The Knee Doctor: When, Where and How to get Help

Skiers and snowboarders have emerged from the gloom of the pandemic and made their return to the mountains – the hope is that when they get home again, they bring with them only new memories and new skills, not any new injuries. Here, I thought I’d cover a topic close to my heart, and a frequent source of frustration to those who are injured: how to navigate the system and where and when to get help. Let’s start by looking at some of the more frequently occurring causes of pain and what to do about them. Significant injuries are, fortunately, relatively infrequent and are usually quoted at 1-3 per 1,000 skier days. Knees are the most vulnerable part of the body for skiers, while the upper limbs are most at risk for snowboarders. But what about knee pain that isn’t from a ski accident, but rather is giving you trouble before your ski holiday?

SELF-MANAGING YOUR PAIN

Picture this: your annual trip is in six weeks’ time and your knee hurts. It’s not acute enough to justify a wait at A&E, it’s difficult to get a GP appointment, and a knee specialist is a significant cost. So you do what we all do in this situation – you search your symptoms online and find out that your medial (inner side) knee pain could be meniscus, ligament, fracture, osteoarthritis or knee cap pain. It’s not clear which of these is your diagnosis. Your preferred search engine then presents you with lots of treatment options based on whoever is paying most for their online marketing.

Before you know it you’ve bought a brace, had acupuncture and paid up front for 10 manipulation sessions. You’ve been ‘tricked’ into paying for treatments for a problem that does not yet have a diagnosis, and of which you have no idea of the severity. Can you self-manage? Yes, of course. By all means use online searching, but be aware that it will be rare anyone with expertise is curating the quality of advice

WHAT CAN BE SELF-MANAGED?

Patella femoral pain (typically worse on descent of stairs) is one of the most common knee problems and can, but not frequently, be associated with osteoarthritis. The problem is an overload issue. It can be exacerbated by tightness in the quads and calves. Many people have weakness of the inner quads. The knee may fall inwards due to weak gluteal muscles. It’s more difficult to manage when the protective cartilage is thinner. If swollen, that needs to settle before beginning a strength program. A painful knee on stairs or a flare up of arthritis may respond to simple exercise and a tablet from the chemist. Set a time limit for it to settle of, say, two to four weeks. This principle can be applied to back ache, shoulder impingement and hip pain. The simple stuff should respond within a few weeks, if not, get a diagnosis. Acute injuries need more caution as it is here that the severity of the injury is critical to treatment.

PRINCIPLES TO APPLY:

1. Stop doing the thing that is aggravating the pain. Sorry if this sounds obvious but you’d be surprised how many people continue!

2. Get the swelling under control with ice, rest and over-the-counter medication. Build up a return to activities in conjunction with a stretch and strength program. Nearly all knee, shoulder and hip problems benefit from strengthening. In the lower limb focus on generalised strengthening, such as quads, calf and gluteal strengthening. Just remember to start with easy exercises to test that they don’t flare up the problem.

3. If the problem is not settling you have two paths. First, succumb to the marketing and start buying treatment stuff and scans. Second, get a proper diagnosis.

GETTING A DIAGNOSIS

How do you get a diagnosis? Physiotherapists are probably the specialists who most fit the bill. They are relatively easy to access, and affordable, when compared to surgical specialists and MRI scans. When you see the physiotherapist they should assess you, suggest a diagnosis and an assessment of severity. They should give you a specific treatment plan, estimate how long it will take to get better, and also have a mind as to what point they recommend additional help from a specialist or scan.

If you sustain a serious injury that requires lengthy or surgical treatment, make sure you don’t overlook what’s called ‘late-stage rehabilitation’. This is the final preparation to get ‘match fit’. Psychological recovery is often overlooked. Plan with your treating specialist how to mimic the movements and challenges of your sports, and reintroduce return to the slopes under a very controlled situation. Ski with a coach: I have found that taking my own patients to an indoor ski slope in the UK helps immensely.

FACTFILE

Jonathan Bell is a keen skier and consultant orthopaedic knee surgeon at Wimbledon Clinics. His areas of expertise include treating sports injuries, ligament reconstruction, knee replacement and non-operative management of arthritis. Jonathan founded Wimbledon Clinics where he runs a team of orthopaedic specialists and sports injury experts offering a multidisciplinary approach to keeping the active active.