Osteopath Gareth Milner
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''An Osteopathic Treatment for Knee Pain''
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In a typical day at an Osteopathic Clinic, around 2-3 people each day will present with knee pain and injury. Because the knee is a relative unstable joint, allowing a large range of motion, the muscles, tendons, ligaments, cartilage and bursae can get easily damaged. This Blog post is insight into how us Osteopaths approach knee pain and joint dysfunction.
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Gareth Milner's History of Knee Pain ... Gareth first started getting knee problems at the age of 21. During his teens name a sport and he did it. Golf, tennis, rugby, football, judo, cricket. At 15 years old he started heavy weight training. By 17 years old he was squatting 120kg on the smith machine at his school gym. Obviously Gareth didn’t know much about our musculoskeletal system then, and he was pushing his growing body too hard. Regarding squatting he was incorrectly fully flexing his knees, lower than detailed in the illustration below (from his Book Sorry! We're Closed) doing 3 sets of 8 reps with 120 kg on his shoulders. A recipe for knee injury and pain.
Gareth remembers at 21 years old getting knee pain in both knees with swelling visible. They were very sore. He was suffering from tendinitis caused by a patella (knee cap) tracking syndrome, predisposed by flat feet. He improved the situation by holding back on leg weight training, performing daily stretching and orthotic prescriptio. These days at 44 years old, they ache after a long run, but he can still run! From Gareth's experience as an Osteopath, knee pain is so common. Let’s now look at everything about the knee.
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Basic Knee Anatomy & Biomechanics
The knee complex involves the articulation of the femur (upper thigh bone) with the tibia (lower leg bone). The patella bone (kneecap) also articulates with the femur. As the knee joint has to be stable there are many ligaments. Ligaments are stretchy (soft tissue) bands that connect a bone to another bone. There are numerous muscles (shown below) that cross the joint acting to move it in flexion, extension and rotation.
Like all muscles, the knee muscles have an origin (from a bone) and an insertion (to a bone) and this is via a tendon. Tendons join muscles to bone.
Lots of muscles! As Osteopaths, directly or indirectly we are looking to normalise the function of these muscles, reducing the over contraction/ increasing the stretching ability of some and increasing the strength of others. There are many structures of the knee, but in our quest to keep this Blog simple and jargon free, cartilage is the last one we will mention. Cartilage covers all articular joint surfaces. In the knee the femur (upper leg bone) is lined with cartilage, and so is the top of the tibia, which are called the menisci (see image below). Cartilage allows for joint shock absorption and joint mobility.
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Knee Injuries (musculoskeletal disorders)
As an Osteopath, the most common knee injury Gareth sees is Osteoarthritis in patients that are between 50 to 70 years old. Osteoarthritis is simply cartilage degeneration due to the natural ageing process. However we can speed up osteoarthritis of the knee if we weigh too much for our height; over exercise or do the wrong exercises; eat a processed, unhealthy diet; wear footwear that does not shock absorb or wear footwear that puts the foot in a compromised biomechanical position etc.
Osteoarthritis of the knee can be bilateral (i.e. both knees) and can range from aching and stiffness (especially in the morning) to a really swollen knee that aches/ burns at rest and gives sharp pain on use like when get ting out of a chair and walking up/ down stairs. Severe osteoarthritis of the knee is debilitating and can dramatically impair the quality of your life. Luckily orthopaedic surgery for the knee is great in its effectiveness. Gareth Milner remembers as a student Osteopath going to Maidstone Hospital in 2003 to watch a knee replacement. It was pure blood and guts carpentry, but within days the patient would be walking with a dramatic reduction in pain with much improved knee function. However Gareth recommends doing what you can (i.e. keep reading) to never get to this position.
Knee tendonitis is very common also. In osteoarthritis, most of the tendons around the knee will be inflamed, the ‘itis’ part of tendonitis. The most common tendonitis is to the infrapatellar tendon (image to the left). This is common in people who regularly run or practice sport.
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Lastly, trauma is a causation of knee pain. Fractures can happen, especially from skiing or from contact sports. The most common traumatic injury is to the Anterior Cruciate Ligament. This is the ligament Paul Gascoigne ruptured in the 1991 FA Cup Final. He was never the same player again :( For those of you who know football, you can tell who Gareth Milner supports. COYS.
Osteopathic Clinical Assessment & Treatment
From www.nhs.uk/conditions/osteopathy they define Osteopathy as...
Osteopathy is a way of detecting, treating and preventing health problems by moving, stretching and massaging a person’s muscles and joints. Osteopathy is based on the principle that the wellbeing of an individual depends on their bones, muscles, ligaments and connective tissue functioning smoothly together. Osteopaths use physical manipulation, stretching and massage with the aim of:
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Increasing the mobility of joints
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Relieving muscle tension
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Enhancing the blood supply to tissues
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Helping the body to heal
Clinical Assessment
A clinical assessment always starts with a Case History. This includes gathering information from the patient about their symp toms. With a knee pain presentation the Osteopath asks the patient:
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Where it hurts?
