PHYSIOTHERAPY CARE PROTOCOL – OA KNEE

CONTENTS PAGE
1. Definition 2
2. Overview 2
3. Diagnostic Triage 4
4. Assessment 6
5. Goals of treatment 9
6. Intervention:
General intervention 10
Intervention according to patient profile 17
7. Discharge Plan 21
8. Algorithm 22
9. References 26
10. Glossary 27

11. Appendix:
Appendix 1 29
Algofunctional Index for OA Knee
Appendix 2
Do’s and Don’ts 31
Appendix 3
Exercise 35

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1. DEFINITION

Osteoarthritis is a chronic disease causing deterioration of the joint

cartilage and the formation of new bone (bone spurs) at the margins of the
joints (Medline Plus, Health Information).

2. OVERVIEW

Causes

Osteoarthritis(OA) is a multifactorial disorder whose cause is often

unknown.
OA Knee is currently understood as a process rather than a disease,
which may be triggered by diverse constitutional and environmental
factors. Race, genetics, body build, obesity, gender, occupational use,
repetitive use, and previous injury have all been shown to have an
influence on development of OA. Age is the most powerful predictor of OA
knee (CPG for OA, MOH,2002).

Incidence
It may first appear without symptoms between 30 and 40 years of age and
is present in almost every one by the age of 70. Before the age of 55 it
occurs equally in both sexes . After 55, however, the incidence is higher in
women (Medline Plus, Health Information).
The estimated prevalence of symptomatic knee OA in population above
65 is 30%. (CPG for OA, MOH,2002)

Pathophysiology
Biomechanical stress that feeds back onto the cartilage surface and
subchondral bone may lead to biochemical changes in the tissues. When
an injury occurs, there may be an anti-inflammatory response with cellular
infiltrate and a fibroblastic response with the formation of fibrocartilage.
Osteophytes form as the result of endochondral ossification of both
existing cartilage and reparative cartilage at the joint margins.

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Bone cysts occur as over lying cartilage is lost and increased intra-
articular pressure is transmitted to the marrow.
Later on other definitive changes occur i.e. subchondral bony sclerosis,
osteophytic proliferation and cartilage loss.
End-stage osteoarthritis is typified by extensive loss of joint space seen on
x-ray with bone to bone contact across joints.

Signs and Symptoms

Most common impairments are:
• Pain
• morning stiffness
• reduced flexibility
• reduced muscle strength and stability
• joint deformation
• reduced aerobic capacity.

Pain is the most common presenting symptom of OA Knee. The cause for
pain is usually unclear and is likely to vary in severity, location, and
precipitating cause between individuals. According to Veerapan K, (2000),

By the time a person seeks help for pain caused by OA Knee, the
likelihood of disability related to squatting, climbing or walking is high. Pain
is located in and around the knee joint mainly at the dorsal side. It can
also occur in the thigh and hip

In OA of the knee, pain is located in and around the knee joint, mainly on
the dorsal side. Pain can also occur in the thigh and hip. Night pain is
usually a sign of joint inflammation or very serious arthritis.

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3. DIAGNOSTIC TRIAGE

The aim of the diagnostic process is to document the severity, nature and
extent of the health problem. The starting point is the patient’s history
including details of his/her most important complaints.
The assessment of the problem areas of most immediate concern to the
patient; decides which of the patient profile (page 5) best fits the patient.
This also helps to makes a prognosis and assess whether the pain in the
knee is a direct result of osteoarthritis.

The following are consistent with the diagnosis of OA knee.

• Less than 30 minutes of morning stiffness
• Long-standing pain that increases with weight bearing or stairs and
lessens with rest.
• Insidious onset
• Bony deformity (osteophyte) – on x-ray
• Contracture / decrease range of movement
• Crepitation on movement
• Effusion which is not warm as in inflammatory arthritis

The following are inconsistent with OA knee:

• Fever or chills
• Erythema
• Warm
• Large effusion
• Locking or giving way

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Table 1: Three distinct profiles of patients with OA Knee

Patients’ profile Description

Patients’ profile A The active inflammatory process in the joint;
The most important complaints are pain and
impairments related to movement of the knee.

