The best treatment for knee pain

Knee pain is a common reason people book an appointment with a physiotherapist. There can be plenty of reasons for this knee pain to occur and over the years I’ve seen an amazing amount of solutions. However recently it has become apparent that if your physiotherapist is not starting you on some form of graded exercise program then something is not quite right.

Studies from around the world are highlighting the benefits of supervised exercise more and more:

• Exercise reduces pain and does not cause increased inflammation or the loss of cartilage (Bricca et al., 2019).
• Surgery does not give superior results to exercise in patients with degenerative meniscal tears (Kise et al., 2016).
• The costs of physiotherapy and likely beneficial results mean it should be considered ahead of surgery for non-obstructive cartilage tears (van de Graaf et al., 2019).
• A recent editorial in the British Journal of Sports Medicine further supported this with the unequivocal statement “there is convincing evidence that exercise therapy works.” (Crossley & Cowan, 2019).

This would all appear reasonable and yet out in the community this level of care is not always common place.

An article in 2016 found that physiotherapists still spent time with patients with osteoarthritis performing low value care options such as electrotherapy and ice (Spitaels et al., 2016). Furthermore it has recently been reported that the use of imaging, recommendations for surgery, prescription of opioid medication and failure to provide adequate education remain common problems in the management of musculoskeletal pain (Lin et al., 2019).

So the next time you visit your doctor or physiotherapist with a sore knee ask yourself if you are receiving high value care. Were you;

• Given a graded exercise program and offered supervision to assist?
• Educated on the reasons for your knee pain and ways to improve it?
• Discouraged from receiving a scan unless there was unsatisfactory improvement in conservative management or unexplained progression of symptoms?
• Advised not to take opioid medication?
• Encouraged to continue work and exercise in some capacity?
• Felt that the care and treatment provided was specific to you and your goals?

If any of these questions cause you to reflect then maybe it’s time to consider, are you receiving high value care?

References

Bricca, A., Roos, E. M., Juhl, C. B., Skou, S. T., Silva, D. O., & Barton, C. J. (2019). Infographic. Therapeutic exercise relieves pain and does not harm knee cartilage nor trigger inflammation. British Journal of Sports Medicine, bjsports-2019-100727. https://doi.org/10.1136/bjsports-2019-100727

Crossley, K. M., & Cowan, S. M. (2019). VMO retraining or graduated loading programme for patellofemoral pain: different paradigm with similar results? British Journal of Sports Medicine, 0(0), bjsports-2017-098736. https://doi.org/10.1136/bjsports-2017-098736

Kise, N. J., Risberg, M. A., Stensrud, S., Ranstam, J., Engebretsen, L., & Roos, E. M. (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: Randomised controlled trial with two year follow-up. British Journal of Sports Medicine, 50(23), 1473–1480. https://doi.org/10.1136/bjsports-2016-i3740rep

Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., … O’Sullivan, P. P. B. (2019). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med, bjsports-2018-099878. https://doi.org/10.1136/bjsports-2018-099878

Spitaels, D., Hermens, R., Van Assche, D., Verschueren, S., Luyten, F., & Vankrunkelsven, P. (2016). Are physiotherapists adhering to quality indicators for the management of knee osteoarthritis? An observational study. Manual Therapy, 1–12. https://doi.org/10.1016/j.math.2016.10.010

van de Graaf, V. A., van Dongen, J. M., Willigenburg, N. W., Noorduyn, J. C. A., Butter, I. K., de Gast, A., … Poolman, R. W. (2019). How do the costs of physical therapy and arthroscopic partial meniscectomy compare? A trial-based economic evaluation of two treatments in patients with meniscal tears alongside the ESCAPE study. British Journal of Sports Medicine, bjsports-2018-100065. https://doi.org/10.1136/bjsports-2018-100065