A topic that is often raised when exercising, but also can be exacerbated by treatment and/or menopause. Hannah explores the topic in more detail, following her Member's clinic session in January.
What is knee pain?
Did you know, the knee is the largest joint in the human body?
Did you also know it is considered to be one of the weakest? This is due to its weight-bearing function and complex structure! Knee pain is the second most common musculoskeletal complaint, after back pain (Khan, 2020).
Knee pain can occur suddenly (an acute injury) or can develop slowly over a longer period of time (chronic pain). You may experience knee pain in just one knee or in both sides.
What causes knee pain?
There is an extensive list of reasons that someone may experience knee pain, due to the complex structure of the knee joint and the many soft tissues (muscles, tendons and ligaments) that surround it.
The most common general causes of knee pain are ageing, injury and repetitive stress.
It is very important to get the right diagnosis, in order to understand knee pain and manage it appropriately. Your GP or physiotherapy will be able to assess and explain what is causing your pain. They will refer on for further investigations if these are needed.
Osteoarthritis is the most common diagnosis for people aged over 45 and experiencing knee pain is osteoarthritis (Khan, 2020).
Patellofemoral pain is another common cause of knee pain, found in around 22.7% of the population (Smith, 2018) - that’s one in four people! It is twice as common in women (Boling, 2021).
Local causes of knee pain refer to problems within the knee structure itself. Examples of this may include:
Osteoarthritis.
Injury e.g. muscle strains, fractures, anterior and posterior cruciate ligament injuries, meniscal injuries, medial and lateral collateral ligament injuries, quadriceps or patellar tendon rupture, patellar dislocation.
Tendonitis (inflamed tendon) e.g. patellar tendonitis.
Patellofemoral pain e.g. “runners knee”
Patellar subluxation.
Bursitis (inflamed bursa) e.g. prepatellar bursitis
Regional causes of knee pain refer to issues in the lower limb and nearby joints, which can include:
Complex regional pain syndrome (form of complex chronic pain that affects one limb)
Referred pain from hip or lumbosacral spine e.g. osteoarthritis of hip
Systemic causes are conditions that usually affect multiple joints or areas of the body and may include:
Joint hypermobility syndrome.
Inflammatory conditions e.g. osteomyelitis, gout, rheumatoid arthritis, ankylosing spondylitis.
What can I do to support my knee health?
It is important to incorporate strengthening and stretching into your routine, in order to take care of your joints. Since your knee is one of our main weight-bearing joints, maintaining strength is essential to optimal functioning and injury prevention. The tables below give some examples of strengthening and stretching exercises to try:
Exercise | Position | Weight |
Squats | Standing Chair | Bodyweight Dumbbell Kettlebell Barbell Weight plate Resistance band |
Single leg squats | Standing Chair | Bodyweight Dumbbell Kettlebell |
Monster walks | Standing | Bodyweight Resistance band |
Bridges | Lying | Bodyweight Weight plate Resistance band |
Straight leg raises | Lying | None Resistance band Ankle weight |
Knee extensions | Sitting | None Resistance band Ankle weight |
Hamstring curls | Standing Lying | None Resistance band Ankle weight |
Hip abduction | Standing Sitting | None Resistance band Ankle weight |
Stretch | Position | How? |
Hamstring stretch | Standing Sitting Lying | Standing stretch, lying with band, downward dog, forward lean in chair, happy baby |
Quadriceps stretch | Standing Chair Lying | Prone knee flexion, standing knee flexion, seated knee flexion, |
Iliotibial band stretch* | Standing | Crossed leg side lean, crossed leg wall lean, |
Hip flexor stretch | Standing Prone lying | Deep lunge, seal pose, cobra pose, standing hold, prone knee and hip flexion. |
Gluteal stretch | Standing Sitting Lying | Piriformis stretch, knee hugs, pigeon pose, |
Adductor stretch | Standing Lying | Tree pose, wide child’s pose, |
Calf stretch (gastrocnemius) | Standing | Weight through front knee |
Calf stretch (soleus) | Standing | Weight through back knee |
Commonly asked questions around knee pain
My knees hurt when I do high impact activities such as running - what can I do to help?
High impact activity puts increased pressure through your joints and may exacerbate joint pain. Examples include: running, netball, tennis, jumping jacks, squat jumps, burpees, etc.
