Q I am a 45-year-old man. I had a bike accident 25 years ago and bruised my left knee badly.
I recovered but injured my knee again while playing squash and suffered a third-degree ligament tear. An arthroscopy was done and floating meniscus was removed.
I started doing a lot of elliptical fitness crosstrainer (EFX) and built up my hamstring.
In the past year, my knee has been hurting when I climb the stairs and I feel the strain on my lower back.
I have put on a lot of weight recently. I am 86kg and 173cm tall. How can I improve my condition without surgery?
A From the description of your previous injury, it is likely that you may have injured your anterior cruciate ligament (ACL).
It is commonly injured in sports activities involving pivoting movements such as rapid changes in direction.
The majority of ACL injuries do not occur in isolation and are commonly associated with concomitant injury to the meniscus.
Those with ACL deficiency or tears are usually able to tolerate straight-line activities like jogging and running.
However, they usually complain of instability when it comes to pivoting movements involving rapid changes in direction.
Meniscal tears are not necessarily symptomatic unless they are unstable or of a significant size.
Common complaints related to meniscal tears include pain and symptoms of locking.
The meniscus are very important structures in our knee joints, their major role being load distribution across the joint surfaces.
Historically, the treatment involves removal of the whole affected meniscus (total meniscectomy). This almost always leads to rapid degeneration of the articular cartilage due to loss of the load- distribution mechanism.
Unfortunately, I do not have any information on the extent of your meniscal injury and how much of the meniscus was resected during your surgery.
I'm concerned that you may have early osteoarthritis (cartilage degeneration and wear) which could explain your current symptoms.
The focus of non-surgical management for early osteo- arthritis is to optimise the bio- mechanical stability of the knee joint by strengthening the dynamic knee stabilisers, including the quadriceps and hamstring muscles. This will significantly reduce the shear stresses across the knee joint.
The exercises should involve closed-chain exercises (cross trainer machine, stationary bicycle) in order to minimise stresses that will further deteriorate the affected knee joint.
It is common that the muscles supporting the knee, including the quadriceps, hamstring and gluteus, become weaker after surgery.
This may explain why climbing stairs is painful because the muscles cannot cope with that activity.
The loading to the lower back will increase when your legs are not stable and strong.
The post-op rehabilitation programme needs to focus on building up the maximal strength and increasing muscle bulk around the knee.
The aim of rehabilitation is to ensure the muscles are strong enough to support the knee when doing any functional activity or sports. It is also to prevent further overloading of the remaining meniscus.
Doing the crosstrainer helps to build up cardiovascular fitness. It is a general whole-body strengthening exercise, hence it may not be sufficient to build up key muscles around the knee.
A holistic strengthening programme has to build up the quadriceps, hamstring and gluteus muscles, not only the hamstring.
The programme also needs to include proprioceptive exercises such as balancing on a wobble board to restore the knee joint sense and stability.
Do seek further advice from an orthopaedic surgeon to evaluate the extent of your injury so that an appropriate and effective physiotherapy programme can be formulated for your condition.
Dr Henry Soeharno
Consultant in the department of orthopaedic surgery at the Singapore General Hospital
Ms Khoo Shin Jiun
Senior physiotherapist at the Singapore General Hospital