Knee pain - a guide for human resources and management
Part One: Knee pain – The facts
Knee pain can arise in either knee or both knees and typically, but not exclusively, will be the result of trauma / injury, inflammation due to an underlying disease or degeneration (a natural phenomenon that occurs due to the aging process). The age group affected can also vary, but generally one would expect to see degeneration in the older population and trauma or inflammation in the younger group.
Occasionally knee pain is the result of a foot or ankle condition, which results in abnormal gait and subsequent additional stress on the knee. Pain in the knee may
be “referred” - i.e. pain that starts somewhere else, like the lower back or hips but is interpreted by the body as being in the knee. By the same token, knee problems can result in pain being felt in the ankles or the hips. It is therefore important for anyone complaining of knee pain (with or without an obvious cause) to be assessed by a health professional; this could be a GP, physiotherapist or occupational health practitioner.
Part two: How knee disorders affect people (Functional requirements)
Standing - There may be a need for long periods of standing still (in operating theatres, for example). When standing the pressure of all one’s body weight is transferred through the knees. A knee that moves, compared to one that is in a fixed position (like standing), will have a better flow of blood. Surgeons and scrub nurses often stand for several hours at a time with little break between procedures / cases. Having the opportunity to sit or even walk around would give the knee some respite from those pressures.
Manual Handling - Heavy manual handling is unusual for doctors and dentists, with the exception of anaesthetists and orthopaedic surgeons. However many nurses, physiotherapists and occupational therapists (and others) have heavy manual handling as a part of their daily work requirements. Even the “safest” of lifts will involve a load being transferred to the knees, and manual handling of patients or their limbs is rarely as simple or as straightforward as lifting a static weight such as a box.
Knee Bending – Health professionals may have to squat down to examine patients, treat or communicate with patients. This is especially the case in paediatrics.
Kneeling – Is usually only needed during emergencies like chest compressions in cardiopulmonary resuscitation and occasionally in paediatrics.
Walking – Is a common requirement, and the extent will depend on the nature of the role and the layout of the work environment, including whether the health professional is based in one ward, clinic or other setting or if they have to cover several sites or have responsibilities that span multiple areas of the same site.
Bending, kneeling and walking all require a certain level of mobility within a knee joint. A stiff or painful joint will make this difficult.
Stair climbing – Each step up involves a lot of strength and power across the knee, whereas a step down requires more control than power; sufferers often complain of more problems going down. Stair use at work depends more on location than specialty or role. GPs doing home visits are probably most affected, as they may not have access to a lift in patients’ homes or blocks of flats. Smaller buildings may also not have lifts but this will rarely be a problem in larger sites like main hospital buildings.
Rising from sitting – Any clinic-based role will have this as a regular requirement with movements from sitting at a desk to standing to call patients and to standing by an examination couch. Ward-based roles make demands for regular sitting to complete notes and other administrative duties and standing up for clinical tasks. Roles in laboratories may require movement between siting at desks for computer work to tasks at higher workbenches. Mounting and dismounting from vehicles is similar to ascending / descending stairs but more extreme, and will affect ambulance and air ambulance based staff.
General knee investigations may include the following list
- X ray
- MRI scan
- CT Scan
Anterior knee pain
Could be from the kneecap (patella), including tendonitis, arthritis, dislocated or fractured patella and inflammation of the fluid sac around the kneecap (bursitis). Anterior knee pain affects kneeling, standing from sitting, and stair use. Possible treatments include taping the knee, steroid injection into the knee, and physiotherapy to strengthen the knee. Physiotherapy is especially important, as strengthening of the muscles supporting the knee will ensure that the surrounding muscles do more of the work and load bearing rather than the knee joint itself.
The cartilage allows for smooth movement of the knee joint, and the meniscus is a cushion between the weight bearing bones of the thigh and the lower leg. Problems can occur after trauma, especially post skiing and other sports injuries, and also with degeneration. The knee can lock in a certain position or can make a grinding noise during movement.
Ligament problems include ACL / PCL (anterior and posterior cruciate ligaments), and lateral ligaments.
Again these are common in sports / skiing accidents and also possible with significant degeneration. The knee can give way at times and may feel unstable to the sufferer. For a currently unknown reason, ACL injuries are far more common in women than men. Treatments include physiotherapy and strengthening exercises, as well as surgery to repair damage and / or the wearing of a brace. They affect actions like standing up from sitting, bending the knee on stairs or kneeling plus mounting and dismounting vehicles.
Arthritis - Osteoarthritis is very common, especially in an aging population. Rheumatoid arthritis less commonly affects the knees compared to other joints like the hands. Gout may affect the knee and usually presents as intermittent pain / swelling for several days at a time.
The inflammatory component of arthritis usually results in difficulty with early morning mobility and is a particularly notable symptom in rheumatoid arthritis. Individuals with inflammation of their joints usually describe early morning stiffness in their joints and that it takes them an hour or so ‘to get their joints moving.’ Adjustments at work to accommodate this may include altering the individual’s working pattern so that they can start work later or hold activities such as ward rounds or theatre lists later in the day.
Recovery times after total knee replacement is related to the weight and fitness of the individual rather than the surgery itself. Some people feel able to do part-time sedentary work after 2-3 weeks, but they may find travel to and from work difficult. The Royal College of Surgeons suggests a return to non-manual work by 6-8 weeks and manual work by 12 weeks following a total knee replacement. A replacement may result in a “normally” functioning knee. However, it may also limit sustained standing, walking, rising from sitting and stair use, dependent on the success of surgery. These limitations may then need permanent restrictions from certain activities.
Adjustments to facilitate retention in the workplace
Managers are advised to seek advice from an occupational health practitioner at an early stage if a health professional has chronic knee pain, as a detailed assessment of the cause, treatment and working environment will be required. Adjustments will need to be tailored to the individual but include:
- Providing increased breaks where prolonged standing is required
- Allowing time to attend physiotherapy
- Gradual phased build up post surgery / procedure
- Removing the requirement for stair use: e.g. temporarily working elsewhere or not visiting certain sites.
- Providing a foot stool if appropriate.
- Temporary alteration in working hours
(for reference and background information)