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Knee Pain in Athletes: Rehabilitation Protocols with Singaporean Specialists

The causes of Asian knee pain are varied. Knee pain can be acute or chronic. Acute knee pain is often caused by recent injury, while chronic knee pain usually creeps up over time due to an underlying knee condition. Chronic knee pain is prevalent in all age groups, but can be seen more often in older adults. It’s not surprising that arthritis, an ailment generally associated with old age, is seen in 70% of persons over 70 years. Another group with an increased risk for knee pain is athletes, as they are more likely to sustain an injury to the knee due to increased activity. A study conducted in Singapore has shown that knee pain is the most common injury athletes experience. It is a problem as it often affects an athlete’s performance and requires temporary or complete withdrawal from sports. Due to these reasons, both old age and increased injury rate in athletes, it is important to have an effective strategy to treat knee pain. Rehabilitation is an important step to curbing knee pain. It is defined as the process of restoring the normal state or condition after damage or injury. This may involve encouraging tissue repair, or simply getting the individual back on their feet. The latter stage is very much true for an athlete who has experienced an incident of acute knee pain. They will likely want to return to their previous state of performance, and failure to do so may be a result of inadequate treatment. The overall goal of rehabilitation is to improve quality of life, and this can be related to many forms of knee pain. For example, an elderly person with chronic knee pain may view an improvement as being able to walk to the shops and back with reduced pain. A competitive team sportsman recovering from knee surgery may view an improvement as being able to begin training again with his team.

Understanding Knee Pain in Athletes

There are many good biological reasons to be concerned about knee pain in athletes. When we consider that many sports result in an unusually high number of knee joint injuries, it becomes clear that many young athletes are doing great damage to a very important tissue. Knee pain in athletes can be caused by trauma, overuse, or other underlying conditions (such as infection or arthritis). In any case, it is always a serious injury when an athlete cannot perform their usual activities. For knee pain related to a specific trauma, the athlete can at least identify when and how the injury occurred. But for chronic overuse type injuries, the athlete may just begin to notice pain in the knee without a specific incident that caused the pain. This distinction can be very important when considering treatment for the injury.

Importance of Rehabilitation Protocols

Rehabilitation is defined as the process of returning an injured person to a previous status of well-being through the use of physiotherapy and other protocols. It has been widely emphasized in the treatment of sports injuries, including anterior cruciate ligament (ACL) reconstruction of the knee. There are two basic types of rehabilitation that occur after knee surgery. The first is traditional supervised physical therapy, in which the patient works with a physical therapist for less than an hour, two to three times a week for several weeks. The second type of rehabilitation is home-based, in which the patient performs specific exercises without the direct supervision of a physical therapist. Once rehabilitation has been completed, the patient’s ability to return to pre-injury status of well-being is evaluated. High levels of patient satisfaction and return to sport have been reported after the utilization of postoperative protocols for ACL reconstruction. This will include an accelerated program beginning 6 weeks after arthroscopically assisted ACL reconstruction using the patellar tendon technique, comparing the effectiveness of the program with previously reported findings using the same type of reconstruction.

Rehabilitation Techniques for Knee Pain

There are many methods used in rehabilitating knee pain. These could include improving flexibility in the hamstring and quadriceps muscles, increasing the strength, endurance, and reaction time of the muscles that support the knee, and normalizing muscle imbalances. Manual therapy techniques could be utilized to reduce any knee pain and improve the range of movement of the knee and surrounding joints. Electrotherapy modalities have been used in the effort to reduce pain and swelling in the knee and accelerate the healing process. An example of this is the use of TENS (transcutaneous electrical nerve stimulation) to help control pain, or ultrasound to encourage soft tissue healing. These treatment methods are particularly useful in specific cases of knee pain. Again, the effectiveness of such treatments has been observed in a study comparing muscle stimulation and exercise against muscle stimulation and no exercise in a group of Osgood Schlatter’s disease patients, showing the former group having significantly better strength and functional performance measures.

