGS 12.25A TO F)

Stand comfortably at the side of a chair. Place one hand on
the chair. Abduct your leg from the hip, and hold for 10
seconds. Repeat five times. Do the same on the opposite leg
(Fig. 12.25A).
Stand behind the chair taking its support. Push the leg
backwards and medially (Fig. 12.25B).
Stand at the side of chair. Abduct the hip (Fig. 12.25C).

Stand with the feet shoulder width apart. Keep the hands
on the waist(Wing standing). Bend knees as if sitting. But
don’t bend beyond 90°, and see to it that the COG is within
the BOS (Fig. 12.25D).
Stand straight and lift the knee as much as the patient
can (Fig. 12.25E).
Stand behind the chair and extend the knee as much as
he/she can (Fig. 12.25F).
B
D
Figs12.25A to F: Various types of standing exercises

RECOMMENDED EXERCISES
Motion Strengthening Exercises
Before factor, PWHs were advised to refrain from exercise.
Not so today. With factor and home infusion, physical
activity is much less risky than ever before. And with more
PWHs putting their bodies to work, there is growing
evidence that exercise increases joint function and
decreases the incidence of bleeds.
To keep joints healthy, physical therapists urge the
patient to strengthen the surrounding muscles and
increase their range of motion. This can be done through
regular exercise.
The Most Susceptible Joint

The knee is the most susceptible to injury in people with
and without hemophilia. It’s truly an irony of our physi-
ology that the knee joint, which enables us to participate
in such vigorous activities as football and rollerblading, is
so delicate and so easily injured. Considering that when
one simply walks up a few stairs he is putting pressure
across knee joints that is approximately four times the body
weight.
To further understand the knee, let’s take a closer look at its
anatomy: The knee is a relatively straightforward hinge joint
which connects the thigh bone (femur) with the leg bone
(tibia). Where the bones meet, they are padded with a
tough substance called cartilage. In addition, between the
bones and around the joint are the synovial cells, which
produce synovial fluid, a thick liquid that protects and
lubricates the joint. Surrounding the entire joint is a tough,
stretchy coating referred to as the capsule. The knee relies

on several muscle groups to work effectively. The
quadriceps extend the knee; the hamstrings and calf
muscles flex the knee. There are also the hip abductors,
located on the outside of the leg, and the hip adductors
located on the inside of the thigh. These muscles provide
strength and stability to the knee.
Bleeds and the Knee

When People With Hemorrhage (PWHs) bleed into the
knee either spontaneously or as a result of an injury, blood
leaks into the joint space. If the area is not treated with
factor immediately, the joint continuous to fill up with
blood like a reservoir behind a dam. This infusion of blood
stretches and swells the capsule around the joint far beyond
its original size. The swelling creates so much pressure that
bleeding may stop by itself. But the swelling also leaves
the joint severely traumatized and painful.
How significant is the damage? After several bleeding
episodes in the knee, degenerative changes may occur. Scar
tissue may form which shrinks the space inside the joint,
making it harder to bend. Cartilage may also get destroyed,
leaving less padding between the bones. This can happen
because the synovial cells release enzymes to digest the
extra blood and these enzymes may also digest some
cartilage. The result is hemophilic arthropathy. Hinge joints
such as the knee, elbow and ankle are especially susceptible
to bleeding, trauma and development of arthropathy
because they have a relatively large amount of synovium
and they are less able to withstand rotary and angular
stress. Socket-type joints like the hip and shoulder are less
susceptible to trauma.
Many PWHs get caught up in a debilitating cycle of knee

problems. Frequent injuries and bleeds into the joint cause
pain and decrease in mobility. With a decrease in mobility,
muscles grow weaker and can no longer protect the joint -
and strong muscles are needed to support the joints! The
greater the muscle strength, the greater the stability of the
joint. For example, if one jumps down a step and the
muscles are strong, they actually absorb stress and
minimize the compressive forces to the knees. Weak
muscles cannot do this and the impact is on the joint itself.
Keeping Muscles Strong

So it is particularly important for PWHs to participate in
an exercise program that will help strengthen the muscles
around the knees, increase the joints’ range of motion and
build up endurance. The goals of these exercises are both
reparative and preventative. As a PWH with joint damage,
the patient find that both range of motion and
strengthening exercises help increase joint mobility. These
same exercises can also help prevent further joint
destruction. To keep joints strong, one also need exercise
for endurance which increases the overall strength and
improves stamina. This allows muscles to handle more
stress. Swimming, cycling, rowing are some of the activities
that can help build up endurance without putting too much
pressure on knees. The exercises on these pages improve
joint range of motion and strengthen muscles. Beginners
should aim for sets of six repetitions (“reps”), then increase
reps over time. If any pain is felt during an exercise stop
immediately. A PWH should never work toward the pain
(as in “no pain, no gain”) that is a popular credo in some
gyms. For exercises that call for weights, begin with one
or two pounds and slowly progress from there.
Avoiding Injury
For many PWHs, the fear of injury is perhaps the greatest
obstacle to exercise. Do not start the exercise on an
overzealous note. PWHs who are sensible and careful
about working out, usually avoid injury. This means that
one has to perform these exercises slowly, steadily and
regularly. It is best to exercise joints twice a day regularly
for five days a week. In the beginning one may experience
some bleeds at first. Most likely, these bleeding episodes
will decrease or stop. Be sure to discuss this exercise
program, and any other, with the doctor. Or work out
under the guidance of a physical therapist who can monitor
the intensity of the exercise and then help in progress.
The following exercises are geared to teenagers and
adults. Since young children do not generally like regular
exercises programs, parents (under direction of a physical
therapist) encourage children in more playful forms of
exercise such as kicking a ball, safe and supervised jumping
and bicycling with an elevated seat which puts less
pressure on the knee.
Knee Flexion (Fig. 12.26)

