That old football injury: why knees hurt 30 years later

Leslie Budzynski DC | Doctor of Chiropractic | GCC No. 00043 | BCA No. 0072 | 39 years in practice | About Leslie | Old football injury knee pain explained

A sporty person usually in their early fifties sits down and tells me their knee has started playing up. No fall, no twist, nothing obvious. Then, almost as an aside, they mention that they hurt their cartilage playing football when they was nineteen, had it cleaned out, was back playing within a few months and has not thought about it since. They usually say it as though it is irrelevant. It is often the most relevant thing they have told me. Old football injury knee pain is probably one of the most common presentations I see in people between forty-five and sixty-five and there are sound reasons why a knee stays quietly pain free for thirty years and then starts to complain as time passes.

This blog post explains what typically happened to the knee back then a few short decades ago, why the pain arrives years later, why it is not always the old injury after all and what the evidence actually supports doing about it now. I have been in practice for thirty-nine years, so I have seen a high number of these types of knee problems and I have watched the approved medical advice change considerably over that time.

What usually happened to the knee

The injuries that matter most are the ones involving the cruciate ligaments and the menisci, the two crescents of cartilage that sit between the thigh bone and the shin bone and act as shock absorbers and stabilisers. In the era most of my patients were playing, a torn meniscus was frequently trimmed out arthroscopically, and a partially torn cruciate was often managed by getting back to fitness and hoping for the best.

Both approaches got people back on the pitch, which was the goal at the time. What was less well understood then is that removing meniscal tissue changes how load is distributed across the joint surface for the rest of your life and that a knee which has lost some of its rotational stability works harder to control itself with movement.

Why the knee pain arrives decades later

The answer to that question is that a significant knee injury increases the long-term risk of osteoarthritis in that knee considerably. A systematic review and meta-analysis covering approximately one million participants found that the odds of developing knee osteoarthritis are roughly four to six times higher following a cruciate ligament injury, a meniscal injury or both together.¹ The subsequent international consensus work on knee health after injury reached similar conclusions about the scale of the risk.²

What that means in practice is that the injury did not cause pain in 1992 when you hurt it. The injury changed the mechanical conditions inside the joint and the consequences of that change accumulated quietly for the next two or three decades. The knee reaches the point where the surface can no longer keep up with the demands placed on it and that is usually the point at which somebody books an appointment with me. This is why I say to patients that the knee has not suddenly gone wrong. It has been on a slow trajectory and it has only just become noticeable in recent months.

A few things tend to be the trigger for the pain becoming apparent: a change in job, a new fitness regime, weight gain over a few years which increases load on the knee or simply reaching an age where the tissue tolerates less. None of these are the cause. They are just bring about the old injury.

It is not always the old injury that is to blame

However, assuming that the football injury is to blame can sometimes lead you down the wrong path.

Knee pain is quite often referred from the hip. Osteoarthritis of the hip classically produces pain in the groin and thigh, but it can present with knee pain as the main or only complaint and the knee itself may be perfectly normally when examined. I have often seen patients for a knee problem that was orginating from the hip. If your knee hurts but it has full movement and no swelling and your hip feels stiff putting socks on, the hip needs examining. I have written a fully referenced piece on hip pain and what tends to cause it that covers that pattern.

Pain can also refer from the lower back. Nerve irritation in the lumbar spine can produce thigh and knee pain, sometimes with no back pain at all, which is one of the reasons I always assess above and below the painful joint rather than just the joint itself. My guides to sciatica and to trapped nerves cover those patterns in more detail.

If your knee has been bothering you and nobody has looked at your hip or your back, that is worth correcting. Call me on 01202 937568 or book a free 15-minute consultation and we can work out where your pain is actually coming from.

What the evidence supports doing now

The strongest evidence in this area is for exercise. A Cochrane review of land-based exercise for knee osteoarthritis found high quality evidence of reduced pain and improved physical function, with benefits sustained for some months after a programme finishes.³ That is not a glamorous finding, but it is a consistent one and it is why NICE guidance on osteoarthritis places exercise and, where relevant, weight management at the centre of a treatment plan.⁴

Walking specifically is important and useful, because most people with an old football knee assume they should be protecting it. In a study of adults over fifty with knee osteoarthritis, those who walked for exercise were less likely to develop new frequent knee pain than those who did not.⁵ The instinct to wrap the knee in cotton wool is understandable but is generally unhelpful.

