The Role of Physical Therapy in Managing Knee Pain: Insights from Singapore

Benefits of Physical Therapy for Knee Pain


Mutation in the SLC39A13/ZIP13 gene is a recently identified cause of a rare neurodegenerative disorder called the onset of the disease can occur in children or adults, and is characterized by severe muscle spasticity and contractures. An often unrecognized or under-treated issue for individuals with muscle and joint pain is a strength deficit in the muscles surrounding the knee. This is a pertinent issue for the aging individual with knee osteoarthritis, who may have altered movement patterns due to knee pain, which can result in muscle atrophy. For those with an acute injury such as an anterior cruciate ligament tear, or following surgery, there is an inevitable strength deficit in the quadriceps and hamstrings muscles. Strengthening exercises are the most obvious and direct way to address a muscle strength deficit, and evidence supports their use to relieve pain and improve physical function in those with knee osteoarthritis. High-quality research has shown therapeutic exercise to have a moderate to large effect on both pain and function in the short and long term. Additionally, there are many randomized controlled trials with positive findings for PFP and those with ligament injuries.

Pain relief is often the first and foremost objective for an individual with a painful knee. This will typically be achieved through a variety of modalities, which can include: ice, heat, electrical stimulation, taping, or the use of an unloader brace. Electrical stimulation has been found to be effective in reducing pain in patients with knee osteoarthritis. Taping is particularly useful for patellofemoral pain (PFP), and bracing has been shown to significantly reduce symptoms of knee osteoarthritis. Manual therapy. The benefits of each of these methods are largely due to peripheral sensory nerve endings, which have an impact on pain transmission. A physiotherapist may also use hands-on techniques to alleviate pain, through a variety of methods including soft tissue massage or joint mobilization. This manual therapy has been found to improve pain and function in those with knee osteoarthritis.

Physical therapy can be a highly effective way to alleviate pain and prevent chronic knee problems from developing or worsening. The focus of physical therapy will vary depending on the precise condition, however the primary aim will be to alleviate pain and restore normal function of the knee. This is a concise overview of the various ways in which a person can expect to benefit from physical therapy.

Pain Relief Techniques

Passive therapies have been claimed by some to be less effective in providing lasting relief of knee pain, but all have been shown to improve pain as a short-term effect. Manual therapies include a variety of hands-on techniques to affect the soft tissues and joints of the body. Massage can reduce muscle tension and increase relaxation, releasing endorphins and creating a sense of well-being. It is relatively safe and can be useful if it does not cause prolonged discomfort. Myofascial manipulations have recently been shown to reduce the sensitivity of myofascial tissue by decreasing the irritability of trigger points. There are many different forms of manual therapy, and physical therapists usually have training in several of them. Due to the risks of several passive treatments, it is advised that those with knee pain seek a therapist with a wide selection of various treatment options.

Pain relief techniques have been classified as either active or passive. Active therapies are designed to alter joint mechanics, and many are ultimately aimed at improving muscle strength and coordination. They may be the most useful therapies in that they can be taught to the patient and employed by the patient in a home program. Regular physical activity has been shown to be important in the prevention of knee pain in the future. Weight management is also a key factor, as being overweight has significant effects on the progression of knee pain. Aerobic exercise has been recommended, with walking being the most useful and requiring the least aggravation of knee symptoms. A slow progression to longer durations or increased intensity of walking is advised.

Strengthening Exercises

Different kinds of strengthening exercises are used to treat particular knee injuries. Isotonic exercises increase the joint angle during muscle contraction, while isometric exercises contract the muscle without movement. Closed chain exercises are those in which the foot is in a fixed position, and the force applied by the leg is transmitted to the knee and hip. Open chain exercises are those in which the foot moves freely and the force applied is not dependent on the resistance of the leg. An effective exercise program will include a combination of isotonic, isometric, closed chain, and open chain exercises, with the type of exercise changing as the knee responds to treatment and the pattern of muscle recruitment normalizes.