Physical Therapy Exercises

Therapeutic exercise is one of the primary interventions for the goal of restoring normal joint motion, strength, and flexibility around the knee complex. McConnell taping (figure-of-eight wrap) has been demonstrated to be effective in improving vastus medialis obliquus activity, which has been shown to improve symptoms and slow the rate of joint space narrowing in patellofemoral pain patients. Isometric and isotonic quadriceps strengthening exercises at the terminal range with the knee extended are used in an attempt to avoid exacerbating anterior knee pain. Isotonic hip abduction and external rotation exercises with the knee flexed have been shown to strengthen the hip musculature and facilitate an increase in lateral trunk displacement, which is associated with a reduction in varus moments at the knee. This may reduce symptoms and disease progression in knee osteoarthritis. Exercise has the added benefit of addressing the numerous identified risk factors in the development of knee pain and osteoarthritis in athletes. These include obesity, previous knee injury, poor fitness, and intrinsic anatomic factors. High levels of strength and intrinsic factors such as increased joint stability or improved congruence associated with specific functional sports movements may increase the risk of a higher joint surface load in certain areas. This leads to the development of symptoms around these joints and indicates that the matched joint surface contact and relative joint stability for specific activities are points to be considered in conditioning and retraining athletes with knee pain.

Manual Therapy Techniques

There are many manual therapy techniques which can be used to treat knee pain. Transverse friction massage (TFM) is a specific technique which can be used to maximize the healing process of the athlete. Cyriax described TFM as a method to treat tendon and ligament injuries. The main purpose is to put stress on the specific tissue, which will cause a local inflammatory response. This, in turn, will promote absorption and removal of the irritant and will initiate a phase of repair. On the cellular level, TFM causes fibrillation and disruption of the tendon, which starts the healing process. TF massage has also been shown to prevent adhesions from forming and disrupting normal gliding of a tendon or tendon sheath over its associated joint. TF massage must be done within pain limits of the athlete, and a treatment of 7-10 minutes is necessary to provoke a new inflammatory response. Shorter treatments will perpetuate the cycle of inflammation, and longer treatments may cause hypersensitivity in the area.

During this phase of rehabilitation, physiotherapists use their hands to alleviate muscle tightness and improve soft tissue extensibility. The basic premise of manual therapy is to restore mobility and improve the tissue extensibility, which in turn will allow the athlete to continue with their exercise program. The goal of manual therapy is to produce a desirable change in soft tissues and joints, which can affect range of motion, strength, and restore optimal function.

Electrotherapy Modalities

Various electrotherapy modalities are used as part of rehabilitation of athletes with knee injuries. These include Transcutaneous Electrical Nerve Stimulation (TENS), iontophoresis, high-voltage pulsed galvanic stimulation, and interferential therapy. Low-rate (2 pulses per second) TENS produces an endorphin-mediated analgesic effect which can be useful in managing pain. It is unlikely to have any positive effect on muscle strength or reduce atrophy. High-rate TENS and acupuncture-style TENS are not recommended as they have been found to cause muscle contraction which may exacerbate pain and inhibit recovery. Both iontophoresis and high-voltage pulsed galvanic stimulation have been found to be ineffective at producing any physiological effect on soft tissue and therefore cannot be recommended. Interferential therapy may potentially have an effect on pain reduction and increasing blood flow but despite its widespread use, there have been no research studies published on its effects in the treatment of sports injuries. The most researched electrical modality is neuromuscular electrical stimulation (NMES). NMES is the application of electrical stimulation to the skin in order to produce a muscle contraction. It is used to prevent muscle wasting, maintain or increase muscle strength. This is of great importance to athletes with knee injuries as quadriceps muscle atrophy is common and has been shown to be a predictor of poor outcome. NMES has produced positive results in both preserving the size of the quadriceps muscle and increasing the strength of the muscle in patients with anterior cruciate ligament (ACL) injuries. These patients have also shown a decrease in the amount of atrophy and strength deficit when NMES has been applied in conjunction with traditional rehabilitation including knee exercises.

Singaporean Specialists for Knee Pain

Singapore boasts some of the highest educated and quality knee pain specialists in the world. The Singapore General Hospital (SGH) has an Academic Medicine Centre (AMC) designed to better link teaching and research to enhance the quality of patient care and training for healthcare professionals. This provides great benefit to the patient with the law that the more educated a doctor is, the better care and advice he can provide. Due to this AMC, SGH is also linked with the National University of Singapore, which is a college with no small achievement in the global university ratings. With such high education standard, there may even be Singaporean knee pain specialists with an interest in knee injuries who have also been athletes themselves. This creates an empathy and understanding between doctor and patient that is a necessary bond for the best possible care.

