Knee pain is a very common complaint of pickleball players due to the effects of gravity and aging on the joints.

THE STRUCTURE AND FUNCTION OF THE KNEE

The knee is the largest joint in the human body and is formed by the articulation of the femur and tibia. This joint is a synovial pivotal hinge joint which permits flexion and extension with slight amounts of rotation. The joint is contained in a synovial membrane bathed in synovial fluid. The knee has two articular surfaces, the medial and lateral condyles, with the patella (kneecap) in the anterior portion. The patella is attached to the tibial tuberosity by the patellar tendon. The condyles are protected from rubbing and shock by articular discs known as menisci, which thin and wear out with age and trauma. The sides of the knees are stabilized
by the medial and collateral ligaments, while forward and backward movement is limited by the anterior and posterior cruciate ligaments. Extension of the knee is facilitated by the quadriceps muscles, while flexion is accomplished by the hamstring muscles.

CAUSES OF KNEE PAIN

There are numerous causes of knee pain, the most common being trauma, muscle weakness or imbalance,
overuse and arthritic and degenerative conditions. Fortunately the majority of knee problems are minor and can be resolved with rest, therapy, stabilization, rehabilitation, ice or medication. Persistent or more serious problems may require extended rest, injections, invasive or surgical intervention. In aging athletes, a common cause of knee pain is osteoarthritis-degenerative joint disease or wear and tear arthritis.

Unfortunately, this is an inevitable part of the aging process and the symptoms of this problem begin to appear as you reach middle age. The symptoms of osteoarthritis include:

• Pain and stiffness associated with movement or exercise
• Grating, rubbing or a crackling sound with movement, known as “crepitus”
• Morning pain and stiffness which usually improves with mild activity
• Tenderness and swelling around the joint with a painful and limited range of motion

Degenerative changes can be exacerbated or initiated by being overweight, long-term overuse, excessive weight bearing and unlucky genetics. This condition cannot be cured and it usually worsens with weight-bearing activities and aging. This condition can usually
be controlled with medication, exercise, rest, strengthening and rehabilitation. Glucosamine and chondroitin are natural compounds derived from articular cartilage that have been shown to benefit the synovial fluid by strengthening cartilage, particularly in the knee. In advanced cases injecting corticosteroids will provide temporary anti-inflammatory and pain relief, as will hyaluronic acid supplement injections such as Synvisc and Hyalgan. In extreme cases, a total or partial replacement of the joint may be indicated.

PREVENTING KNEE PROBLEMS: STRENGTHEN AND STABILIZE THE KNEE

The best way to prevent knee problems is by strengthening and stabilization, with exercises that focus on the hamstring and quadriceps muscle groups. The quadriceps consists of four muscles in the front of the thigh, while the hamstrings are three muscles in the back of the thigh. These two muscle groups are responsible for supporting and stabilizing the knee. The following exercises are designed to strengthen and stabilize these two muscle groups.

STEP-UPS: This exercise is for strengthening the quadriceps muscle group. Begin by standing in front of the step (12-15 inches tall) facing forward. Place your right foot in the middle of step and step up as you balance your body for 1-2 seconds on the right leg. Your left leg should be behind your body to help stabilize your weight as it is shifting. Step down with your left leg first and continue on down with your right. Try for three sets of 12-15 repetitions for each leg.

LEG EXTENSIONS: This exercise is used to strengthen the quadriceps muscle group. For maximum efficiency these should be done one leg at a time for better isolation, to prevent the dominant leg from doing an unequal amount of the work. Sit comfortably on the padded seat with your back firmly against the back pad. Adjust the machine so that the front pad comfortably contacts the front of the foot and ankle. Start with light weights that allow you to extend the leg with moderate resistance, and slowly increase the amount of weight as you develop more strength. Hold the head steady and face forward, grip the bars firmly at each side, exhale with maximum exertion and inhale on recovery. With each leg do 15- 20 repetitions and three to four sets.

SQUATS: Squats are primarily used to strengthen the quadriceps muscle group. These can be done with free weights or with the barbell in a squat rack. Initially this exercise should be performed inside a squat rack for safety purposes with light weights until you develop more confidence and strength. Stand with feet hip- or shoulder-width apart. Place the barbell just above the shoulders on the trapezius muscles (i.e., the “bulky” part of the shoulders). If you feel uncomfortable, use a bar pad or towel to protect your back. Bend the knees and lower into a squat position, stopping just before your knees are at a 90-degree angle to the floor, or before you lose the natural arch of your back. Make sure you are facing forward with the feet straight and your weight on the heels. Contract the glutes and legs while stabilizing your body with a strong torso. Slowly stand back up without locking the knees and repeat for two to three sets of 15-20 repetitions. Use care and be very cautious when doing this exercise for the first time. Start with a light weight you can easily handle and practice getting your form perfect before moving on to heavier barbells.