Patients’ profile B The patient has episodes with pain

complaints, associated with movement, and
gradually increase the activity; generally the
patient looks for solution to the problem
himself and feels a high degree of self
control; only during episodes of intense pain
the patient needs extra guidance.
Patients’ profile C The patient has a long lasting or chronically
recurring complaints; the disabilities and
possible participation problems are of central
concern; the patient regularly feels little or no
control over the situation and makes little
attempt to look for solutions to his problems.

NB
If there is no indication for physiotherapy, patient is referred back to
the referring doctor.

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4. ASSESSMENT
Using the Peripheral joint assessment form – Physio /Ax. 9 / 2000,
Kementerian Kesihatan Malaysia..

History taking:
Gain information on the following:
• The most important complaint.
• The health problem with regard to the nature, progression and
prognosis including:
1. severity and nature of impairment
2. disabilities and participation problems
3. onset of problems – long term, chronic or episodic pain
4. prognostic factors – causative, helpful, hampering
(motivation, load bearing capacity and psychosomatic
factors).
5. details of previous diagnosis, treatment and result of
treatment.

• The current situation:

1. severity and nature of impairment, disabilities and
participation problems that accompany OA knee.
2. general health situation including the patient’s functioning,
activities and level of participation.
3. personal factors – prescription of medication or other
treatment and patient’s need for knowledge and information.

• Patient’s perception:
Patient’s expectation including activity and participation goal.

Use the Algofunctional index for OA knee to record the extent of pain
and disabilities (appendix1)

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Physical assessment:
Inspection includes observation and palpation. Areas to be looked at:
• Postural changes to the knee and hip joints, pelvis and spine.
• Deformity of knee(varus/valgus)
• Inflammatory process (swelling, temperature, synovial enlargement,
and tenderness).

Muscle spasm
Function :

Evaluating leg functions:
- joint movement and ROM
- muscle tone
- muscle strength
- flexibility of joint

Evaluating activities(e.g.) :
- standing
- walking
- sitting down and getting out of chair
- climbing stairs
- picking objects from the ground
- praying

Sensory dysfunction or decrease in proprioception (balance)

- standing on one leg
- functional reach test

Coping strategy: ( examples of questions to be asked)

- have you been able to cope with the complaint so far
- what have you personally done to reduce your
complaint?
- which form of treatment do you think will help most
and why?
- in performing your daily activities, which activity
would you like to improve?

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N.B
Tools for measurement:
Visual Analogue Scale for pain severity
Functional activities in the AlgoFunctional Index (appendix 1)
Goniometer for range of movement
Hand Held Dynamometer for hand strength
Muscle power test for lower limb strength.

ANALYSIS

Analysis is based on interpreting the information gained during history

taking, medical referral data and results of physical assessment.

The following questions should be answered during analysis.

Which problem area is most important: active inflammation impairment,
pain, and reduction of functional movements, limitation in activities,
participation problem and in adequate pain behavior?

Which patient profile (Table 1) is applicable to the patient?

What is the prognosis?

Can the problem be influenced by physiotherapy?

Is the patient motivated for physiotherapy?

Is there any indication for physiotherapy?

Can the patient be treated according to the guideline?

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5. GOALS OF TREATMENT

1. To reduce pain
2. To decrease disability and optimize functional ability
3. To increase strength, flexibility and endurance
4. To encourage optimal good posture
5. To stimulate level of participation
6. To encourage the adoption of an adequate way of dealing with the
complaint

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6. INTERVENTION

I. GENERAL INTERVENTION

Management of OA knee involves multidisciplinary approach with the aim

to relieve symptoms and improved joint function. It involves non –
pharmacological and pharmacological therapy. In certain cases surgery is
involved. In this guideline management that is appropriate to
physiotherapy intervention shall be discuss. The general management
shall include patient education, weight reduction and specific direct
intervention as a result of problems analysis.

A. PATIENT EDUCATION:
Patient education plan should start with an analysis of the patient’s need
for information, identified during history taking. Questions to be considered
asking are:

What does the patient know about the disorder and its treatment?

How is the patient coping?

Does the patient know how to influence the complaints?

What do the patient and the patient’s partner expect from
treatment?

Patient education process should include four tasks.

