Understanding knee pain and knee ligament injuries

What causes knee pain?

Many people are alerted to an issue when they experience knee pain when walking or going about their daily life. In other patients, their knee pain stems from a notable injury. Often the question ‘why does my knee hurt?’ is the first step to uncovering an ongoing condition and getting the help you need.

Knee pain can be the result of any number of issues or injuries. If there is a specific injury that a patient can point to, it may represent an injury to the knee ligaments, meniscus or cartilage. If the pain comes on gradually it may be the result of overload of the joint, such as experienced by runners. For other people it can simply be a case of age-related wear and tear, and even osteoarthritis.

What are the most common types of knee injury?

Sprains and strains

A sprained knee is an old and outdated term. It’s a general term that can refer to a broad range of injuries that can result in knee pain. Whenever that happens, it’s always advisable to obtain a firm diagnosis as the cause the pain may be a simple transient or temporary pain without obvious cause, but it may represent some structural damage that needs attention.

ACL and MCL injuries

These injuries are usually caused by a significant twist or a sudden impact or collision. We see a lot of torn ligaments in football. The most common ligament injury is a tear to the medial collateral ligament (MCL) and then the more infamous anterior cruciate ligament (ACL). While injuries to the ACL often require surgery, an injury to the MCL can usually be treated non-operatively with an initial period of rehabilitation in a brace, including strengthening and conditioning.

Knee fractures

These are usually caused by either a powerful impact or falling heavily onto your knee joint. Typical signs that you may have fractured your knee include pain, bruising, or swelling that happens soon after an injury. It’s often painful to move the knee, either by bending it or simply by putting weight on the affected leg. You may find it difficult to straighten the leg fully or to walk without pain.

Osteoarthritis

The wear and tear process of the knee joint, known as osteoarthritis, is a normal occurrence as we age and tends to be more rapid the more activity that we do. It is therefore a good idea to consider joint preservation techniques as early as possible. This is worth a discussion with a specialist.

Runner’s knee

Patellofemoral pain syndrome, also known as “runner’s knee”, is a common cause of knee pain, often caused by overuse. If you have consistent pain in the front of your knee, you may be suffering from this condition.

Jumper’s knee 

Tendinopathy is a broad term covering inflammation of the tendons as well as overuse of a tendon during certain activities such as running, jumping, or cycling. Tendinopathy of the patellar tendon is called “jumper's knee”, which is common with sports like basketball, where the repetitive force of hitting the ground following a jump strains the tendon.

What symptoms should I look out for?

The first sign of an acute knee injury will usually be pain, rapid swelling of the area and difficulty standing, walking or bearing weight on the leg.

Within a few hours of an injury, fluid will start to collect inside the joint. This is a natural reaction of the body. It may be painful and feel very unstable, as though the knee is about to give way when you put any weight on it. Your knee may also feel “locked” as though you can’t fully straighten your leg.

This could all be a sign of a fracture or ligament or meniscus damage. If you have any of these symptoms and sensations, it’s really important to seek urgent medical help.

Which sports cause the most knee injuries?

Knee injuries are common in all sports, but particularly those that involve a lot of twisting, high impact or collision, like football, netball or rugby. These can lead to torn knee ligaments, patellofemoral pain, meniscus tears and more.

Sports that involve landing from a high area like gymnastics or that put repetitive stress on the knee can also cause knee injuries and long-term knee pain.

When should I see a specialist for knee pain?

Fortunately, most mild to moderate knee injuries will get better on their own or with physiotherapy and supervised rehabilitation rather than needing surgical intervention. It may also mean some time away from intense activity. If your pain persists beyond a few days, or if your knee becomes warm, swollen or you have a sensation of locking or instability, you should see an orthopaedic specialist for evaluation and diagnosis.

How are knee injuries diagnosed?

Medical history and examination

The first step to diagnosing a knee injury will usually be a consultation with a specialist who will ask you questions about your symptoms, your physical, sporting and medical history and offer a physical examination. They may want to check for any inflammation and assess the overall stability of the joint.

X-rays

Your specialist will usually request an X-ray as first step to check for any fractured or broken bones. They can also use the X-ray to spot any signs of arthritis in the joint.

MRI scans

Your specialist may also recommend an MRI scan to get a more detailed view of the condition of the soft tissue surrounding and supporting the joint, and identify any tears to the ligaments, meniscus or tendons.

CT scans and specialist investigations

In some cases, a CT scan could help identify fractures that don’t show up on an X-ray. On rare occasions, your specialist might request other investigations such as arthroscopy or radionuclide bone scan to aid the diagnosis.

What are the treatments for knee pain?

Your treatment plan will depend on your specific injury. It may be enough to simply take some time to rest and recover at home and give your knee a chance to heal, but if this doesn’t help after a few days you should seek advice.

