How To Treat A Knee That Gives Out

Learning how to treat a knee that gives out involves building strength in the muscles around the knee, including the calf, quads and hamstrings, whilst also building balance in both standing and the sporting or activity positions that you want to get back to being able to do. We do this through balance progressions and sport-specific drills.

All of which we discuss below.

What causes a knee to give out?

It is always multifactorial, involving a mixture of local variables to the knee, and system wide variables.

Local variables include prior trauma that may have caused injury to the medial patellofemoral ligament leading to laxity in the ligament or even rupture, injury to other ligaments, possible injury to the chondral surfaces (called an osteochondral lesion), or significant weakness of the surrounding muscles (Post et al., 2018).

Systemic variables include fear avoidance around loading the knee during activities or positions.

Changes in emotional and pain processing areas in the brain in people with patella instability have recently been documented compared to people with no instability or knee pain (Kadowaki et al., 2017). In people with patellofemoral pain, kinesphobia (fear of movement) is associated with increased neural activity in certain regions of the brain (Foss et al., 2022) and that this hyperconnectivity between specific regions important for pain, fear, and sensorimotor control may amplify the negative experiences of pain with this condition (Diekfuss et al., 2022).

The Progressive Approach On How To Treat A Knee That Gives Out

One of the first things you need to do is identify that movements and positions you don't like getting into with the knee. It might be a squat, getting on or off the chair... changing direction during netball.

Once you have established this, you now need to create stability in a quiet standing position. This is achieved through single leg balance exercises, and side lying plank progressions. For balance progressions, as a physiotherapist I would usually suggest 2x 60 second holds, twice daily every day. Starting eyes open and progressing to eyes closed.

The next phase focuses on loading the knee through flexion. Here we introduce exercises like the leg press and the split squat. We progress the load using schemes of 2-3 sets of 5-15 repetitions. We might also begin to vary the visual feedback on the single leg balance here by getting you to close your eyes, and to begin reaching tasks with the arm.

The penultimate phase looks at exercises and movements the are similar to the sporting positions or activities that you want to return back to.

During this return to sport phase, small sided games and drills are used to challenge the knee in many different positions whilst having your attention focused on the successful completion of the task. During this phase, I constrain the environment using rules, cones, manipulate movement of certain limbs... all to encourage the patient to find new ways of moving and see if those patterns produce more success than the current for minimal pain and successful task execution.

References

Post, W. R., & Fithian, D. C. (2018). Patellofemoral instability: a consensus statement from the AOSSM/PFF patellofemoral instability workshop. Orthopaedic journal of sports medicine, 6(1), 2325967117750352.

Kadowaki, M., Tadenuma, T., Kumahashi, N., & Uchio, Y. (2017). Brain activity changes in somatosensory and emotion-related areas with medial patellofemoral ligament deficiency. Clinical Orthopaedics and Related Research®, 475(11), 2675-2682.

Foss, K. D. B., Slutsky-Ganesh, A. B., Diekfuss, J. A., Grooms, D. R., Simon, J. E., Schneider, D. K., ... & Myer, G. D. (2022). Brain activity during experimental knee pain and its relationship with kinesiophobia in patients with patellofemoral pain: a preliminary functional magnetic resonance imaging investigation. Journal of sport rehabilitation, 31(5), 589-598.

Diekfuss, J. A., Grooms, D. R., Nissen, K. S., Coghill, R. C., Bonnette, S., Barber Foss, K. D., ... & Myer, G. D. (2022). Does central nervous system dysfunction underlie patellofemoral pain in young females? Examining brain functional connectivity in association with patient‐reported outcomes. Journal of Orthopaedic Research®, 40(5), 1083-1096.