Informing: providing the patients with facts about the
disorder, its treatment and patient care.

Instructing: providing concrete guidelines that the patient
must follow in order to influence the treatment
process.

Educating: detailed explanations of the disorder and it’s
treatment from which the patient learns about the
background to the disorder and its consequences
and learn to keep the disorder under control.

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Guiding: providing emotional support so that the disorder

and its consequences can be accepted and
emotionally processed by the patient.

Weight Reduction.
Overweight patients should aim to lose weight. Weight loss decrease pain
substantially in those with OA knee. Losing 5 kg. of weight reduces the
force on the knee by 15-30 kg with each step (Altman et al, and Pendleton
et al. 2000).

B . EXERCISE PROGRAMME.

Physiotherapy should be started as soon as possible to improve joint

mobility, increase muscle strength, reduce pain and prevent further
disability. All patients should participate in this exercise program. Exercise
program should be individualized. An appropriate exercise program is the
one that combined range of motion exercises and strengthening exercise
with aerobic program. This exercise program should have flexibility (range
of motion exercise) and strengthening.

Flexibility (Range of motion exercise)

Static stretching exercise recommendations

Exercise daily when pain and stiffness are minimal.

Exercises can be preceded by warm shower or by application of
superficial moist heat.

Relax before beginning stretching exercise.

Perform movements slowly and extend the range of motion that is
both comfortable and produces a slight subjective sensation of
resistance. Breathe during each stretch.

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Hold this terminal stretch position for 10 to 30 seconds before

slowly returning the joint or muscle group to the resting length.

Modify the stretching exercises to avoid pain or when the joint is
inflamed (decrease the extent of joint range of motion or the
duration of holding the static position).

Strength training
Isometric strength training recommendations

Exercise:
Exercise involve major muscle groups, especially:
Muscles of the lower limb and back

Intensity:
Low intensity isometric contraction. The initial maximal
voluntary contraction and intensity should begin at
approximately 30% of maximal effort. As patient tolerance
increases, progress gradually to 75% of maximal voluntary
contraction.

Volume:
the contraction should not be held more than 6 seconds, start
with one contraction per muscle group and then gradually increase
from 8 to 10 contractions as tolerated. There should be 20 seconds
rest between each contraction. The patient is instructed to breathe
during each contraction.

Frequency:
exercise should be perform twice daily during acute inflammatory
periods. The number of exercises should be gradually increased
from 5 to 10 per day as tolerated by patient. As strength develops,
resistance may be added.

Precaution:
contraction more than 10 seconds can increase blood pressure.

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N.B.
Quadriceps weakness in common amongst patients with OA knee.
quadriceps weakness may be a risk factor for the development of
knee OA , presumably by decreasing stability of the knee joint and
reducing the shock attenuating capacity of the muscle.(Slemenda et
al, 1997; Slemenda et al, 1998).

Isotonic exercise and recommendations:

Although OA knee sufferers with a sedentary lifestyle are likely to have
diminished physiologic reserve. This exercise is recommended so as not
to fatigue the muscles involved

Exercises:
8 to 10 repetitions involving major muscle groups.

Intensity:
begin at 40% of one repetitive maximum (1 RM). Maximum
resistance should be 80% of 1 RM.

Volume:
the beginner should complete one set of 4 to 6 repetitions without
muscle fatigue.

Frequency:
maximum of 2 days per week.

Progression:
5-10% increased per week in the amount of resistance used.

Proprioceptive exercises:
e.g. – ¼ squats –within the limit of pain(with support if necessary)
- one leg stance - hold as long as possible(max. 20 second ,use
support if necessary)
- heel raises
- ball throwing with trunk movements

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Aerobic exercise:
Exercise depends on several factors: the patient current disease activity,
joint stability, resources and interest.

Examples of aerobic exercises are:

Bicycling especially on a static bike
Swimming

Low impact aerobics (walking, dance or Tai Chi),

Exercising on equipments such as treadmills or rowing machines.