Muscle-strengthening activities work best when the muscles are gradually increased in load or resistance. This can be achieved by increasing the amount of weight, the number of repetitions, or the duration of the exercise. It is an acute overload that challenges the muscles but does not cause pain or significant fatigue. Exercises should stress the muscles and cause them to contract. High resistance and low repetition exercise results in greater muscle strength, whereas lower resistance, high repetition exercise results in greater muscle endurance.

Strengthening exercises are the keys for stopping knee pain. The muscles in and around the knee are responsible for knee movement and stabilization. By strengthening the muscles in the thigh and leg that support the knee, one can relieve knee pain and prevent further injury. Strengthening exercises can also correct muscle imbalances around the knee and further protect the knee from injury.

Range of Motion Exercises

Range of motion (ROM) is a term used to describe the amount of movement available at a joint. This is determined by measuring the angle formed between the bones that make up the joint. The goniometer is a device used to measure joint angles. Full knee extension is defined as the point when the angle formed between the femur (thigh bone) and the tibia (shin bone) is 0 degrees. Normally, the knee has an ROM of 0-140 degrees. (Hyperextension is defined as any movement more than the normal terminal extension of 0 degrees). The amount of knee ROM can affect a person’s ability to perform everyday tasks such as walking, stair climbing, and sitting. Pain, swelling, or muscle weakness can all lead to decreases in knee ROM.

Recovery from knee disorder or injury can be achieved effectively through carefully planned movement exercises designed to restore normal range of motion to the knee. This is particularly relevant if the range of motion is hindered following surgery, prolonged immobilization, or to alleviate knee pain associated with stiffness. Progressive active or active assistive exercises directed at restoration of full active knee ROM should be initiated as pain decreases. This is especially important to ensure a full return to function of the knee extensor mechanism and to maximize functional recovery of the patient.

Specialized Physical Therapy Approaches for Knee Pain

Ultrasound therapy is a method of applying sound waves to an area of soft tissue injury. It is thought to stimulate tissue repair and increase blood flow to the affected area. A study has shown that ultrasound therapy can improve the rate of recovery of an exercise-induced muscle injury. This type of therapy may be useful for patients suffering from an acute knee injury and may aid in accelerating the healing process.

Electrical stimulation involves the use of a machine that produces electrical current, which is transmitted through electrodes and into the skin over the area of pain. It is thought to work by reducing one’s awareness of pain and by acting on the nervous system’s control of muscle tension and blood flow. A study investigated the effects of electrical muscle stimulation on quadriceps muscle strength in patients with knee pain. The treatment group underwent electrical stimulation therapy for the quadriceps muscles on the affected knee, three times per week for six weeks. The treatment group demonstrated a 16.9% increase in quadriceps muscle strength compared to the placebo group, who underwent a similar protocol of electrical stimulation but the machine was not turned on, demonstrating no improvement in muscle strength.

Apart from exercise therapy, there are a few specialized treatments that physiotherapists will use to reduce pain and inflammation and promote tissue healing of the knee. Manual therapy techniques are used to improve the mobility of soft tissues and joints. It has been shown to help reduce pain and improve function in knee osteoarthritis. One such manual therapy technique is joint mobilization. This is a slow, rhythmic, passive movement that is performed on the knee joint by the therapist. A study showed that patients with knee osteoarthritis who underwent a 3-week treatment of knee joint mobilization techniques combined with exercise demonstrated greater improvement in pain, function, and range of motion of the affected knee and maintained these improvements for a year after the treatment.

Manual Therapy

One small randomized clinical trial has been performed to investigate the effects of manual therapy. It compared the effectiveness of manipulation versus mobilization versus a placebo procedure in 45 patients with knee osteoarthritis. In this study, manipulation showed significantly greater improvement in pain and physical function compared to both placebo and mobilization, with no serious adverse effects. This is a highly positive result for knee pain sufferers, as with no effective pharmaceutical treatment for knee osteoarthritis, the potential for a hands-on treatment that is both effective and safe is very promising.