Sit upright on a chair and cross legs with the left leg on the
bottom. Slowly use the right leg to push the left leg
underneath the chair while keeping hips flat on the chair.
Hold this position for six seconds. Return to starting
position and do six repeats. Repeat entire exercise with
right leg on bottom.
Fig. 12.26: Knee flexion exercise posture
Knee Extension (Fig. 12.27)

Sit up straight with your back against a chair. Slowly
straighten the left knee. Hold this position for six seconds.
Relax and lower the leg to the standing position. Do six
repeats with the right knee.
Fig. 12.27: Knee extension exercise postures

Heel Slide Knee Extension (Fig. 12.28)

Lie on the back, with left knee bent and left foot flat on
floor. Slowly slide the left heel away from the body so that
both legs are parallel. Hold for six seconds. Do six repeats
and repeat the exercise with right leg.
Fig. 12.28: Heel slide knee extension posture
KNEE MOTION EXERCISES

Straight Leg Raise-Knee Extension Raise (Fig. 12.29)
Lie on back, with right knee bent and right foot flat on
ground. Gradually lift the left leg up about thirty centimeters
Fig. 12.29: Straight leg raise-knee extension raise posture

(twelve inches) in the air. Keep the knee straight and the
toes pointed up. Hold this elevated position for six seconds.
Slowly return leg to ground and start again. Repeat six times,
and then start again by lifting the right leg. Slowly add
weights to ankles to increase resistance.
Straight Leg Raise — With Internal and External

Rotation (Fig. 12.30)
Lie on back, with right knee bent and foot flat. Move left
foot to 10 O’clock position. Lift left leg in air about thirty
centimeters (twelve inches). Keep the left knee straight.
Hold this position for six seconds. Then move left foot to
2 O’clock position. Lift the leg up 30 centimeters and hold.
Repeat this exercise six times and then switch legs. Slowly
add weights to ankle.(Check weights with physio-
therapist).
Fig. 12.30: Straight leg raise—with internal and external

rotation
Quadricep Set-Knee Extension (Fig. 12.31)

Lie on the back and slowly press left knee into the mat.
Then tighten the muscles on front of the thigh. Try not to
hold the breath. Hold the muscles tight for six seconds.
Repeat six times and then tighten right leg muscle.
Fig. 12.31: Quadricep set-knee extension posture
Hip Abduction (Fig. 12.32)

Lie on left side with bottom knee bent, raise top leg. Keep
knee straight and toes pointed forward. Do not let top hip
roll backward. Hold this position for six seconds. Do six
repeats and then switch sides. Progress slowly to just under
1 Kg at the ankle.(Check weights with physiotherapist).
Fig. 12.32: Hip abduction posture

Hip Adduction (Fig. 12.33)

Lie on left side with top leg on chair. Slowly raise the
bottom leg up to the chair seat. Hold leg up for six seconds.-
Do six repeats and then switch sides.
Fig. 12.33: Hip adduction postures
KNEE EXERCISES
After injuring the knee (Fig. 12.34), one of the most important
things one can do to recover, is to follow the RICE principle:
R - REST: Rest the knee until he/she can walk without a
limp. Crutches can be of great help.
I - ICE: Ice the injured knee until all swelling is absent.
Using an ice bag, apply the ice for 20 minutes, 3-4 times a
day.
C - COMPRESSION: Wrap the knee, as directed by the
doctor, to help reduce swelling.
Fig. 12.34: Right knee viewed from the front patella has been
removed
E - ELEVATION: Elevate the knee above the level of the

heart. This also aids reduction of the swelling.
Range of Motion
The patient should try to gain full range of motion in the
knee as soon as possible (Fig. 12.35). By doing this, he/she
Fig. 12.35:Gaining the range of motion in the knee joint

may be preventing scar tissue formation and a loss of knee

strength. Perform these exercises after icing. Never pull or
force the knee; only go to the point of pain:
Flexion: Lying on stomach, raise the heel, bending knee as
much as is comfortably possible. Hold this position for 5
seconds, lower leg, relax. Repeat 10 times.
Extension: While sitting, try to straighten the leg as much as
possible. The goal should be to be able to touch the back of
the leg to the floor. Hold for 5 seconds, relax. Repeat 10 times.
Quadricep Setting
While sitting, tighten the muscles around the kneecap.
Concentrate on tightening the muscle on the inside and
slightly above the kneecap. Start time count when the
muscles are tight; start relaxation count when totally
relaxed and use a watch with a second hand. Use the
following progression:
Day Hold Relax Repeat
1 5 sec 5 sec 10 times every waking hour
5 9 sec 9 sec 10 times, 4 times per day
6 10 sec 10 sec 10 times, 4 times per day
Hamstring Setting
With the knee slightly bent, put the heel over the edge of a
couch or table. Tighten muscles on the back side of the
thigh. Think of bringing the heel towards the body.
However, no movement should take place—just tighten
the muscles. Again, start counting when tight and start

relaxation count when fully relaxed. Follow progression
as in quadricep setting portion (see Chart on page 154).
Straight Leg Raises (Fig. 12.36)

Lying on your back, keep injured leg straight and bend
the uninjured leg. Tighten the muscles on the front of the
leg (quadriceps) and slowly lift the leg as high as possible.
Lower slowly, then relax. Repeat as the progression chart
directs. When the patient can perform 50 repetitions in a
row, weight (ankle weights work the best) can be added.
The average male should be able to lift 30 lbs, 50 times.
The average female should be able to lift 20 lbs, 50 times.
Day Repetitions
1 25
2 30
3 35
4 40
5 45
6 50
Fig. 12.36: Straight leg raises

The knee joint combines mobility with strength.