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What type of pain is it?
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Aching?
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Sharp on movement?
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Shooting?
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Burning?
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Any locking or giving way?
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How long have they been suffering from this pain?
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What do they think may be causing the pain?
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What makes it better?
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What makes it worse?
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Does the pain vary during the day?
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Who have they consulted about this pain?
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Doctor? Physio?
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Are they taking any pain killers?
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If so, what drug and what dosage?
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Any accidents/ traumas? Etc.
As well as questioning the patient about their knee pain, the Osteopath will also record the patient’s Medical History. Once this has been recorded on the patient’s file the Osteopath will start their physical assessment of the patient. We say 'of the patient’ and not the ‘knee’ as Osteopaths are holistic therapists.
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Here in the left photo Gareth is observing Emma’s right knee, looking for visible signs of swelling, joint deformity, alignment, skin changes and muscle size. As well as the knee he focuses on the biomechanical positions of her feet, hip and pelvis, as well as observing her left knee. This would be the first consultation. During subsequent consultations Gareth would observe her spinal mechanics to see if there were any biomechanical affects from the spine on the knee.
Following this he palpates (feels) her right knee whilst she is seated on the clinic bench. Gareth is looking for any painful points, checking for swelling and specific anatomical structures.
After the observation and palpation (with his findings written on Emma’s consultations file) he then tests the mobility of her knees. First the right knee, with passive knee flexion assessment (middle photo below).
Then Gareth tests knee hyper-extension as shown in the left photo below. In all passive mobility tests the Osteopath is looking for range of movement (is it normal, reduce or increased?) and checking for pain. Then he tests knee rotation as shown in the middle photo below.
Then checking the integrity of her knee ligaments. First the Anterior Cruciate Ligament with the Anterior Drawer Test as shown below.
Then Gareth tests the integrity of her right knee’s Posterior Cruciate Ligament (less commonly injured this one) with the Posterior Drawer Test as shown below.
And then Gareth tests the integrity of the knee’s Lateral Collateral ligaments. With all these ligament tests you are assessing if there is pain and increased joint laxity i.e. is the joint moving too much? Is the ligament damaged?
Gareth then assesses if there is swelling in the knee with the ‘Joint Effusion Test’ as shown in the left photo below. This was positive for joint swelling in Emma’s right knee.
Then personally for Gareth (with his history of knee pain), his least favourite knee test (when it is done on him), the ‘Patella Femoral Grinding Test’ shown in the right photo above. Here he places his first finger and thumb of his left hand on the top of the knee cap, and then asks Emma to push her leg down into the bench i.e. contracting her right leg quadriceps (front of thigh) muscles. In her, there was no sign of cartilage wear behind the knee cap i.e. there was no grinding. Gareth is also checking for the movement of her knee cap to see if it deviates out of its anatomical (i.e. normal) movement pattern when the front of thigh muscles contract.
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​Emma did not report any locking of the knee, but as part of a comprehensive Osteopathic and Orthopaedic Clinical Knee Assessment Gareth tests to see if her knee has any menisci damage with the ‘McMurrays Test’ and the ‘Apleys Test’.
And lastly Gareth tests to see if there are any loose bodies (bits of bone and/ or cartilage) floating around in her knee with the ‘Bounce Home Test’ shown in the photo below left.
As you can see this is a comprehensive assessment of the knee. This takes around 10 minutes, and is what Orthopaedic Consultants should perform if you ever have the misfortune of seeing them i.e. you have a very painful knee injury. The Osteopath should question whether the knee is amenable to Osteopathic treatment. Does the patient need referring to their Dr/ an Orthopaedic Consultant/ a Podiatrist for specialist orthotics, or all three Professionals.
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​In Emma’s case she did not complain of knee pain, and has no history of knee pain. She has a moderate somatic dysfunction in her right knee due to contracture (shortening) of her right quadriceps which is affecting the tracking of her right knee cap. This would be the cause of the biomechanical irritation of her knee joint, and the subsequent swelling.
As Osteopaths, we are obsessed with looking at the whole. In the first treatment Gareth would always keep to treating the right leg with a focus on the knee, however on subsequent treatments he would look at whole body biomechanics to see if there were any areas/ joints that were negatively impacting her right knee. Osteopaths use the following ‘hands on’ manual techniques:
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Soft tissue massage (to muscles, ligaments, tendons)
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Myofascial Trigger Pointing (to muscles)
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Joint Articulation & Oscillation
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High Velocity Thrust Joint Manipulation (the technique with the audible ‘crack’)
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Muscle Energy Techniques (stretching the muscles)
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Passive Muscle Stretching
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Fascial Release
And then passive lateral (external) rotation knee articulation by fixing her upper leg with his left hand and gently moving her tibia (lower leg bone) laterally with his right hand. Gareth then articulates her right knee using the lateral gapping articulation as shown in the 2 photos to the left.
