​Osteoarthritis is the type of arthritis that happens over time as the cartilage layers change over time making them less resilient. Cartilage is the spongy tissue that coats the ends of bones in joints and acts as a shock absorber. Normally, damaged cartilage is constantly being repaired as old cartilage is degraded. When the balance between degradation and repair is thrown off, cartilage thinning occurs. As a result of cartilage thinning, the joint has more friction causing a joint to become inflamed. 

​Osteoarthritis is the most common type of arthritis, resulting from thinning cartilage levels. Rheumatoid arthritis is less common and occurs when the immune system mistakenly attacks the joint lining, causing painful swelling that can eventually result in deformity of the joint.

While there is still much to learn on the subject, some known risks factors include:

• Overweight: increases load through the knee
• Age and gender the older you are
• Gender: women over 50 are more likely to have OA than men over 50
• Genetics
• Trauma: previous injury to the knee, including sports injuries, can lead to OA Knee.
• Repetitive stress injuries: which are usually associated with certain occupations, particularly those that involve kneeling or squatting.  

​Pain is the most common symptom of osteoarthritis, occurring primarily when the joint is moved, rarely at rest. Other symptoms include:

• Limited range of motion
• Crackling sounds
• Stiffness
• Buckling or locking of the joint
• Swelling / inflamed joints

​Our clinicians can diagnose osteoarthritis of the knee based upon the symptoms you are experiencing and through a physical examination. In terms of imaging, x-rays can be done to verify osteoarthritis and show the level of progression in the joint. 

​It depends on the severity. Initial treatment is generally directed at non-invasive pain management. Pain related to joint osteoarthritis may have different causes, depending on the individual and the stage of the disease.

We ensure individualised treatment prescription based on your examination findings. This is best current practice (1).

In general, treatment is

Specific targeted exercise to address, strength, agility, coordination to cushion joints, stimulate healthy cartilage and minimise friction.
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Also included is:

• Health and behaviour modifications, such as patient education, physiotherapy, exercise, weight loss, and bracing.
• Physiotherapy is aimed towards strengthening muscles around the joint and participating in a low impact graded cardiovascular exercise program.

• Treatment options also include medication for pain relief such as anti-inflammatories or Panadol.
• Corticosteroid injections are also an option.
• Platelet Rich Plasma injections are becoming more common place with good outcomes in the short term. The longer-term benefits are still being investigated by researchers.

Unfortunately for some people, especially those whose osteoarthritis is at a more advanced stage, conservative treatment is not enough for a lasting solution.
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When quality of life and makes daily activities difficult to perform then a joint replacement maybe recommended whereby the knee joint is replaced with an artificial prosthesis. This surgical procedure has been shown to reduce pain, enhance quality of life, and improve your ability to perform everyday activities with fewer or no restrictions.

​The anterior cruciate ligament [ACL] plays a vital role in the stability of the knee joint, preventing anterior translation of the tibia on the femur as well as providing rotational stability and preventing excessive hyperextension (Levangie & Norkin, 2011). Movements such as rapid deceleration, hyperextension or sudden rotation place an increased load on the ACL and can result in rupture (Dai et al., 2019). Rupture of the ACL is a highly prevalent musculoskeletal injury in Australia (Lobb, Tumilty & Claydon, 2012). Once ruptured, the surrounding tissue damage and lack of stability have been known to contribute to secondary knee pathologies, such as osteoarthritis and meniscal damage (Ajuied et al., 2013).