Other activities can include raking the leaves, playing golf and brisk
walking. Aquatic exercise or pool exercises performed in warm water (86
degrees Fahrenheit)

Activities to be avoided:
High impact aerobic training
Standing working on ladder
Jumping down instead of carefully stepping down steps
Kneeling ( use cushion if cannot be avoided)

Exercise Prescription

Intensity :
maximal heart rate ( 220 – years in age) , start with
50%and range to 70-75% of maximal heart rate.
“Talk test” (whether an exerciser can converse
comfortably during activity without getting short of
breath)

Volume:
Recommended volume for the beginner is 20-30 minutes
per day. Older sedentary adult exercise is modified to suit
their capability.

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Frequency:
Initial frequency at least 3 days but not more than 4
days per week.

Progression:
The progression to aerobic training intensity and
volume should be gradual to allow time for adaptation.

A 2.5% increase per week of the intensity or volume may be

compatible with reduced physiologic reserve associated with
older arthritic patient.

Precautions:
Avoid excessive amount of activities. Injuries can be avoided if the patient
gradually works up to the desired activity level.

C. JOINT PROTECTION.
Joint protection can include any of these when and where appropriate.

Assisted walking device:

According to Neumann D.A (1998), In hip and knee OA , the proper use of
walking stick in contra lateral hand reduces forces through these joints by
as much as 50%. Canes should be of correct height. The top of this cane
should reach the patient’s wrist when the patient is standing with the arm
at the side. Shoes with good shock absorbing properties are
recommended.

Knee brace:
The use of knee brace has been shown to lessen the load on
degenerative knee (Komistek et al, 1999). And may be appropriate in
patient medial compartment arthrosis and varus misalignment (Hewett et
al, 1998; Binette et al, 2001).

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Patellar taping:
Medial patellar taping in patello-femoral OA followed by quadriceps
exercises has been shown to reduce pain and improve function
(Cushnaghan et al, 1994).

D. PAIN RELIEF MODALITIES

There are several pain relief modalities available for use in the treatment
of OA knee. These includes thermo therapy, cryotherapy and
electrotherapy.

Thermotherapy:
Thermal modalities may be useful in reducing pain, increasing flexibility
and reducing swelling. The application of warmth can result in more joint
flexibility and, therefore, can make exercise therapy easier and less
painful (Nylhom et al(1993). However thermotheraphy is only
recommended when there is little inflammation. Thermotherapy can be
used in the form of hot packs, infrared lamp and traditional hot bath.

Cryotheraphy:
According to the conclusion of an overview study by Mens (1989), the use
of cold packs in arthritis seems to delay inflammatory processes in acute
period, usually in the first 48 hours. Ooster and Rasker(1994) concluded in
their research which involved the application of cold pack and hot packs in
healthy volunteers that the use of cold pack lead to temperature reduction
in both the body surface and in joints. Short treatment by cold pack is

recommended if the primary aim is to reduce pain and stiffness. Although

it is not possible to draw any evidence-based conclusions on the use of
cryotherapy, literature reports do indicate that applying cold packs seem to
be important for reducing pain during the acute/inflammatory phase.

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Transcutaneous Electrical Nerve Stimulation (TENS):

TENS has significant benefit in pain relief if treatment duration is more

than 4 weeks. Both high frequency and strong burst mode TENS have
shown benefit (Donohue and Rasner, 1995).

II. INTERVENTION ACCORDING TO PATIENT PROFILE

A. ACTIVE INFLAMMATORY PROCESS

Problem areas.

Impairments related to active inflammatory process:

Pain

Treatment goals.
Reduction of impairment related to an active inflammation process.
Improving insight into joint load and joint capability.
Pain reduction.
Improving joint load capability.
Improving necessary pain behavior.

Treatment.
Inflammatory process and pain

Informing / advising.
About relationship between joint load and joint load bearing
capacity. See appendix 2 for Do’s and Don’ts.

Guidance in functions and activities
Exercise therapy in which the load applied is within the limits of the
joint’s load bearing capacity(involves passive, assisted active and
active movement)

Walking aids (if needed)
Crutch or cane in contra lateral hand .

Cold pack (if needed)

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Given when there is an indication of inflammation or to lessen pain.

TENS (if needed)
Given for pain reduction if needed.

Traction(manual)
Apply traction to joint in a resting position to reduce pain if
necessary.

B. EPISODIC COMPLAINT

Problem areas.

