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Injuring the knee is one of the most common general and sporting injuries and can give long-term problems with pain, stability and functional activities. Physios begin with the subjective examination, asking about the cause of the injury, the amount of force involved, whether the knee swelled up quickly or the knee was unstable afterwards and the person found it difficult to weight bear.

The amount of pain a patient suffers indicates the severity of the injury involved and the particular location of the pain can point to which anatomical structures have been injured. As the knee will be very difficult to walk on in the presence of a fracture these injuries are rarely missed in diagnosis. During the examination the physiotherapist will test the knee structures to look for the cause of the injury.

The Knee Examination

The physiotherapist will look at the knee and check for effusion by observation or doing the patellar tap test. The knee can swell greatly and be very tight, needing aspiration by a needle. How well the knee can move when not weight bearing is assessed by the physio. Knee extension is the movement of straightening the knee out and flexion is bending the knee. The knee does have a certain degree of rotation but that is rarely checked in the initial period.

The reaction to examination testing indicates how the treatment plan should proceed. The pain level, ease of joint movement and reaction to tests are included in this assessment. The patient moves the joint actively with the physiotherapist adding passive movement to test the joint further. The power of the main antigravity muscles, the hamstrings and quadriceps, are tested by manually resisting the knee movements or asking the patient to perform weight bearing movements.

The medial and lateral collateral ligaments of the knee give side to side stability to the joint, and the anterior cruciate ligament and posterior cruciate ligament provide front to back stability. Provided pain is not severe the physiotherapist will test these ligaments manually, pushing the knee into knock-knee and bow-leg for sideways stability and the forward and backward movement of the shin bone to assess cruciate function. The physio will palpate round the joint manually to search for clues to injured structures.

Physiotherapy treatment plan

An acutely painful knee is treated using the PRICE technique, starting with protection of the joint if necessary by using a brace to stabilise it. Crutches or sticks can be used to reduce weight bearing on the knee and allow a good walking pattern. Ice treatment, or cryotherapy, is a first line treatment for an acute knee, reducing pain and the swelling which permits increased movement and progression of treatment. A neoprene knee sleeve may be worn to squeeze the swelling and increase stability.

A reduction in swelling and pain allows the physiotherapist to give exercises to improve the knee’s ranges of movement and strength. The largest and most powerful muscles are the quadriceps and the hamstrings. The quadriceps allows knee power for getting up from sitting, going up and down stairs and walking, keeping the knee stable. After the knee copes with exercise on the plinth the physio will move to exercises in weight-bearing and in more active activities.

A normal knee joint involved in activity sends a stream of impulses up to the brain, informing us of the joint position at all times, the degree of muscle activity and movement. This is known as joint position sense (JPS) or proprioception, which is lost to some degree after injury and restoring it to a normal level is vital if the knee is to successfully return to activity. The physio starts with balancing on one leg and progresses to standing on a wobble board and finally works on active, dynamic exercises in preparation for sport.

Cervical spine pain and disability is one of the commonest problems for which people consult a physiotherapist. The first part of the examination is to find out the cause of onset of the pain and how it has behaved since then. The cause of the pain is clear in about half of all cases but the rest can give no good idea why the pain came on. Where the pain is and how it behaves gives indications to the physio about where the underlying pathology might be found and what treatment approach might be

The physio will ask about the location and nature of the pain. Neck problems often involve other areas and the presence of shoulder and arm pains will tell the physiotherapist what kind of pain they are dealing with. Sharp, localized pain on movement could be a joint sprain, generalized neck ache a postural or segmental problem and severe arm pain could be a nerve root compression from a disc prolapse.

Because neck pain could be an indicator of various pathologies the physio will ask all the special questions such as general health, past medical history, weight loss, bladder and bowel control, quality of appetite and sleep and medication usage. The objective examination begins by getting the patient to take their upper body clothes off and looking at the posture of the trunk, neck, shoulders and arms. A humped thoracic spine with rounded shoulders and a poking chin are a common postural abnormality which can lead to pain.

Cervical ranges of movement are tested to elicit important information about what is going on in the neck. The response to movement testing will help the physio understand the kind of neck pain problem and how to start treating it. Cervical rotation, flexion, extension, side flexion and retraction are all assessed to try to pinpoint the problem. Muscle strength, sensation and reflexes are tested to ascertain that the nerve conduction to the arms is working well.

To narrow down the area responsible for the pain the physiotherapist will employ mobilization techniques in assessment of cervical spine lesions as well as treatment. The individual joint levels can be assessed for movement dysfunctions in a systematic manner, palpating the neck in lying when the spine is relaxed. If the symptoms are brought on by pressure on the spinal joints at a certain level then the physio can infer that the changes at that level are important in the diagnosis and subsequent treatment.

Mobilization techniques are a core manual skill for physiotherapists and abnormal joint mechanics, known as dysfunctions, can be identified by palpation of the main spinal and facet joints by the physio. Treatment can use repetitive small movements to relieve pain an encourage normal motion, to more forceful manipulations which take the joints beyond their typical ranges and restore movement. Any increases in movement gained by treatment is maintained by home exercises.

Other treatment techniques commonly employed by physiotherapists are strengthening exercises for the deep neck flexor muscles, generalized exercise to get fitter, neural exercises to ease nerve related problems, mobilization of the thoracic spine, postural correction and pacing activities to prevent overdoing one position or function for too long at one time. In severe cases of nerve root pain in the arm, which is similar to sciatica in the leg, manual traction of the neck may be used to reduce the pressure around the sensitive nerve or autotraction kits can be used, allowing patients to give themselves traction regularly.