Present day knowledge dictates that athletes wanting to return to sport, younger individuals, and patients who experience knee instability despite rehabilitation are likely candidates for ACL reconstruction surgery (Dhillon, 2014). Arthroscopically assisted ACLR using either the patella or hamstring tendon is the standard surgical treatment for patients (Gianotti, Marshall, Hume & Bunt, 2009). Magnussen, Carey and Spindler (2010) found in their systematic review that there is no significant difference in knee stability and strength between those two grafts.
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There is general consensus that physiotherapy plays an important role in the rehabilitation of ACL reconstruction patients to premorbid level of function post-operatively. The rehabilitation progresses essential components of a knee’s function, such as range of motion, stability, neuromuscular control and arguably the most significant: quadriceps’ strength (Cooper & Hughes, 2017). Grindem, Snyder-Mackler, Moksnes, Engebretsen and Risberg (2016) found a 33 per cent re‑injury rate in patients that had less than 90 per cent strength of their non ACLR leg. The challenge during the early stages of rehabilitation is that the graft is undergoing increasing necrosis and hypocellularity, markedly at the centre of the graft, resulting in reduced graft mechanical strength (Janssen & Scheffler, 2013). Despite this, it is vital that this graft and tissue are mechanically loaded, however the level of load is paramount. If the graft is under‑loaded it can lead to significant loss of tensile strength (Ménétrey, Duthon, Laumonier & Fritschy, 2008), whereas conversely, a significant overload of mechanical stress can similarly reduce graft tensile strength (Ekdahl, Wang, Ronga & Fu, 2008).

It is recognised that overloading the graft contributes to graft laxity (Cuomo, Reddi Boddu Siva Rama, Bull & Amis, 2007). ACL graft laxity risks compromising normal knee biomechanics through increased tibial anterior translation and internal rotation, resulting in increased contact stress (Simon et al., 2015). Therefore, ACL graft laxity can significantly contribute to secondary meniscal degeneration, subchondral sclerosis (Kiapour & Murray, 2014) and graft re-rupture (Hewett, 2017). For this reason the open kinetic chain [OKC] versus closed kinetic chain [CKC] approach is heavily debated. It is speculated that OKC exercises (where the distal segment of the limb is free to move) result in increased anterior tibial translation and hence overload the new graft (Escamilla, Macleod, Wilk, Paulos & Andrews, 2012). The use of CKC exercises conversely, (where the distal segment of the limb is fixated) is encouraged in the ACLR rehabilitation process and can be dated back to recommendations made by Henning, Lynch and Glick (1985). It is hypothesised that CKC reduces tibial anterior displacement secondary to co‑contraction of the hamstrings in combination with joint compression forces (Escamilla et al., 2012). CKC exercise is not always practical however. Sigward, Chan, Lin, Almansouri and Pratt (2018) found that an ACLR patient will compensate away from their reconstructed knee through weight distribution for at least 5 months post-operatively during loaded or unloaded squats. This weight distribution coupled with the body’s ability to compensate for weak quadriceps by engaging gluteus maximus and calf muscles to achieve knee extension (Thompson, Chaudhari, Schmitt, Best & Siston, 2013) means that quadriceps’ strength adaptations can be difficult to achieve in CKC. Furthermore Escamilla et al. (2012) showed that a 12-repetition maximum knee extension from 0-90 degrees has comparable, if not less, peak shear forces on the ACL than walking across level ground.

So, to OKC or to not OKC?
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There is a moderate level of evidence to suggest that OKC exercises do not contribute to increased ACL laxity or reduced self-reported function during rehabilitation of ACLR when compared to CKC exercises. There is a significant need for a greater volume of high-quality research to help pilot new guidelines for practitioners of the multidisciplinary team. Until there is strong evidence, practitioners are advised to use clinical judgment and post operative orders as well as take a cautious approach when prescribing OKC exercises during the first 12 weeks of ACLR recovery. Should OKC exercises be prescribed, current evidence suggests they not be used as a replacement to CKC exercises but rather a supplement, and only when the exercise could not be substituted for a CKC exercise.

References:

• Ajuied, A., Wong, F., Smith, C., Norris, M., Earnshaw, P., Back, D., & Davies, A. (2013). Anterior Cruciate Ligament Injury and Radiologic Progression of Knee Osteoarthritis. The American Journal of Sports Medicine, 42(9), 2242-2252. doi: 10.1177/0363546513508376
• Cooper, R., & Hughes, M. (2017). Melbourne ACL Rehabilitation Guide 2.0. Melbourne: Premax.
• Cuomo, P., Reddi Boddu Siva Rama, K., Bull, A., & Amis, A. (2007). The Effects of Different Tensioning Strategies on Knee Laxity and Graft Tension after Double-Bundle Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine, 35(12), 2083-2090. doi: 10.1177/0363546507308548
• Dai, B., Garrett, W., Gross, M., Padua, D., Queen, R., & Yu, B. (2019). The effect of performance demands on lower extremity biomechanics during landing and cutting tasks. Journal of Sport and Health Science, 8(3), 228-234. doi: 10.1016/j.jshs.2016.11.004
• Ekdahl, M., Wang, J., Ronga, M., & Fu, F. (2008). Graft healing in anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 16(10), 935-947. doi: 10.1007/s00167-008-0584-0
• Escamilla, R., Macleod, T., Wilk, K., Paulos, L., & Andrews, J. (2012). ACL Strain and Tensile Forces for Weight Bearing and Non—Weight-Bearing Exercises After ACL Reconstruction: A Guide to Exercise Selection. Journal of Orthopaedic & Sports Physical Therapy, 42(3), 208-220. doi: 10.2519/jospt.2012.3768
• Gianotti, S., Marshall, S., Hume, P., & Bunt, L. (2009). Incidence of anterior cruciate ligament injury and other knee ligament injuries: A national population-based study. Journal of Science and Medicine In Sport, 12(6), 622-627. doi: 10.1016/j.jsams.2008.07.005
• Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L., & Risberg, M. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British Journal of Sports Medicine, 50(13), 804-808. doi: 10.1136/bjsports-2016-096031
• Henning, C., Lynch, M., & Glick, K. (1985). An in vivo strain gage study of elongation of the anterior cruciate ligament. The American Journal of Sports Medicine, 13(1), 22-26. doi: 10.1177/036354658501300104
• Hewett, T. (2017). Editorial Commentary: Increased Risk of Second Ruptures and Poorer Outcomes After Anterior Cruciate Ligament Injury and Reconstruction in Hypermobile Athletes: A Potential Synergism of Passive Ligamentous and Active Muscular Control of Dynamic Knee Stability Related to Age and Sex?. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(10), 1859-1861. doi: 10.1016/j.arthro.2017.07.012
• Janssen, R., & Scheffler, S. (2013). Intra-articular remodelling of hamstring tendon grafts after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 22(9), 2102-2108. doi: 10.1007/s00167-013-2634-5
• Kiapour, A., & Murray, M. (2014). Basic science of anterior cruciate ligament injury and repair. Bone & Joint Research, 3(2), 20-31. doi: 10.1302/2046-3758.32.2000241
• Levangie, P., & Norkin, C. (2011). Joint Structure and Function (5th ed., pp. 405-408). Philadelphia: F.A. Davis Company.
• Lobb, R., Tumilty, S., & Claydon, L. (2012). A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation. Physical Therapy in Sport, 13(4), 270-278. doi: 10.1016/j.ptsp.2012.05.001
• Magnussen, R., Carey, J., & Spindler, K. (2010). Does autograft choice determine intermediate-term outcome of ACL reconstruction?. Knee Surgery, Sports Traumatology, Arthroscopy, 19(3), 462-472. doi: 10.1007/s00167-010-1277-z
• Ménétrey, J., Duthon, V., Laumonier, T., & Fritschy, D. (2008). “Biological failure” of the anterior cruciate ligament graft. Knee Surgery, Sports Traumatology, Arthroscopy, 16(3), 224-231. doi: 10.1007/s00167-007-0474-x
• Sigward, S., Chan, M., Lin, P., Almansouri, S., & Pratt, K. (2018). Compensatory Strategies That Reduce Knee Extensor Demand During a Bilateral Squat Change From 3 to 5 Months Following Anterior Cruciate Ligament Reconstruction. Journal of Orthopaedic & Sports Physical Therapy, 48(9), 713-718. doi: 10.2519/jospt.2018.7977
• Thompson, J., Chaudhari, A., Schmitt, L., Best, T., & Siston, R. (2013). Gluteus maximus and soleus compensate for simulated quadriceps atrophy and activation failure during walking. Journal of Biomechanics, 46(13), 2165-2172. doi: 10.1016/j.jbiomech.2013.06.033