Manual therapy is a specialized form of physical therapy used to provide ‘hands-on’ treatment to soft tissues around the knee. This is done to reduce stiffness that has set in following an injury or to reduce tightness in muscles, which may be exacerbating knee pain. In knee pain Singapore, the techniques in manual therapy are primarily massage-based and fall into one of two categories: mobilization and manipulation. Mobilization involves moving or ‘wiggling’ joints within their normal range of movement, whereas manipulation is a more aggressive technique that takes a joint beyond its normal range of movement to produce a sudden change. Both techniques have been shown to be effective means of treating knee pain, with manipulation showing superior results to mobilization.

Electrical Stimulation

Electrical stimulation is a popular treatment for knee pain. There are different forms of e-stim including TENS, interferential, and neuromuscular electrical stimulation. All forms of e-stim have been shown to help with decreasing knee pain. TENS is a form of e-stim that uses a small handheld device connected by electrodes to send a low current of electricity to targeted areas. TENS has been shown to be effective in reducing pain because the electrical current sent to the nerve fibers will block the transmission of pain perception to the brain. This is the most widely used form of e-stim, and is something that can be used in the clinic or at home. Interferential e-stim is similar to TENS, but it uses two different electrical currents at the same time. The point of this is to help promote endorphin release, which will also block pain perception to the brain. Interferential e-stim is not practical for home use because it is more expensive and requires a machine to be brought home. Neuromuscular electrical stimulation uses a higher current of electricity sent to the motor points of muscles in an effort to create a muscle contraction. This can help with re-educating the quadriceps muscles that may have inhibited firing patterns due to pain and swelling. E-stim and studies supporting its usage make it a viable option for someone looking to decrease their knee pain.

Ultrasound Therapy

There are three primary benefits to ultrasound treatments. The first is the speeding up of the healing process from an injury. Scar tissue from any injury can be gently “massaged” by the waves, creating a more flexible scar and ultimately reducing the chance of re-injury. The second effect will be the decrease of pain from the malfunction of the pain receptors at the site of the injury. Finally, ultrasound can create a deep heating effect on the muscle tissue. This promotes muscle relaxation and, therefore, a decrease in muscle spasm and chronic pain. Combined with the reduced pain experienced by the exceptional quality electrical stimulation, this can be very effective at relieving pain. Overall, ultrasound can help chronic injuries by creating an environment conducive to normal healing and can be applied to acute injuries to prevent chronic problems from developing.

Ultrasound therapy is a treatment technique that uses high frequency sound waves produced by a specialized tool to stimulate the tissue beneath the skin’s surface. Upon absorption of these waves, there is a temperature rise in the targeted tissue. This, in turn, enhances/decreases the flexibility of the tissues, the rate of the chemical reaction taking place in the tissues, and can also provide pain relief. Treatment with ultrasound is painless and takes a matter of minutes to perform, depending on the size of the area being treated.

Heat and Cold Therapy

Cold: Cold therapy is also beneficial in reducing pain by slowing down the blood flow to an injury, thus reducing swelling and inflammation. It also acts as a local anesthetic by slowing down the speed of nerve impulses in the area, decreasing pain. Cold therapy is generally used for acute pain or swelling occurring from an injury. This can include ice packs or ice massage, or cooling sprays.

Heat: Heat opens up blood vessels, which increases blood flow and supplies oxygen and nutrients to reduce joint or muscle pain. This helps to relax and lengthen soft tissues, including muscles and connective tissues. Heat therapy can encompass many approaches, from hot water bottles, saunas, whirlpools, heat or light lamps, to heat shields. Heat should be used in chronic conditions to help relax and loosen tissues, and to stimulate blood flow to the area.

Heat and cold therapy involves the use of heat or ice packs to help reduce pain and muscle spasm. Heat and cold therapy can be an effective pain reliever for various types of knee pain. There are several methods to use heat and cold to relieve pain and reach maximum effectiveness.