Movement impairment (not movement fear)

Activity limitations

Inadequate pain behavior ( may/may not be)

Treatment goals.
Reduction of movement related impairments.
Improving activities.
Improving pain behavior (if necessary)

Treatment.

Informing/ advising
On how to build up joint load relative to load bearing capacity and
on how to build up joint load over time

Stimulating functional activity with improvement in joint capability.
Muscle strength, joint mobility and stability to build up endurance .

Improve flexibility and range of movement
Emphasis should be to achieve optimal extension and good
quadriceps control.

Usage of behavioral related principles (if necessary)

Walking aids (if necessary)

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C. CHRONIC AND LONG LASTING COMPLAINT

Problem areas.
Activity limitations.
Participation problems (may/ may not be)
Inadequate pain behavior.

Treatment goals.
• Improving activities
• Improving household and occupation participation
• Improving adequate pain behavior

Treatment

Participation problem:
• Informing and advising the patient about participation in activities
such housework or those necessary for carrying out his profession.
• Increasing, through exercise, the level of activity associated with
daily tasks , sport and hobbies while building up joint loading
duration and intensity.
• Giving instruction, if necessary, on the use of walking aids and
modification /alteration to the patient home/work environment.

Inadequate pain behavior problem:

• Informing and advising the patient about the true significance of his
complaints while, at the same time, encouraging the patient to gain
control over the complaints.
• Encouraging the activities with an increase in the load (duration and
intensity), regardless of the pain and in a graded manner.

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This approach focuses on the activities and teaching the patient

how to operate within his physical capabilities rather than on pain
by pacing the activities over time:

1. Take frequent ,short breaks

2. Gradually increase the amount
3. Break-up tasks into smaller bits.

NB: Suggested reading

Manage your pain- Practical and Positive ways of Adapting to Chronic
Pain. By Dr. Michael Nicholas et.al.(2002).

• Changing aspects of the patient’s environment from acting as a

barrier to acting as facilitator e.g. getting carer to learn on how to
focus more on adequate pain behavior (refer above).

REEVALUATION.

Reevaluation should be done at every visit. It includes subjective,

objective, analysis and planning (SOAP). Reevaluation is an important
basis for planning and modifying intervention.

DOCUMENTATION

Documentation should done on each patient encounter and include all the
important information of demography, assessment, planning, reevaluation,
intervention, measurement and modification of intervention.

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7. DISCHARGE PLAN

Goals / Outcome for discharge:

Cardiovascular fitness through activities that do not exacerbate joint

symptoms, such as swimming, upper body ergometry, and aquatic
aerobics.

Functional strength:
Stair negotiation
Independent transfer to and from sitting.
Ability to retrieve objects from the floor.

Patient is able to walk on all surfaces with/without assistive device
as needed.

Return to previous functional status for ADL and vocational,
recreational and sport activities as identified by patient.

Able to continue progressive home exercise program with
emphasis on function.

Patients may be discharged when all other rehabilitation goals except

inability to retrieve objects from the floor without assistance and return to
previous functional status for recreational and sports activities are met.

Home Program

Advice on:
1. Exercise program
2. Aerobic activities e.g. walking, swimming, cycling
3. Minimizing stress to joint
4. Avoiding slope climbing.

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OA KNEE MANAGEMENT
ALGORITHM 1

Referral information
Diagnosis – OA knee
Extra information – medical
intervention

Assessment
History taking
Present status
Observation/Palpation
Physical assessment
Functional evaluation

Analysis
Prioritize problem
Categorize to applicable profile
Prognosis
Patient motivation

Profile A Profile B Profile C

Inflammatory process, Movement impairment, activity Activity limitation, participation
pain, impairment limitation, inadequate pain problem, inadequate pain
behavior. behavior
Refer to Algorithm 3 Refer to Algorithm 4

Indication for No Refer to

Physiotherapy doctor

Yes

Refer to
Algorithm 2

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OA KNEE MANAGEMENT
Algorithm 2 (FOR PROFILE A)

Profile A
Active inflammation process

Interventions
Informing/advising
Helpful aids
TENS,Cold Packs,Traction
Behavioural Therapy