The setting up of an appointment with a knee pain specialist is, doubtlessly, the most intelligent move to make if you want a real answer and fix to your knee pain. There are numerous experts in knee pain Singapore who can aid you in your journey to a back to full fitness, some of which have their own personal experience with treating athletes. Some athletes will have sustained injuries serious enough to require a surgical opinion. Many knee problems in athletes do not require surgery and can be treated by conservative means. A Singapore Sports Medicine Doctor with an interest in knee injuries, Sports Physiotherapist, or Sports Orthopaedic Surgeon would be able to help in making this assessment. They will also be able to help you better understand the nature of your injury and the treatment options available. A good understanding between both the patient and the knee pain specialist is crucial in obtaining the best possible treatment for the knee problem.

Finding the Right Knee Pain Specialist

The sports physician is often the first medical contact for an athlete with knee pain. In the public sector in Singapore, referral to a knee pain specialist typically begins with a visit to a primary care physician at a polyclinic. On provision of a referral, the patient will then attend the appropriate outpatient clinic at a restructured hospital. If the knee pain is non-acute and does not require an immediate surgical opinion, the patient may be referred to the AHP. For a sports-related injury, the athlete may seek care directly from a sports physician either in the private or public sector. These various entry points into the medical system make it somewhat confusing for a patient with knee pain to find the most appropriate specialist. This issue is exacerbated by the fact that many mild to moderate knee problems can be effectively managed by a primary care physician or a sports physician. This can lead to an overload of the more specialized services and over-referral of patients with conditions that do not require specialist intervention.

Knee pain is a significant source of morbidity in the community. In athletes, it can significantly impact performance and even end careers. The treatment of an athlete with anterior knee pain will depend on the correct diagnosis being made. The complexity of the differential diagnoses and the often subtle findings seen on physical examination make this a challenging problem for the sports physician and surgeon.

Qualifications and Expertise of Singaporean Specialists

Singapore is rich with a variety of healthcare specialists. A great number of local sportsmen and women who have suffered from higher degree injuries such as ACL tears or knee joint dislocations may choose to seek treatment in Singapore considering the presence of well-qualified orthopaedics and sports medicine doctors. For those who may not have too much knowledge on specialists, they need to have at least very good qualifications and be experienced for the job. “Just because a specialist charges more, does not mean he is more experienced,” stated by Dr Wong Hwee Jong, head of orthopaedic department in the Singapore General Hospital. Dr Wong has been an orthopaedic surgeon for more than 20 years and his specialty lies in knee and shoulder surgery. This is not confined to orthopaedic surgeons, sports medicine physicians are required to go through the mainstream medical training before sitting for the membership exams hence having internal medicine qualifications. An example would be former Singapore national sailor and team doctor for the US Sailing team to the Beijing Olympic Games, Dr Ben Tan, who is currently the chief of sports medicine in Changi General Hospital. He has represented Singapore in sailing for many years and was team doctor for the Singapore Sailing team to the 1996 Atlanta Games. Both Dr Wong and Dr Ben Tan are members of the Singapore Sports Medicine Centre and have co-published the Singapore Sports Medicine Book. Their academic qualifications play a significant role in their expertise with athletes because sports medicine is not only about the treatment of sports injuries but promoting exercise and good health. An additional quality that athletes will feel at ease with is good communication. Dr Low Whee Siong, a consultant orthopaedic surgeon, Mount Elizabeth Hospital, had experienced minor knee injuries while playing hockey for the national U21 team. He revealed that the injury experience enabled him to understand patients much better and his patients have always given feedback that he is easy to talk to. This means that athletes are better able to express how the injury has affected them. Communication may not necessarily come from personal injury experience but having a keen interest in sports. Dr Kevin Lee, an orthopaedic surgeon trained in Melbourne, has worked with Melbourne Storms rugby league team and AFL teams such as the Collingwood Magpies and Melbourne Demons. His explanation for working with athletes was having a special interest in sports injuries and wanting to make a difference in these players.