Collaborative Approach in Managing Knee Pain

Behavior modification is a complex process involving awareness, interpretation, decision making, and alteration, and the most effective methods to achieve these changes tend to be specific to the individual. This is where it becomes of great importance to kinesiology and health science students, as well as health professionals, especially those with a musculoskeletal focus, to understand the nature of behavior changes and methods to effectively aid in behavior modification for the various client populations.

Self-management is an ever more popular topic in healthcare today, and with healthcare costs continuing to rise and ever-increasing knee pain largely due to an aging population, it is one that is not likely to disappear. Self-management is gaining popularity because it is a cost-effective approach to managing chronic conditions and health, utilizing the most plentiful health resource: the patient. By the patient performing the various tasks and behavior modifications, it allows for more effective use of clinic time for skilled services, physiotherapy sessions, and decreases dependency on more costly healthcare resources such as surgical procedures and pharmacological management. Self-management has been shown to be effective for a variety of health conditions and in many populations.

With knowledge being the key to change, it is important to assess the patient’s understanding at various points along the way to ensure that they are capable of making informed decisions about their condition and healthcare. This may be done through using various teach-back techniques. Ultimately, arming the patient with knowledge, but there exists a huge void between knowing what to do and actually doing it, and it tends to get information on knee pain in that patient’s hand.

The therapist can use various means to educate the patient, while considering the individual’s learning style and health literacy. These means can include discussion, written materials, and various multimedia sources. Patient education materials may be found on, a website developed by the APTA. Search under symptoms and conditions and access free tip sheets, podcasts, and videos.

The overall goal in the management of knee pain is to prevent it from becoming a chronic condition. By providing the patient with the knowledge and tools to effectively manage and treat their condition themselves, the therapist is enabling them to avert a chronic ailment. This can be done through educating the patient about the nature of their specific condition, potential aggravating and easing factors, prognosis, and potential interventions to reduce symptoms and improve their function. This knowledge can help the patient make more informed decisions regarding their healthcare and its implications, which ultimately can affect their condition.

In the article “Public Health in Physical Therapy”, public health is defined as “function inter, intra et extra individuum” or “function within, between, and among each person”. This definition of public health stresses the importance of feats accomplished. This definition, soon to be published by an expert in the field, recognizes the function of any one person to be what they do, what they are able to do, and functional activities are directly related to the prevention of chronic ailments and diseases. This is an important concept when discussing patient education and self-management pertaining to knee pain or any other condition.

Physical therapists are well known for their expertise in range of motion and strength, and the delivery of exercise and manual therapy interventions to manage musculoskeletal conditions, pain, and physical impairments. Lesser known is the role of physical therapists in the prevention of chronic diseases and conditions. In an effort to effectively meet the needs of the patient, physical therapists customize interventions to enhance the patient’s participation in their plan of care, emphasizing the importance of patient education and understanding for the individual’s overall health.

Role of Physical Therapist

Though the role of a physical therapist in knee osteoarthritis is well established, there is little evidence to illustrate the effectiveness of PT in terms of cost and quality outcomes. It is commonly known that PT with OAK is a lengthy process that may involve many modalities of treatment. With the emphasis of healthcare resources on cost-effective quality care, it is essential for PT to be able to justify the treatment provided to patients with KOA. This involves an examination into problems existing within KOA management and how PT may provide solutions to these problems. This approach can help the physician understand the value of PT for their patients with KOA and take on a more collaborative approach to overall management and potential referrals to PT. By having a more active role in patient care, PT may be able to promote earlier conservative intervention, providing greater benefit to patients in contrast to more invasive procedures and also reduce unwarranted use of narcotics and surgery for end-stage disease. This approach to steer patients toward more conservative interventions is in line with the recent American Academy of Orthopedic Surgeons Clinical Practice Guideline, which strongly recommends using a combination of non-pharmacologic and pharmacologic interventions for patients with symptomatic knee OA. Non-pharmacologic interventions with strong evidence for use in KOA are PT, weight loss in patients who are overweight or obese, self-management, and the use of insoles or bracing. PT may collaborate with physicians to facilitate patient referrals to other interventions and manage these treatments to help patients avoid more severe and costly interventions.