While we can find ways to manage knee pain in order to run further, pain is generally our body’s way of telling us it is unhappy with something. Staying active is very important, but finding alternative ways to exercise that put less stress through the joint is vital to maintain bone and joint health.
You may consider wearing a knee brace during high impact activity to support your knee, but there is little evidence to support that this is physiologically beneficial. There is some evidence to support kinesiotaping as a way of supporting joints during higher impact activities.
Low impact activity is a more controlled form of exercise that puts less pressure through your joints and may be a better choice when experiencing increased knee pain. Examples include: walking, swimming, cycling, rowing, yoga, resistance/weight training, etc.
Mix up your exercise styles, to maintain your cardiovascular fitness and minimise stress through your knees.
How to manage knee pain when taking hormone blockers for breast cancer?
Hormone therapy and aromatase-inhibitors (AIs) affect the hormone levels in the body and cause physiological changes. AIs reduce the amount of oestrogen to prevent certain breast cancers from growing. Oestrogen plays many important roles, including bone health and remodelling; with lower levels of oestrogen, joints and bones can cause more discomfort and pain.
Approximately 50% of those on AIs report new or worsening joint pain by 1 year after starting their treatment. Only 50% remain fully compliant with AI after 3 years, as treatment is discontinued due to their symptoms.
For this reason, it is important to find ways of managing aches and pains, in order to tolerate your full prescription of hormone therapy.
Research by Gupta et al. (2020) has found that the antidepressant duloxetine reduced aromatase-inhibitor pain in 70% of treated patients. Other pharmacological options may include non-steroid anti-inflammatories (NSAIDS), steroid injections, bisphosphonates or changing AI medications. It is important to discuss this with your oncology team, who will be able to recommend the best options for you.
Non-pharmacological options include hot and cold therapy, massage, strengthening/stretching and a recent guideline (Long et al, 2022) made a strong recommendation for acupuncture in breast cancer patients to relieve aromatase-inhibitor induced joint pain.
See last month’s blog post for more information: https://www.getmeback.uk/post/joint-pain-and-cancer
I am experiencing cramping in my legs during chemotherapy, what else can be done?
Some chemotherapy drugs are more likely to cause aches and pain in the joints. Around 86% of people on taxanes report experiencing joint or muscle pain. This is known as TAPS (Taxane Acute Pain Syndrome), which usually starts around 2 days after receiving chemotherapy and can last up to 7 days.
A study by Asthana et al (2020) found that most people experiencing chemotherapy-induced pain describe it as “aching”, with words such as “burning” and “sharp” occasionally being used in the later stages of treatment. This may suggest that there is initially an inflammatory component, occasionally followed by neuropathic (nerve) pain. Both these types of pains require different pharmacological and non-pharmacological management.
Recent preliminary evidence (Smith et al, 2020) also suggests that the antihistamine loratadine may help reduce the severity of aching legs during chemotherapy.
Stretching, heat therapy, massage, acupuncture, relaxation and pharmacological options are all important to explore.
Keeping well hydrated, staying warm and avoiding sudden movements can prevent triggering of muscle cramps. Adapting exercise or trying activities such as tai chi and yoga, which are controlled, may be beneficial.
It is important to discuss this with your oncology team, who will be able to recommend the best options for you.
Where do I start to find a physiotherapist to help?
GP referral to NHS Physiotherapy
Booking an appointment with your GP and requesting a referral to your local NHS Physiotherapy Service for joint pain is the most common option. Waiting times are generally longer but are variable depending on where you live. The musculoskeletal physiotherapists you see may not have experience with oncology.
Self-referral to NHS Physiotherapy
You may be able to complete your own referral to your local physiotherapy service. Self-referral is suitable for routine musculoskeletal issues like joint pain; your GP practice will be able to tell you whether self-referral is an option in your area.
Direct referral to NHS Physiotherapy
Some physiotherapists work in GP practices as a first point of contact. This means you can book an appointment directly with a physiotherapist at your GP practice, without the need for a referral to a separate physiotherapy service. Your GP practice will be able to tell you whether direct referral is an option in your area.
Private Physiotherapy
Private physiotherapy will allow you to be seen quickly and with more flexibility, e.g. choosing a convenient location, choosing a clinician with specialist knowledge, etc. This may be self-funded or insurance funded.
Physio2u | The Chartered Society of Physiotherapy (csp.org.uk)
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