Refer Algorithm 1

Reevaluation
SOAP
no better,
no worse

Severe No Progress to Refer Algorithm 3

Pain ? Improvement
episodic pain

Yes (optimal function)

Refer to Discharge
doctor With home
programm
e

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OA KNEE MANAGEMENT
Algorithm 3 (FOR PROFILE B)

Profile B
Episodic complaints

Interventions
Informing/advising
Stimulating functions & activities
Traction
Behavioural Therapy in required
Refer algorithm 1 Helpful aids if necessary

No better, no
worse

No progress
Severe
to improvement Refer algorithm 4
Pain ?
Chronic pain

yes Yes (optimal level of function)

Refer to Discharge
doctor With home
programme
e

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OA KNEE MANAGEMENT
Algorithm 4 (PROFILE C)

Profile C
Chronic and long lasting
complaints

Interventions
Informing/advising
Stimulating functions &activities
Behavioral Therapy if required
Helpful aids if necessary
Home programme

No
Improvement Refer to doctor

YES
(optimal function)

Discharge
Advice, Home
programme, Activity
modification

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References

KNGF-guidelines for physical therapy in patients with osteoarthritis of the

hip or knee. V06/2003/US

American College of Rheumatology Subcommittee on OA Guidelines,

2000. Recommendations for the Medical Management of Osteoarthritis of
the Hip and Knee. Arthritis and Rheumatism.
Vol. 43, 9.

Hochberg et al, 1995. Guidelines for the Medical Management of

Osteoarthritis. Arthritis and Rheumatism. Vol 38 no. 11.

Worrall J.G. 2001. Understanding Arthritis & Rheumatism. Family Doctor

Publications Limited.

Bukowski E.I. 2000. Physical Therapist’s Clinical Companion.

Springhouse Corporation, Springhouse, Pensylvania.

Villar R. 2000. Undeerstanding Hip and Knee Arthritis Surgery. Family

Doctor Publications Limited.

Minisstry of Health Malaysia, 2002. Clinical Practice Guidelines on the

Management of Osteoarthritis. MSD.

O’Young B.J. et al. 2001. Physical Medicine and Rehabilitation Secrets.

Second Edition. Henleyb & Belfus Inc. Philadelphia.

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GLOSSARY

ADL Activities of daily living

VAS Visual analogue scale

Coping The cognitive and behavioral effort made by

an individual to control,reduce and tolerate
the internal and external stress created by
the condition.

Functions Physiological functions of the body

systems(including psychological functions)

Impairment Problem with body function or

structure,such as a significant deformation
or loss .
Disability Difficulty in carrying out an activity.

Load-bearing capacity The magnitude of load an individual can

handle.

Load or loading force The magnitude of load an individual can

handle.

Participation Involvement in life situations

Participation problem Problem an individual may experience

with involvement in a life situation.

Patient profile All the prognostic characteristic of the

patient which are associated with the
health problem and the course of recovery.

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11. APPENDIX

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Appendix 1:
Algofunctional index for OA Knee

Pain or discomfort
During nightly bed rest::
• None or not significant 0
• Only during movement or in certain position 1
• In resting positions 2
Morning stiffness or decreasing pain after getting up:
• For 1 minute or less 0
• More than 1 minute but less than 15 minutes 1
• For 15 minutes or more 2
• After 30 minutes standing 0–1
Walking:
• None
0
• Only after walking a certain distance
1
• Immediately after starting to walk and increasing after
a certain duration 2
• After starting to walk but not increasing 1
• Getting up from a chair without using arms 0–1
Maximum walking distance (Pain allowed):
• Unlimited 0
• More than 1 Km, but with restrictions 1
• Approximately 1 Km (in about 15 minutes) 2
• Between 500 - 900 m (in about 8 –15 minutes) 3
• Between 300 – 500 m 4
• Between 100 – 300 m 5
• Less than 100 m 6
1
• With a cane or crutch
2
• With 2 canes or crutches
Daily Life Activities:*
• Able to walk up stairs 0–2
• Able to walk downstairs 0–2
• Able to squat or bend the knees 0–2
• Able to walk on uneven ground 0–2

Total score

*In the assessment of daily activities: without difficulty: 0: with little

difficulty: 0.5; with moderate difficulty: 1; with great difficulty: 1.5; and
unable to perform: 2.