Mobility is required so that we can move our legs freely,
and strength so that we can cope with the tremendous
impact forces produced during running and jumping. The
knee is the largest joint in the body. It is formed between
the thigh bone (femur) and tibia (shinbone). It is a complex
joint containing the patella (knee bone), semilunar disks
of cartilage (menisci), and several ligaments that criss-cross
between the tibia and femur (cruciate ligaments).
Although the knee appears to be a hinge joint, it moves
in more than one plane. In addition to flexion (bending)
and extension (straightening) it can rotate slightly. This is
essential during walking and running. Its ability to rotate
makes it susceptible to injury during physical activities.
Between one-quarter to one-third of all sports injuries
involve the knee. Zipper-like scars decorating the knees of
many professional sports people (especially body-builders
and weight-lifters) is evidence of the high rate of injury.
Many knee disorders involve the patella. There are a
number of anatomical factors (for example, flat feet and
unequal development of thigh muscles) that predispose a
person to patellar injury, but most injuries are due to
overuse (chondromalacia patellae and patellar tendinitis).
Flexibility exercises; correction of foot deformities with
orthotics; and knee exercises which improve the alignment
and coordination of leg muscles, can minimize patellar
problems, but sometimes surgery is needed to realign the
forces on the patella.
Other knee injuries include dislocations, ligament tears
and strains, bursitis (housemaid’s knee), and torn cartilage
(more correctly called a meniscus tear). Because the knee
is such a complex joint involving so many structures,
diagnosis of injury is notoriously difficult.
The following exercises are often performed after

recovery from a knee injury to minimize the risk of
recurrence. These exercises will also improve knee mobility.
Knee exercise 1: Make the patient flat on his back with legs
extended and feet turned slightly outwards. Lift the right
foot about 10 centimeters (3 inches) off the ground. Hold
for about 10 seconds, relax, and repeat with the left foot.
Do this exercise for about 10 times.
Knee exercise 2 (Fig. 12.37): Lie on the back with legs straight.
Push the right knee into the floor by tightening the quads
(the muscles at the front of your thighs), pull the toes and
ankles of right leg towards the patient. This should result
in the heel being lifted off the floor. Hold for 10 seconds,
relax, and repeat with the left leg. Do this exercise about
10 times.
Fig. 12.37: Knee exercise type 2
Knee exercise 3 (Fig. 12.38): Stand about 60 centimeters

(2 feet) away from a stable surface that is about the same
height as a chair. Keeping both legs straight, place the right
heel on the surface (e.g. chair seat). Put both the hands on
right knee and lean gently into it, holding it firmly and
steadily for 30 seconds. Do not rock. Relax. Repeat using
the left leg. Do this exercise about five times.
Exercises can be used to stretch and strengthen the thigh
muscles.
Fig. 12.38: Knee exercise type 3
Strengthen
The vastus medialis should be selectively strengthened
(Figs 12.39 A to C) Press leg into table, foot stays on table,
toes up and slightly pointed in. Straighten leg, toes up and
slightly pointed in. Straight leg, lift, hold and gradually
relax.
A
Figs 12.39A to C: Strengthening the vastus medialis
Leg Press
Each single exercise should take 6 seconds. For example,
lift-2-hold-2-relax-2 (Figs 12.40A and B). Do 3 sets of -10 for
each. Some resistance can gradually be added or number
B
Figs 12.40A and B: leg press
increased as strength improves, thus controlling the patella

in the groove.
Stretch
Stretching exercises for various structures in the leg are
described as follows:
– Illiotibial band (Fig. 12.41)
– Achillis tendon (Figs 12.42A and B)
– Quadriceps (Fig. 12.43)
– Hamstrings (Fig. 12.44)
Fig. 12.41: llliotibial band
A B
Figs 12.42A and B: Achilles
Fig. 12.43: Quadriceps Fig. 12.44: Hamstrings
1. Stretch and strengthen.

2. Proper training principles, i.e. warm up and down,
gradual increases.
3. Proper equipment, e.g. shoes.
4. Proper use of equipment, e.g. for cycling, high seat, low
gears.
5. Maintain desirable body weight. However, if over-
weight, the above points are even more important.
Nonweight bearing activities such as swimming, cycling
may be more appropriate.
6. Continue to apply ice after exercise or activity.
Special Devices
Apart from exercises there are some special devices that
help in treatment of OA. These are:
1. Braces or supports to hold patella in groove.
2. Taping (Fig. 12.45), similar to this, can be done by a
physio as part of a specialized physiotherapy program.
Fig. 12.45: Taping the patella for support
3. Orthotics (Fig. 12.46), if the cause of the knee pain is

foot structure or lower leg alignment.
Fig. 12.46: Variovis devices to support the patella
There are other conditions and problems that cause pain

around the patella, such as recurrent subluxation or
dislocation of the patella, meniscal lesions, bipartite patella,
synovial plica, fat pad lesions, quadriceps contractive.
Making an Injured Knee Functional