Integration with Other Healthcare Professionals

Traditionally, the most common medical intervention for various knee joint osteoarthritis conditions has been a knee joint replacement for patients aged 60 and older. It is evident that this has changed in recent years to a more conservative management approach for symptoms of pain and functional limitations. A recent study found that the rate of total knee arthroplasty has not increased in the past 15 years, particularly for the population of patients with knee osteoarthritis who are younger and more active. This is a direct reflection of the shift in knee OA management by both patients and physicians to treatments aimed at symptom relief and improved functional mobility, as well as the awareness of the possible risks of joint replacement and minimal age and activity restrictions for participation in various physical therapies. Thus, understanding the perspective of an orthopaedic surgeon for patients with knee OA is important, as it is likely that the orthopaedic surgeon will continue to be involved in managing this patient population with the incidence of ligament or meniscal injuries and to determine the appropriateness of surgical versus conservative interventions. This would include periodic discussions with the patient’s physical therapist to compare subjective and objective findings and functional goals.

Integration of physical therapy with other healthcare professionals in managing knee pain throughout the lifespan is essential to maximize the patient’s function. It has been suggested that physical therapists and primary care physicians are the two healthcare professionals who are seeing an increase in the knee pain population. A closer relationship with the primary care physician and the physical therapist could be the key to improving the quality of care for patients with knee pain. This relationship could facilitate a smoother transition of care for the patient from one healthcare provider to another, timely access to the physical therapist’s services, and appropriate and periodic progress reports on the patient’s status. The progress reports on the patient’s status will enable the physician to determine the appropriateness of continued physical therapy services or if other medical interventions are necessary. In addition, it allows for the opportunity for the physician to educate the patient on the effects of weight loss and exercise in conjunction with physical therapy on knee pain, as an alternative to medication, injections, or surgery. This is important for the patient as evidence of physician support for physical therapy and knowledge of the PT scope of practice is associated with a higher level of physical therapy utilization and lower rates of progression to advanced medical interventions.

Patient Education and Self-Management

The major shift in the current healthcare environment is the adoption of patient-centered care. Involving patients in their own care is a crucial decision. Informed and educated patients are more likely to succeed in managing their own medical problems. Education gives patients a sense of control over their condition – what can be done about it, how, and why. Self-management is the most cost-effective method of improving health. Patient education and self-management are broad terms and can encompass many activities. This may range from encouraging weight loss and regular exercise to having surgery or other forms of treatment, depending on the patient’s condition. But medical treatment decision is also a form of self-management. Self-management support is defined as the provision of psychological, emotional, or practical support to help patients assimilate and manage their own condition. This may be provided by one healthcare professional to their own patients or a patient support may be set up. The objective is typically to improve a patient’s confidence and ability to cope with his/her condition in daily life. Health professionals use a variety of behavioral and cognitive strategies to achieve this. This might involve goal setting, action planning, use of diaries, relaxation training, or learning specific skills such as how to administer an injection. A self-management program is a planned package of interlinked activities designed to enable people to take more responsibility for and active involvement in the management of their own condition. These may be delivered by a health professional or lay tutor. The disparities between patient education and self-management are often unclear and can be seen as a continuum of activities. Both are effective in knee OA and can lead to a reduction in pain and disability. Studies have shown education to be a predictor for self-management program participation, and patients with higher education may prefer self-directed interventions. Higher intensity, more complex self-management interventions are typically suitable for patients with higher disease severity. Self-management programs can affect a large number of outcome measures in knee OA, but the most compelling evidence is that of a reduction in surgical intervention. This is important as surgical procedures are highly costly and generally only provide symptomatic relief, as well as being less effective than they should be in reducing the patient’s overall burden of disease.

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