Then passive flexion and extension articulation of her knee shown directly above. This helps with draining the knee of excessive fluid. As shown in the far right photo above, Gareth is applying a stretch or as us Osteopaths put it ‘traction’ to her right leg. This helps to decompress the knee, allowing drainage of excessive fluid.
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Then prone (lying on her front) cross-fibre massage of the hamstrings (below right) and direct Neuromuscular Technique to the hamstrings (far right photo below).
Tension, contracture and dysfunction of the calf muscles is directly related to knee pain and dysfunction, so Gareth applies soft tissue techniques to Emma’s right calf muscles (shown in the photo below left).
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​As her right Piriformis muscle (image below right) was tight, Gareth applied a passive stretch to this muscle by moving the hip joint (moving the lower leg outwards away from the bench) as shown in the middle photo below.
At the European School of Osteopathy where Gareth Milner achieved his Bachelor of Science Degree in Osteopathy, he mastered the broadest range possible of Osteopathic Techniques. In the photo below left, he is applying Muscle Energy Technique to Emma's right quadriceps. In the photo below right, Gareth applies Muscle Energy Technique to her hamstrings. These are very effective techniques to lengthen muscles and improve musculoskeletal function of joints.
As Emma has a long history of running, her IT Band (shown in the image above right) is very stiff, and is treated with a technique (photo below left) involving her right leg being crossed over the left leg, and by fixing the left side of her pelvis with his right hand, Gareth brings her legs off the bench with his left hand. This is also a great stretch for the lower back; in this case the right side of her lower back.
To finish the Osteopathic treatment Gareth Milner applied a High Velocity Thrust Technique to realign her right fibula bone (shown in the image to the right). This manipulation is a side lying technique with her right leg lying straight on top of the flexed left leg.
2 useful Electrotherapy machines Gareth also uses are Therapeutic Ultrasound (below left), to stimulate the body’s healing cells, and Interferential (middle photo below with suction cup applicators and right photo below with electrode applicators) to reduce pain and stimulate muscle activity.
Electrotherapy has its place, but nothing can beat Osteopathic Manipulative Techniques.
As this Blog has been titled An Osteopathic Treatment for Knee Pain the final section will be short, and you can find as much information about these subjects as you want on the internet.
Medical Therapy
Traditional Medical Therapy would be to consult a Physiotherapist; who are within the Professional world of Physical Therapy, like Osteopaths and Chiropractors. Drug therapy would involve Non-Steroidal Anti-Inflammatories (NSAIDs) including Ibuprofen, Voltarol and Naproxen. If the pain is severe, like for example when on a waiting list for Knee Replacement surgery, the opiate Tramadol would commonly be subscribed by your GP or Orthopaedic Consultant. Surgery should always be the last resort. Key hole surgical interventions can be very successful. Knee Replacement surgery will always be when there is basically ‘bone on bone’. Ouch. Getting Osteopathic Treatment in early is the upstream prevention.
Rehabilitation Exercises
Crucial if you want your knee to get better. A daily 20-30 minute combination routine of muscle strengthening, muscle stretching (also using Therabands), leg muscle trigger pointing with a foam roller will work best. Check out Gareth Milner's prescriptive Rehabilitative Exercises here as well as The Pain Free Podcast with Osteopathic Solutions Team Member and Osteopath Jonathan Simmonds here.
Nutritional & Supplement Treatment
Having a balanced diet with lots of different fruits and vegetables, low fat meats and fish is recommended to keep your weight in a healthy zone. Being overweight simply loads your knees more, and speeds up cartilage degeneration. Gareth Milner recommends supplementing with Omega-3 Fish Oil and Glucosamine/ Chondroitin each day.
Healthspan UK and Holland & Barrett are Gareth's go-to suppliers.
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That’s enough I think for supplements, we can take too much!
Complementary Therapies
Many people get significant benefit and relief from Acupuncture. With any musculoskeletal disorder, as a qualified Osteopath, coupled with the Expert knowledge of human biomechanics, Gareth would always recommend you visit an Osteopath first before going for Acupuncture. Acupuncture allied with Osteopathy would be an excellent approach to getting your knee better.
Podiatry is an essential with chronic knee pain. The prescription of custom fit Orthotics can have an immediate and dramatic effect on improving knee function and reducing pain. Check out The Pain Free Podcast where Gareth interviews a Podiatrist.