HAMSTRING CURLS: This exercise is used to strengthen the hamstring muscle group. Set the machine to fit your height and lie facedown on the leg curl machine with the pad of the lever comfortably on the back of your legs just below the calf muscles. As with doing the leg extension, it is recommended doing each leg individually to obtain better isolation. It is preferable to use a leg curl machine that is angled as opposed to flat, since an angled position is more favorable for hamstring recruitment. Keep the torso flat on the bench, stretch the legs fully and grab the side handles of the machine. As you exhale, curl your leg up as far as possible without lifting the upper leg or body from the pad. Once you hit the fully contracted position, hold it for a second. Inhale and bring the leg back to the starting position. Repeat for the recommended amount of repetitions, and then do the other leg. Start with light weights to perfect the technique and avoid injuring the hamstrings or lower back. Start with two to three sets and 15- 20 repetitions.

LEG PRESS: This exercise primarily strengthens the quadriceps and hamstring muscle groups with some partial benefit to the calf muscles. Using a leg press machine, sit down on the machine and place your legs and feet at shoulder width directly in front of you on the platform. Slowly and carefully lower the safety bars, holding the weighted platform in place and press the platform all the way up until your legs are fully extended in front of you. Your upper body and legs should make a perfect 90-degree angle. As you inhale, slowly lower the platform until your upper and lower legs make a 90-degree angle. Pushing mainly with the ball of your foot and using the quadriceps, go back to the starting position as you exhale. Perform three to four sets of 20-25 repetitions starting with moderate weight and slowly increasing as strength and stability increase.

DUMBBELL LUNGES: This exercise strengthens the quadriceps, hamstring and gluteal muscles. Initially begin doing lunges without holding dumbbells to get a feel for the exercise and to perfect the technique and develop strength. Start with 1-2 lbs. in each hand and slowly increase the amount of weight. Pick up the pair of dumbbells while standing upright with your feet facing forward, shoulder width apart and the arms fully extended. Lunge the right leg forward about 3 feet in a stepping motion until the knee joint forms a 90-degree angle. The right thigh should be parallel with the floor and the leg should be perpendicular to the floor. The back knee should almost be touching the floor. Contract the right leg muscles and return to the standing starting position. Repeat this exercise utilizing the left leg. Perform three to four sets of 20-25 repetitions depending on fitness level and goals.

ASSESSING, TREATING & RECOVERING FROM KNEE PAIN

Knee pain generally develops slowly and is usually precipitated by trauma, overuse injuries or a change in the exercise regimen. Do an honest assessment, looking for any changes or factors that may have initiated this onset of new symptoms.

Avoid significant changes in your exercise regimen, such as playing in cold weather without knee protection, worn-out or improper footwear, reduced stretching, not warming up properly and resistance training with excessive weight. The biggest problem with any injury in an athlete is the hesitation to take time off and rest, for fear of losing skill and fitness. Initially, take a few days off from playing and begin a regimen of topical/ oral analgesics, compression, elevation and frequent ice application.

NSAIDS (non-steroidal anti- inflammatory drugs such as Ibuprofen, Naproxyn and aspirin) help reduce pain, inflammation and swelling. Athletes with a history of ulcers or GI problems should consider using Tylenol, (Acetaminophen). The application several times daily of topical analgesics such as Capsaicin, bio- Freeze or Cryoderm is another effective way to help reduce pain, swelling and inflammation.

If there is swelling, elevate the knee on pillows and wrap the area in an elastic or Ace bandage while applying ice. To reduce pain, inflammation and swelling, apply ice or a cold pack to the area for 10-20 minutes, 3-5 times/day. Wrap the pack in a cloth or paper towel to prevent direct contact with the skin. After 48-72 hours, if the pain and swelling have decreased, begin applying heat several times a day to the area for 10-20 minutes.

You can now begin to do easy workouts, walking, swimming, elliptical or cycling with a gradual return to pickleball. After a week or so, if the pain has subsided, you can return to your normal playing regimen. If the pain persists for more than two to three weeks or returns after rest and other conservative treatment, it is time to visit a qualified health care professional for diagnosis and treatment. The first step will likely be a comprehensive examination followed by diagnostic studies to assess the location, type and extent of the injury.

Hopefully, the problem or injury can be treated using conservative, non-invasive treatment. Corticosteroid injections directly into the joint can dramatically reduce pain, inflammation and swelling. Unfortunately, the injections only provide relief for a limited time and more than three injections over the period of a year can be harmful. Cruciate ligament and meniscus tears are common injuries that can usually be treated with arthroscopic surgery. Before submitting to any surgery or invasive procedures, obtaining a second opinion is always a good idea.