I want to refer back to a recent study1 that found arthroscopic surgery for osteoarthritis (OA) of the knee is no better than physical therapy to relieve moderate to severe knee OA. Considering knee OA is the most common form and has been predicted to grow in the upcoming years, this is a huge step for our profession as it is reported in a well respected journal (not even a physical therapy one!). It makes sense as surgeons aren’t able to perfectly keep all healthy tissue in the joint and change the mechanics of the tibiofemoral joint giving us an edge. I do hope more studies that are similar to this one continue to arise in the literature to be available to all health professionals and the public for the sake of physical therapy. A great review of it and other quotes can be found on the APTA website here.
What is typically found?
Conventional radiographs show localized nonuniform joint space narrowing in one of the compartments, most particularly the most affected medial compartment. This is likely due to the medial compartment having 2.5x the amount of force acted upon it leading to excessive varus torque. This can be seen from sclerosis on the radiograph and most of the time upon observation and palpation clinically with larger mass & tenderness medially.
The pain from OA typically leads to an antalgic gait pattern with less weight acceptance on the involved side, as well as a significantly reduced internal knee extensor moment compared to normal subjects2. Over time, the tibia begins to rotate externally that also provides a larger base of support through the foot for balance. Nevertheless, the change in biomechanics for improved balance and possibly less pain leads to more rotation of the tibia externally.
From a manual therapy standpoint.
Not only do we need to continue to address strength deficits, especially in the shock absorbing quadriceps; but the biomechanics of the knee as well through hand contact.
-Combination of therapeutic exercise and manual therapy has been shown to yield functional benefits and delay or prevent surgical intervention3.
-Deyle et al found that A/P mobilization of the tibiofemoral joint has been shown to immediately produce local and widespread hypoalgesic effects on knee OA4.
-In addition, having individualized care by a physical therapist through supervised exercises, manual therapy and HEP resulted in 2x the improvement in WOMAC scores than only HEP5.
Not only do sagittal plane accessory mobilizations give relief and greater ROM, providing an internal rotation movement of the tibia on femur (see picture) has been shown anecdotally to provide great pain relief and more efficient ambulation. This technique seems to work well for me and makes sense biomechanically as the tibia can become externally rotated.
What manual therapy techniques do you use for knee OA patients? Do you know of any research that favors the above notion?
- Kirkley et al. A Randomized Trial of Arthroscopic for Osteoarthritis of the Knee. The New England Journal of Medicine. 2008; 359: 1097-1107.
- Kaufman K. Gait characteristics of patients with knee osteoarthritis. Journal of Biomechanics. 34; 7: 907-915 Deyle GD, Henderson NE, Matekel RL et al. Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee. Annals of Internal Medicine. 2000. 132; 3: 173-181.
- Moss P, Sluka K, Wright A. The initial effects of knee joint mobilizations on osteoarthritic hyperalgesia. Manual Therapy. 12; 2: 109-118.
- Deyle GD, Henderson NE, Matekel RL, et al. Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a Home Exercise Program. Phys Ther. 2005; 85; 12: 1301-1317.