The key to making a full recovery from any injury is not
just correct treatment and healing but also restrengthening
and regaining coordination of the joint and all the
movements it is involved with. Any injury requires a
certain amount of time for treatment and healing, but once
this is complete do not assume that one can start full
training and competition immediately. If the process is
hastened there will be recurrence.
To bridge the gap between the treatment bench and full
competition, without risking another setback, one has to
go through a planned and progressive rehabilitation
training program.
The aims of this program are:
1. to strengthen the muscles involved in the injury to be
just as strong as the unaffected side
2. to regain full proprioception (joint position sense) in the
injured joint
3. to regain power and coordination of all sports-specific
movements.
In terms of progression, the program must start with
low-intensity and low-volume work, gradually increasing
so that you build up to the full intensity and volume
required for full competition performance. This is quite
difficult to do, since the training must be tough enough to
have an effect but not too tough so that the injury is
aggravated.
In addition, it is often difficult to remember that while
the muscles respond quickly to strength loads, the tendons
and ligaments take much longer to gain in strength. This
is why athletes must sometimes stick with training loads

that feel easy so that the joint will be significantly tested.
The following is a planned progressive rehabilitation
program for a knee joint injury.
Let us assume that a successful healing period has
already been completed, that most, if not all, mobility has
been regained and that some basic strength work has been
performed. This is the time that one may be tempted to go
for it, but resist the temptation. Follow this program instead
and results will be positive.
Phase 1 (4-6 weeks)
In the first phase of rehab training, one must concentrate
on functional strength exercises, balance training and
regaining aerobic fitness.
The knee strength exercises at this stage must be closed
kinetic chain movements. A CKC exercise involves ankle,
knee and hip joints, where all the muscles round the knee
and involved in knee stabilization are recruited, thereby
ensuring the exercises are fully functional. It is generally
agreed that much less benefit is gained from performing
isolated quadriceps exercises since it is important that a
hamstring and quadriceps co-contraction occurs during
an exercise, so that the correct neuromuscular patterns are
trained. For this reason, the squat exercise is chosen as the
key knee strength exercise because it seems to be one of
the best knee exercises for hamstring/quadriceps co-
contraction. In addition, the hamstrings are a priority for
strength development because they play a crucial role in
knee stabilization, and the hip muscles must also be
trained.
Strength training: 2-3 times a week with rest days between.
Barbell squat. 2-3 × 8-10.

The technique for this lift is: feet shoulder width apart,
barbell across back of the shoulders. Lower down until
knee angle is at 90°. Keep knees behind the toes. Start with
a very light weight just to retrain the movement. Get
someone to make sure that each leg is weighted evenly.
As the knee gets stronger, gradually increase the weight
each week.
Terminal CKC Knee Extensions. 3 x 10
Take a strong piece of flexaband, make a loop and attach

it around a table leg. Place the other side of the loop behind
the injured knee (Padding may be needed). Start with the
support leg straight and the working leg slightly bent and
up on the toe. Then pull back on the band, straightening
the knee and flattening the heel down. The effort should
be concentrated in the quads. Make sure the body is
completely still. Re-flex the knee and ankle and continue.
Quarter One-legged Squats. 3 x 10

This exercise is performed without any extra weight. Stand
on one leg and bend the knee into a shallow squat position.
Straighten up slowly and continue. This exercise is as much
for balance as it is for strength. Keep the hips level and the
knee behind the toes while squatting down. Use the
stomach and glutes to ensure that stability and balance is
maintained. One may find the injured side is less
coordinated at first; the aim is to ensure that both sides are
performed evenly.
Leg Curls 3 x 10
The standard hamstring isolation exercise, but perform
each leg at a time to make sure the injured side catches up.
Bum Lifts 3 x 10
Lie on the floor on the back, with knees bent. Lift up the
bum until there is a straight line from knee to shoulders;
pause slightly and then lower down slowly. Surprisingly,
this exercise works the hamstrings and gluteals quite hard.
As the patient get stronger, bend the knees less and less
until he/she can perform the movement with straight legs
upon a small step. This is a functional hamstring exercise
as it involves trunk extension.
Hip Adduction, Extension, Adduction 3 x 10

Use the total hip machine to ensure all the hip muscles get
a good workout.
TRUNK EXERCISES
Include the usual exercises for stomach, obliques and low
back to ensure good core stability and strength. Remember,
all links in the kinetic chain are important for injury
rehabilitation.
Aerobic training: 3-5 times a week
At this stage the patient may not be able to complete much
aerobic training and so may have lost fitness. Now that
the knee is pain-free and mobile, he/she can use the
stationary exercise bike with confidence. This would be
the main choice for maintaining aerobic fitness. Running
in the pool with a weighted belt can also be done. Research
into the fitness benefits of pool running for injured athletes

has shown that VO2 (max) can be maintained throughout
an injury period with pool workouts, and practical
experience suggests that the legs definitely get a good
workout in the pool!
Balance and Coordination Training: Every Day