You may need to use the RICE method along with some over-the-counter pain relief (medication or topical gels) to help manage the pain and swelling.

The RICE method:

Rest: stay off your feet as much as possible in the first few days and avoid any heavy activities to give your knee a chance to rest and recover.

Ice (or heat): apply an ice pack OR heat pack for up to 20 minutes every couple of hours to help reduce inflammation, improve circulation and soothe any pain.

Compression: wrap a bandage around the joint for stability and support.

Elevation: raise your leg by resting it on a chair or pillow to limit fluid build-up.

If the pain and swelling are particularly intense or don’t resolve in a few days, you may need physiotherapy or the support of functional knee brace. The type of brace of knee support should be guided by a medical professional. Physiotherapy can also help with longer term treatment to help strengthen the muscles, increase flexibility and better support the structures around the knee.

If exercise doesn’t help, your physiotherapist or specialist may suggest injections such as cortisone (for osteoarthritis only) or hyaluronic acid to help settle any severe inflammation, lubricate the joints and ease the pain and discomfort of osteoarthritis or other injuries. An alternative option for injections is platelet rich plasma, a more natural biologic alternative that is associated with good outcomes. Just like the brace choice, the best injection option following injury should be guided by a specialist.

As a final option, you may want to consider surgery. This can be the best way forward for long-term repair if you have a torn ligament or serious injury. Surgical options range from minor procedures such as arthroscopy to repair internal damage around the knee, to partial or total joint replacement if your pain is due to end stage arthritis. While some injuries to ligaments, meniscus and tendons are helped by early surgery, joint replacements are usually considered when other treatments have failed to make a significant difference.

How long does recovery take?

This depends on the type of injury and treatment you’ve had. Usually, a good principle is to take things slowly and make sure your knee doctor or physiotherapist signs off any return to activity. Don’t try to return to your previous level of physical activity until your injured knee is fully recovered.

Minor knee injuries should improve in around one to three weeks depending on what the issue is. If there is no structural damage, then they may simply improve with rest and ‘RICE’ treatment.

Ligament injuries take longer. This would depend on the severity of the injury. These types of injuries used to be classified as Grade 1, 2 or 3. Grade 1 injuries may improve within three or four weeks with physiotherapy, whereas grade 2 partial tears can take longer – potentially up to 12-16 weeks to see an improvement. Grade 3 tears may take between six and 12 months to heal and often need surgery. This grading system is quite outdated now and treatment should be determined by advice from your specialist.

Recovery from surgery

For keyhole surgery (arthroscopy), the immediate recovery may be two to six weeks depending on what the indication for surgery is. Undergoing a ligament reconstruction, such as an ACL repair, takes much longer to recover and can be a full 12 months before returning to play. A major joint replacement will take up to a year for complete recovery.

Returning to exercise safely

It’s important to take it easy during the healing phase to allow your knee to recover. This may take just a few days, or many weeks or even months for significant soft tissue damage. Major ligament tears or surgeries require anywhere between three and twelve months depending on the ligament and the treatment.

You can safely start gentle mobility movements once any acute swelling and sharp pain begin to settle. However, it’s a good idea to avoid high impact sports initially and look for an alternative that won’t aggravate your knee. Try to ease back into sport slowly, check with your doctor and remember not to overdo it. It is always best to be supervised by a physiotherapist when it comes to recovery from injury and working your way back to sport.

How can I prevent knee injuries?

If you play sport, particularly intense sport, you can’t guarantee that you won’t get injured. But there are steps you can take to reduce the risk:

Warm up properly

Injury prevention strategies can be incorporated into your warmup and cool down exercises to help protect your joints and surrounding soft tissue during activity.

Build strength around the knee

Focus on building thigh (quads and hamstrings) and gluteal strength as that will go a long way to helping ease the burden on your knees. You can also use a knee brace for extra protection during walking, sport and daily activities, depending on what the issue with your knee is and what your specialist advises.

Wear appropriate footwear

Always make sure you wear the right footwear for your chosen activity, with enough support for your feet. For runners in particular, choose trainers that offer suitable shock absorption to protect the joints.

Increase training slowly

It can be really tempting to try to make progress quickly when you’re getting stronger, but that can put you at greater risk of injury if you go too fast. If you want to make your workouts more intense, do so gradually.

Maintain a healthy weight

Being overweight can add stress to your joints, so make sure you are in the healthy weight range for your height.

Listen to your pain signals

Pain is the body’s way of telling you something isn’t right. If you feel pain while exercising, it’s important to stop immediately to minimise any damage.

Adapt your environment

If you’re a runner, consider running on a synthetic track or soft surface like grass to offer your joints some protection. If you’re hiking on wet grass, you could use trekking poles to protect your knees against subtle twists and slips.