Rehabilitation Centers and Clinics in Singapore

For those who can afford it, the higher level of care that an athlete would seek in Singapore is available in private physiotherapy practices. These practices offer much higher quality care with longer one-on-one sessions with a physiotherapist and more advanced therapy options. An example is the Physiotherapy Associates Clinic, which offers specific sports rehabilitation and has close ties to the American College of Sports Medicine. Other advanced options for sports therapy and rehabilitation are available in private sports clinics, such as the Singapore Sports Medicine Centre (physician supervised), and at facilities like the former Woodlands Stadium, which has a comprehensive rehabilitation program for athletes including access to medical and sports science experts.

Patients in search of knee pain rehabilitation in Singapore have NGO clinics and polyclinics available to them. These clinics offer more affordable care to citizens and permanent residents in Singapore, compared to the private sector. However, these clinics may not provide the level of specialized care that an athlete would require. Since athletes are looking to return to a high level of activity, public sector rehabilitation may have significant limitations. Physical therapy sessions at polyclinics may be brief and focused on basic exercises without specific progression towards sport-related goals. The wait time to get these sessions at polyclinics may also be long due to the high demand for basic healthcare in Singapore. While these clinics may be suitable for Singaporeans with low activity levels and non-athletes, they are not the best option for someone aiming to return to sport at a high level.

Case Studies and Success Stories

No athlete will ever forget the moment of injury. For a senior national basketball player, the seconds seemed like hours. Confined to the four corners of the basketball court at the fifth and decisive game against China, she had been dribbling the ball down the right wing before executing a swift cut into the semi-circle and attempting a jump shot. That was when she felt a sharp pain deep inside her left knee which caused her to collapse onto the floor. Diagnosis revealed a rare knee condition, Osteochondritis Dissecans (OCD) which led to a loose body in her knee joint and an articular cartilage injury. It was a season-ending injury and required surgery as the loose body had to be removed. The recuperation phase for OCD is long, in order to prevent further damage or degeneration of the knee joint and to reduce the risk of osteoarthritis. Post-operation rehabilitation usually takes about 4-6 months as the cartilage has poor healing potential. Initially, she was devastated and would stay indoors all day, brooding over the fact that she could not represent her country in the upcoming SEA games. With time and the encouragement of friends and family, she gathered her spirits and decided that she would strive to return to play international basketball. She adhered closely to the physiotherapy and rehabilitation protocols and her effort paid off. Today, she has staged a successful comeback and has donned national colors again. Although there is still occasional pain in her left knee, it is a remarkable story given the severity of her knee condition.

Athletes’ Experiences with Rehabilitation Protocols

After surgery with the course of action decided between Tarryn and his physiotherapist, he progressed through his rehabilitation at a rate faster than expected, as the muscles around his knee were stronger than predicted. This took him back to the surgeon earlier than expected for a progress assessment of his knee.

Tarryn: I spent a lot of time researching methods to optimize my knee online and found some very helpful articles from recent medical journals. I would then bring this info to my physiotherapist and discuss its relevance to my own rehabilitation. I found the stuff that I was learning really interesting, probably due to the fact that it was involving me and what I was passionate about. I think this made my determination levels that much higher to get back on the field.

Tarryn (a rugby player) had an extremely high motivation to return to playing rugby, and although his rehabilitation process was a difficult time for him being told to rest his leg as much as possible, he put all his energy into trying to find the latest and most relevant information about ACL rehabilitation. He was determined to become well informed about his condition and participated in making the best possible decisions about his own treatment.

Saji: Coming to the end of my brace phase, my flexibility increased, and I felt that my knee was stable. I started a lot of closed kinetic chain exercises and plyometric drills. This improved the general strength of my knee and the endurance of the muscles around the knee. At that time, I also felt that my knee was able to handle the stress of playing squash. I then moved into the functional phase of exercises where I had to do a lot of movement drills on court, and it was during this phase that I felt that my knee was at its best.

Saji (a squash player) had a surgical reconstruction for his ACL injury and started his rehabilitation process with his knee wrapped in a brace. It was around this time he started his undergraduate studies in Physiotherapy at Nanyang Technological University.

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