At this point, it is vital to include some balance and
coordination training in the program. This component is
often the one that gets ignored, with a very detrimental
effect in the long run.
Spending a few minutes 2-3 times a day on a wobble
board is recommended. Balance both two-legged and one-
legged. Once wobble board is perfected, the patient should
be able to perfect exercises such as catching and throwing
a ball while maintaining balance and minisquats while
maintaining balance.
Phase 2 (3 Weeks)
Use the following guidelines to help assess when the
patient are ready to move into phase 2 training. (i) Even
strength between injured and uninjured sides in the
hamstrings on the leg curl machine. (ii) Correct technique
and balance during both the barbell and one-legged squats,
combined with some strength improvement. (iii) A good
level of skill on the wobble board.
In this phase the patient will continue regaining strength
as above, but now he/she can start running again and
developing the coordination of sports-specific movements
such as jumping, landing and cutting, starting with low-
impact exercises.
Strength Training
Continue with the phase 1 routine, increasing weight
gradually with each exercise. With the one-legged squats,
the range of movement can be increased with a deeper
knee bend but only if the correct balance and technique
can be maintained.
Aerobic Training
Continue using the bike and the pool as before. However,
now one can try jogging. Start with five minutes only. Take
a day’s rest and then try a seven-minute jog. If there is no
adverse reaction, continue building up the distance jogged
every other day until the afflicted can jog for 21 minutes.
If there is a bad reaction, then drop down the time. Once
21 minutes has been established, continue at this distance
but gradually increase the speed up to normal training
speed.
Balance and Coordination Training

Training is needed to retrain the neuromuscular coordina-
tion of the dynamic movements involved in sports,
beginning with low-impact movements. The following is
a sample program.
Mini hops: 3 × 10 each leg building up to 3 × 50 each leg.
These can be performed on the ground or on a trampette.
Starting with just a little lift, hop on one leg on the spot.
Make sure the knee is flexed on landing and contact the
ground with the ball of the foot. Use abs and glutes to
ensure good stability and posture.
Lateral double hops: 3 × 8 building up to 3 × 20
With both feet hop from side to side. Use a line or a small
object such as a tennis ball to hop over. Again, make sure
to flex the knee, contact the ground with the ball of the
foot and maintain good posture and stability. Gradually
build up the height of each hop. This drill begins to train
the lateral side movement involved in most sports.
Landing drill: 2 × 8
Stand on a 6' step. Drop off it and land on the balls of your
feet, flexing the knees to absorb the impact. Step back on
the step and continue. The aim of this exercise is to train
the coordination of landing. He/she should be able to land
accurately, maintain an upright upper-body stability and
quickly absorb the impact with the knees. A good landing
should finish with he/she stock still with knees slightly
bent and body upright. With time, gradually increase the
step height.
Minisquat jumps: 3 × 8
Stand with feet shoulder width apart, squat down to the
quarter position and then rapidly jump up, land correctly,
squat down and jump again. Aim to perform eight squat
jumps with good landings, smoothly linked together.
Slalom Runs
Set up a little slalom course with 4-6 cones. Perform the
slalom run at jogging pace 5-6 times with a brief rest period
in between. In time, gradually increase the speed of the
run but no faster than three-quarter speed at this point.
Phase 3 (2 Weeks)
This phase should finally bring the patient back to full
fitness. All the elements in the training program should
come together so that one can complete a full training

routine. He/she should be able to perform the barbell squat
with correct technique at a full training weight and should
show complete equality between sides on exercises such
as the leg curl, one-legged squats and minihops. The body
should be well-coordinated on the wobble board and at
the landing, lateral hopping and jumping exercises. The
patient should be able to run for at least 20 minutes pain-
free, and have regained full aerobic fitness with the bike
and pool workouts. These final two weeks of rehabilitation
training should include a gradual reintroduction of all the
normal training methods and match play practice.
Lateral Double Hops

Strength, coordination and aerobic training.
Continue with the above schedules half a week for each
as a maintenance training stimulus to ensure the knee
remains strong and coordinated and that one are fully fit.
Plyometric, Sprints and Agility Training

Having developed basic coordination with the low-impact
drills of phase 2, he/she must now reintroduce the normal
plyometric drills. For example, full-squat jumps, bounds,
lateral bounds, and hurdle hops. In the first workout, one
should perform just one set of each exercise. After a few
days rest, try two sets of each and then three. The
plyometric exercises are very important as they develop
the eccentric strength of the hamstrings and quadriceps
and teach these muscles to contract fast and control the
knee joint on impact (but see Nick Grantham’s cautionary
article about plyometrics in this issue).
The co-contraction of the hamstrings and the quads that

occurs during plyometric drills is a very beneficial training
factor. Remember that when reintroducing plyometric
drills it is the quality of technique that is paramount—the
speed or distance can be achieved later.
In addition to plyometric training, one must reintroduce
sprinting at full speed. For the first sprints workout, only
six 30-meter runs with a rolling start at three-quarter speed
is recommended. After a few rest days, try six 30m runs
with a rolling start at full speed. If that is okay, progress to
six 60m runs with a rolling start and then finally to 60m
efforts from a standing start. Agility drills should also be
included at this stage. Lateral runs, shuffles, slaloms,
cutting and side-stepping must all be performed. Again,
start at jogging speed only and then progress gradually to
full-out efforts.
Matchplay
The patient must also start to model the competition
situation. If he/she is a games player, e.g. tennis/rugby,
they should begin with a small period of a noncontact
game. If they are a track and field athlete, begin with a
few throws or jumps or some below-distance race pace
efforts. Again, gradually build things up in terms of time
and intensity.
Although waiting this long after an injury before starting
to play again may seem excessively cautious, it should also
instill confidence. By this stage in the rehab process, he/
she should be fully strong and agile with a good level of
aerobic fitness, and be feeling that they are not too far from
being able to play again. Over the whole rehab period, the
patient will need psychological help from the

physiotherapist, fitness trainer and coach. Goal-setting at
each phase of the rehab process is a good idea so he/she is
clear about what they need to achieve and why they are
doing all this training instead of just getting out there and
playing.
Living with it (Practical Tips) 173
Living with it
13 (Practical Tips)
PRACTICAL TIPS FOR OSTEOARTHRITIS OF THE