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The total score on the Algofunctional Index represents the patient’s

degree of limitation in ADL:

 14 extremely severe disabilities

 11-13 very severe disabilities
 8 - 10 severe disabilities
 5 - 7 moderate disabilities
 1 - 4 minimal disabilities

A total score greater than 11 or 12 can indicate that an operation may be

necessary and provides sufficient reason for contacting the referring
physician.

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Appendix 2

Do’s and Don’ts

The following pages contain the “ Do’s and Don’t’s “ involved in the care
and protection of an osteo-arthritic knee. There are four main “ Do’s and
Don’ts “ to follow during the day.
They concern :
1. JOINT MOBILITY
2. COMPRESSION OF THE JOINT
3. TWISTING OF THE JOINT
4. STRENGTHENING OF SURROUNDING MUSCLES

1. JOINT MOBILITY
Don’t be immobile
Long periods of immobility should be avoided as it means there is no
squeezing effect of the joint fluid into the cartilage.

Also following inactivity , the capsule and ligaments stiffen a little and
initial movement will be uncomfortable until the joint loosens up in a few
seconds to minutes.

Do be mobile
Keep Your Knee Movement Full
Allowing your knees to stiffen and loosing some movement at the extreme
straight or bent positions will restrict your activitiesand reduce nourishment
to the cartilage. Walking will become more uncomfortable if stiffens occurs
and your legs will feel tired and achy more quickly.

The Squeezing-Pump-Squeeze Action

This movement helps to feed the cartilage by pumping the nutrients
towards the joint and squeezing them into the cartilage.This should be
done several times on walking in the morning and repeated again last
things at night.

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Lying down, bend your knee as far as it will go, now grasp it with both
hands and give it an extra pull towards you ( this is the squeeze ). Now
straighten your leg ( this is the pump ) .
Repeat these movements several times.

The Half Hour Rule

If sitting for a long time, for example longer than half an hour, try to
remember to bend and straighten your knee several times every half hour.
This helps to prevent stiffness setting in and the associated stiff discomfort
experienced on first standing up. Stretch your leg first , loosen up and then
stand up.

2. COMPRESSION OF THE JOINT

Don’t compress your joint excessively

For example :
• Long bouts of standing, walking or running
• Sudden impact on your joint ;
-running on concrete
-stepping awkwardly down steps
• Being overweight or carrying extra weight eg. Shopping or carrying
young children for too long.
Each of these is bad for the cartilage nourishment as the pressure pushes
the joint fluid aside, whilst impact on an already vulnerable joint
aggravates the condition further.

Do:
A. Ease off weight on joint regularly.
If standing –
- Keep shifting from one foot to the other
- Bend and straighten your knee like policeman plod
- Sit down to take the weight off your feet whenever possible, for a few
minutes during work or chores.
If walking –

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- Sit down at least twice for a few minutes if shopping or walking for long
periods ( 3 hours ).A shooting stick can be useful.
- Use a walking stick to help reduce the weight going through the joint.

B. Compensate for loss of shock absorption

- Step carefully down steps.
- When kneeling , use a foam cushion
- Wear correct footwear with good shock absorbing soles e.g crepe or
sorbo- rubber.

C. Keep weight down

- Watch your diet
- If you cannot lose weight following medical advice or even a dieticians
advice, try not to increase your weight.
- Use trolleys or ask kind friends and relatives to help you to lift heavy
weights.Remember that young children are heavy weights too.

3. TWISTING THE JOINT

Don’t twist the joint
This stressful movement e.g getting up from the floor.If you have to , use a
stool or a chair to help you.
Avoid sitting back on your heels.
Wear low heels instead of high heels.
Sit on higher cahir with arms and use your hands to help you get up.
Use hand rails when using stairs.Use both hands if possible, especially on
buses.
Sit with your legs uncrossed.

4. STRENGTH OF SURROUNDING MUSCLES

Don’t let leg muscles weaken
If this happens, the support to the knee joint is reduced, and your knee
will be more vulnerable to strain.
Do
Protect your joint by keeping muscles strong by exercising them.

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