KNEE
Osteoarthritis of the knee (doctors call it “gon-arthritis”)
is among the most common forms of arthritis and can lead
to years of pain, limitations and impairment. The following
tips are particularly helpful in early and medium stages
and can help reduce pain and swelling.
Select Shoes Carefully

With osteoarthritis (OA) of the knee, choose the correct
type of shoes carefully (Fig. 13.1).
Here are a few tips:
• Avoid heels that are too high or too hard
• Don’t wear sandals
• Choose shoes with low heels.
Fig. 13.1: Proper and improper footwear for

patients with OA knee
Choose shoes that lace up and provide feet with firm

support.
Avoid Walking Uphill or Downhill

Those who suffer from osteoarthritis should, avoid walking
up or down steep inclines or hills. Both put considerable
strain on the knee. Walk on flat terrain, instead, whenever
possible. Figure 13.2 shows the proper and improper
walking gait for patients with OA knee.
Fig. 13.2: Proper and improper way of walking for

patients with OA knee
Avoid Uneven Terrain

It is equally important to avoid uneven or very soft terrain.
Walk on sidewalks rather than in the grass. Choose well-
worn paths (Fig. 13.3).
Fig. 13.3: Avoiding uneven terrain and choosing well-worn paths

It’s Healthier to Ride a Bicycle

Cycling does not put as much stress on the knee joints as
walking (Fig. 13.4). This is only true, however, if it is done
slowly and avoid hilly terrain. It is also necessary to keep
the appropriate distance and to always ride safely. If the
bicycle has gears, always use a lower gear, which does not
require use of a lot of strength. This in turn helps avoid
situations in which the rider has to brake suddenly. In
addition, adjust the seat to the highest possible level. This
also helps to relieve pressure, particularly on the knee cap
(patella).
Fig. 13.4: Cycling is healthier practise for knee joints

compared to walking
Always Use Elevators

Every stair step puts strain on the knee. If an elevator can
be used instead of taking the stairs, always take the
elevator, even if one travel just one floor or if it means
waiting a few minutes. With osteoarthritis of the knee,
avoid stairs whenever possible (Fig. 13.5).
Fig. 13.5: Using of elevators is beneficial compared to stairs

for OA knee patients
Use the Handrail (Fig. 13.6)

If an elevator is not available and one has to use the stairs,
joint strain can be minimized by:
• Climbing the stairs very slowly.
• Using the handrail as support as much as possible.
• With severe osteoarthritis, allow plenty of time.
Put the healthy foot forward first, followed by the
weaker limb. Do not hesitate to follow these rules. Keep in
mind that they will help the knee joints to feel better.
Fig. 13.6: Use handrails in case elevator is unavailable

Do not Carry Heavy Objects

Because knees are biggest weight-bearing joints, carrying
every extra pound increases the stress on them. Try to make
sure that the person does not have to carry any heavy
objects or, if necessary, only very rarely. Figure 13.7 shows
proper way of carring heavy objects for patients with OA
knee.
Fig. 13.7: Use trolleys for carrying heavy objects under

unavoidable circumstances
Avoid Standing for Long Periods of Time

Many people are often on their feet for many hours at a
time without a break. This puts their knees under
considerable strain, even if they do not feel it directly at
that moment. Therefore try to follow this rule: “Never be
on your feet longer than one hour at a time.” Give a break
after every hour, even if only for 5 or 10 minutes. This gives
renewed strength and protects the knees. Figure 13.8 shows
the way to avoid knee strain while ironing cloths.
Fig. 13.8: Posture while ironing cloths to avoid knee strain

Stretch The Legs While Seated

When seated, gently stretch legs and change their position
frequently. Avoid folding legs under the chair, as many
people do when sitting at a desk. This is particularly
important for those who have osteoarthritis in the anterior
(patellar) part of the knee joint. Figure 13.9 shows the sitting
posture for OA knee patient.
Fig. 13.9: Proper and improper sitting posture for patients with
OA knee
Support with Both Hands

Avoid putting pressure on the flexed knee with
osteoarthritis (Fig. 13.10). When rising from a chair or bed,
push down forcefully with both hands to minimize stress
on the knees. This might be done instinctively to avoid
pain, but this technique is also important when the knees
do not hurt to prevent further damage.
Fig. 13.10: Technique of avoiding putting pressure on the

flexed knee with osteoarthritis
Avoid Low Seats

Choosing the correct furniture is also important (Fig. 13.11).
Avoid sitting on low chairs. To really take the load off the
knees, choose chairs with a higher seat, preferably one with
armrests.
Fig. 13.11: The proper and improper seats for OA knee

patients
Do not Kneel
Kneeling, whether at home or at work, concentrates
pressure directly on the knees and should be avoided
whenever possible. Many activities that require kneeling
Fig. 13.12: Proper and improper posture while working
can usually be accomplished using a low stool or chair

instead (Fig. 13.12).
Note: In summary, one basic rule for osteoarthritis is:
“Movement yes – strain no.”
Alternate Medicine 185
Alternate Medicine
14
ACUPUNCTURE
During an acupuncture treatment, a licensed acupuncture
therapist inserts very fine needles into the skin at various
points on the body. Scientists think the needles stimulate
the release of natural, pain-relieving chemicals produced
by the brain or the nervous system. Researchers are studying
acupuncture treatment of patients who have knee
osteoarthritis. Early findings suggest that traditional
Chinese acupuncture is effective for some patients as an
additional therapy for osteoarthritis, reducing pain and
improving function.
NUTRITIONAL SUPPLEMENTS
Nutritional supplements are often reported as helpful in
treating osteoarthritis. Such reports should be viewed with
caution, however, since very few studies have carefully
evaluated the role of nutritional supplements in osteo-
arthritis.
• Glucosamine and chondroitin sulfate: Both of these nutrients
are found in small quantities in food and are components
of normal cartilage. Scientific studies on these two
nutritional supplements have not yet shown that they
affect the disease. They may relieve symptoms and reduce
joint damage in some patients, however. Clinical trial
are underway to test whether glucosamine, chondroitin

sulfate, or the two nutrients in combination reduce pain
and improve function. Patients using this therapy should
do so only under the supervision of their doctor, as part
of an overall treatment program with exercise, relaxation,
and pain relief.
• Vitamins D, C, E, and beta carotene: The progression of
osteoarthritis may be slower in people who take higher
levels of vitamin D, C, E, or beta carotene. More studies
are needed to confirm these reports.
HYALURONIC ACID
Injecting this substance into the knee joint provides long-
term pain relief for some people with osteoarthritis.
Hyaluronic acid is a natural component of cartilage and
joint fluid. It lubricates and absorbs shock in the joint. In
some countries officials have approved this therapy for
patients with osteoarthritis of the knee who do not get relief
from exercise, physical therapy, or simple analgesics.
Researchers are presently studying the benefits of using
hyaluronic acid to treat osteoarthritis.
ESTROGEN
In studies of older women, scientists found a lower risk of
osteoarthritis among those who had used oral estrogens for
hormone replacement therapy. The researchers suspect
having low levels of estrogen could increase the risk of
developing osteoarthritis. Additional studies are needed to
answer this question.
Alternate Medicine 187
• Acupuncture and acupressure: These alternative treatment

methods are based on traditional Chinese practices about
specific body points that control pain. Acupuncture uses
needles inserted at these points. Acupressure applies
pressure to the same points but does not involve needles.
Studies differ on the value of acupuncture and
acupressure for OA pain. Some patients with soft tissue
pain experience relief while others report no change.
Index 189
Index
A Capsular ligament 6
Cardiovascular insufficiency 100
Acetaminophen 79 Causes of knee pain 39
Acupuncture 87, 185 Characteristics of couplant 106
Acute macro-traumatic injury 24 Charcot joint 37
Aerobic training 168 Chronic inflammation 32
Aim of hydrocollator pack 111 Cold packs 98
Alternate medicine 185 Common
Ankles 58 knee 65
Anterior ligament 9 medicines 79
Anti-cyclic citrullinated peptide Complete blood count 76
antibody test 75 Contraplanar 95
Anti-inflammatory medications Conventional tens 92
83 Coupling media 106
Antinuclear antibodies 76 CPPD arthropathy 35
Arthritic joints 59 C-reactive protein 75
Arthroscopic surgery 87 Cross fire technique 95
Articular capsule 6 Crucial ligaments 12
Articulatio genu 5 Cryotherapy 97
B D
Balance and coordination training Diagnosis of arthritis 73
167, 168 Diagnostic methods of
Bandaging method 102 osteoarthritis 71
Brushing method 101 Dipping method 102
Bursae 15 Direct
Bursitis 65 immersion 102
Burst TENS 92 pouring method 101
Drugs to prevent joint damage
C 82
Dysplasia 29
Calcium pyrophosphate
dihydrate deposition
disease 35
E
Calf stretch 121 Electrodes 92
Capsula articulari 6 Endorphin theory 92
Erythrocyte sedimentation rate 75 I
Estrogen 186
Evaporative cooling 98 Ice
Excitatory cold 98 massage 97
towels 97
Immersion in cold 98
F Indications of surgery 86
Feet 58 Infrared radiation 103
Fibular collateral ligament 11 Injuries and diseases 44
Fingers 57 Inner thigh stretch 118
Folk remedies 87 Intensity 107
Frequency 30 Internal
crucial ligament 12
lateral ligament 10
G Isometric quadriceps
contraction 125
Gate control theory 92
strengthening 131
Gender 41
Genetics 43
Glute stretch 117 J
Joint
H hypermobility 36
pain 59, 93
Hamstring
setting 154
K
strengthening 132
stretch 117 Keeping muscles strong 146
Heel slide knee extension 149 Knee 58
Hemarthrosis 32 bones and ligaments 6
Hemochromatosis 34 exercises 124, 152
High extension 148
frequency TENS 91 flexion 147
intensity TENS 92 joint 5
Hip 58 malalignment 52
abduction 51 motion exercises 149
abductor Kneeling
strengthening 127 calf stretch 122
stretching 134 hamstring stretch 119
adduction 152, 166
adductor strengthening 128
L
HLA tissue typing 76
Hyaluronic acid 186 Laboratory tests 74
Hydrocollator pack 111 Lateral double hops 170
Index 191
Leg O
extension exercises 130
press 159 Obesity 42
Ligamenta cruciata genu 12 Oblique popliteal ligament 10
Ligamentum Occupation 43
collaterale Ochronosis 34
fibulare 11 Osteoarthritis 23, 38, 61, 79, 85
tibiale 10 risk factors 47
cruciatum posterius 12 Osteonecrosis 30
patellae 9 Overweight 42
popliteum obliquum 10
transversum genu 14 P
Long external lateral ligament 11
Low Pain relief 96, 112
frequency TENS 92 Paraffin wax bath therapy 100
intensity TENS 91 Partial knee replacement surgery
Lower body stretch 117 88
Lunge stretch 119 Physiotherapeutic
exercises 115
modalities 91
M Piriformis stretch 120
Posterior
Mechanism of analgesia 92
cruciate ligament 12
Menisci 13
ligament 10
Menopause 38
Practical tips for osteoarthritis of
Metabolic disorders 33
knee 173
Method of application 92, 101,
Preventing knee injury 68
107
Primary osteoarthritis 26
Micro-traumatic injury 24
Mode of transmission 100
Motion strengthening exercises Q
144
Quad stretch 123
Movements of patella 19
Quadricep
Mucopolysaccharidoses 37
set-knee extension 151
Muscle
setting 154
pain 93
stretching 132, 137
strength 42
R
N
Range of motion 153
Nonsteroidal anti-inflammatory Reducing your arthritis risk 53
drugs 80 Relation of estrogen 38
Nutritional supplements 87, 185 Rheumatoid factor 75
Risk factors and causes of Stretch 160
osteoarthritis 48 legs while seated 181
Risk factors for Structures around joint 17
arthritis 53 Support with both hands 182
cartilage loss in knee Surgery 89
osteoarthritis 46 Synovial membrane 14
S T
Techniques of
Secondary OA 29
administering cold 97
Semilunar fibrocartilages 13
application 101, 108
Short wave diathermy 94
Tendonitis 66
Signs and symptoms of
Testing apparatus 107
osteoarthritis 57
Tibial collateral ligament 10
Sitting exercises 138
Total knee replacement 88
Six steps to help knees 63
Transcutaneous electrical nerve
Slalom runs 169
stimulation 91
Smoking worsens knee Transverse ligament 14
osteoarthritis 52 Trauma 29
Special devices 162 Treatment parameters 106
Spine 57 Trunk exercises 166
twist 122
Squats 123 U
Standing
exercises 40 Ultrasound 105
press 136 Understanding osteoarthritis 1
Straight leg raise with Uric acid 77
ankle weights 129 Using NSAIDs 82
internal and external rotation
150 V
Straight leg raise 155
Vapocoolant sprays 98
knee extension raise 149
without weights 126
W
Strength training 168
Strengthen 158 Water bag method 109

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Step by Step®

Syed Musab Rahim Hashmi BPT

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Step by Step® Treatment of Osteoarthritis Knee

© 2011, Jaypee Brothers Medical Publishers

First Edition: 2011

This book Step by Step Treatment of Osteoarthritis Knee is an

Step by Step Treatment of Osteoarthritis Knee can be aptly

Keeping in mind the practitioners’ need of under-

Syed Musab Rahim Hashmi

I acknowledge the contribution of my ‘guru’, Dr K Aditya,

1. Understanding Osteoarthritis .................................. 1

Index .......................................................................... 189

Fig. 1.1: Healthy cartilage and damaged cartilage affected by

Changes in the interaction of cartilage tissue lead to its

knees. Most cases of OA are primary OA, which begin with

KNEE BONES AND LIGAMENTS

The Articular Capsule (Capsula Articulari or

Fig. 2.1: Right knee-joint: Anterior view

Fig. 2.2: Right knee-joint, from the front, showing interior

Fig. 2.3: Left knee-joint from behind,

Fig. 2.4: Sagittal section of right knee-joint

by bands inseparably connected with it. Above and in

The back of the capsule consists of vertical fibers which

The Ligamentum Patellae (Anterior Ligament)

The posterior surface of the ligamentum patellae is

The Oblique Popliteal Ligament (ligamentum

The Tibial Collateral Ligament (ligamentum

The anterior part of the ligament is a flattened band,

The Fibular Collateral Ligament (ligamentum

lateral condyle of the femur and below the summit of the

The Cruciate Ligaments (ligamenta cruciata genu;

The Posterior Cruciate Ligament (ligamentum

The Menisci (semilunar fibrocartilages)

The anterior attachment of the lateral meniscus is

The Transverse Ligament (ligamentum

communicates with a bursa interposed between the tendon

upper part of the tibia and the ligamentum patellae, a third

4. Yet another between the tendon of the semimem-

STRUCTURES AROUND THE JOINT

associated with the fixation of the limb in a position of

on the lateral condyle is pressed against the anterior part

When the knee is forcibly flexed, the medial

They also assist the collateral ligaments in resisting any

Fig. 2.5: Posterior surface of the right patella, showing

When standing erect in the attitude of “attention,” the

prevented by the tension of the anterior cruciate, oblique

Acute Macro-Traumatic Injury (Fig. 3.1)

Micro-Traumatic Injury (Fig. 3.2)

Fig. 3.1: Macro-traumatic injuries: Front view

Fig. 3.2: Micro-traumatic injuries: Side view

Micro-trauma often occurs with a sudden increase in

between the bones narrows. This is an early symptom of

etiology of primary OA is not fully understood, systemic

Table 3.2: Classification

To properly diagnosis OA, clinical evidence needs to

As the cartilage loses its elasticity, range of motion in

Dysplasia, Congenital or Acquired

The mechanisms by which sportsmen may develop

Osteonecrosis of the knee is believed to account for

Other possible contributing factors to the etiopathogenesis

Hemarthrosis, Specially Hemophilia

are allo-antibodies that neutralize the activity of the clotting

The Knee is the Classic Target Joint