The other thing worth knowing is what the evidence says about more surgery. A systematic review and meta-analysis in the BMJ examining arthroscopic surgery for degenerative knee disease found a small and short-lived benefit for pain that did not persist, set against a small risk of harm.⁶ That does not mean surgery is never appropriate and a fully locked up knee is a different subject entirely. It does mean that if you are considering a keyhole tidy-up for a gradually worsening arthritic knee, it is reasonable to ask what the expected benefit is and weigh these factors up.

PCL: Posterior cruiate ligament

ACL: Anterior cruiate ligament

These are the two major ligaments inside the knee joint that cross each other in an “X” shape to provide stability

What I actually do with these old football knees

I start by establishing where the pain is coming from, which means examining the knee, the hip and the lower back. If the picture is unclear or if I think we need to assess the joint surface before making a plan, I will refer for imaging. I would always rather know exactly what we are dealing with.

Where the problem is mechanical, treatment usually combines hands-on work on the knee and the surrounding joints and soft tissues with a specific, progressive exercise programme. Chiropractic care may help manage the pain and stiffness of knee osteoarthritis alongside the exercise and weight management approach that NICE recommends as core treatment. I tell patients about what that means: the aim is to reduce pain and keep you moving comfortably, not to reverse thirty years of change inside a joint.

I also spend time on load. Most of these patients are not doing too little or too much overall. They are doing the wrong distribution, usually a sedentary week followed by a heavy weekend.

When to seek advice sooner rather than later

A knee that locks and will not straighten, one that gives way repeatedly, a knee that swells rapidly within an hour of an incident or a joint that is hot, swollen and accompanied by feeling unwell, all need prompt attention. So does night pain that is not relieved by changing position. Book to se your GP or specialist first.

Frequently asked questions about old football injury knee pain

Can an old football injury cause knee pain thirty years later?

Yes and it can be common. A cruciate or meniscal injury raises the long-term risk of osteoarthritis in that knee by roughly four to six times. The injury changes how load is shared across the joint surface and the consequences build gradually over decades rather than appearing straight away.

Does having my cartilage removed as a teenager cause arthritis?

Removing meniscal tissue changes how load is distributed across the joint and is associated with a higher risk of later osteoarthritis. That was not well understood when many of these operations were carried out and current practice these days is much more conservative about removing meniscal tissue.

Should I stop walking and running if my old knee injury is hurting?

Usually not. Complete rest tends to make things worse over time because the muscles supporting the knee weaken. The evidence supports staying active, with walking specifically associated with less new knee pain in people over fifty with knee osteoarthritis. Adjusting how much and how often is more useful than stopping.

Is keyhole surgery worth having for an arthritic knee?

The evidence for arthroscopic surgery in degenerative knee disease shows a small, short-lived benefit for pain that does not last, alongside a small risk of harm. A genuinely locked knee is a different situation. It is reasonable to ask your surgeon what specific benefit is expected in your case.

Can a chiropractor help with an old knee injury?

Chiropractic care may help with mechanical knee pain and with the pain and stiffness of knee osteoarthritis, used alongside exercise and weight management as core treatment. The first step is a proper assessment to establish whether the pain is coming from the knee itself, the hip or the lower back.

Why does my knee hurt but the examination is normal?

Because the pain may not be coming from the knee. Hip osteoarthritis in particular can present with knee pain as the main symptom while the knee examines normally. This is one of the more common reasons people could have treated previously without improvement.

If that old knee has started hurting

I see a lot of people across Bournemouth, Poole and Talbot Woods who put up with an old sporting knee injury  for years before doing anything about it, usually because they wrongly assume that nothing can be done. If your knee has started to bother you, I would like to help. Call me on 01202 937568, message me on WhatsApp, or book a free 15-minute consultation at the clinic on Branksome Hill Road. If you have never seen a chiropractor, you may find my notes on what happens at a first visit useful.

Written by Leslie Budzynski DC, GCC-registered chiropractor (GCC No. 00043) with 39 years of clinical experience. Principal and sole chiropractor at Bournemouth Chiropractic.

This post is for information only and does not constitute medical advice. If you are experiencing severe or worsening symptoms, please consult your GP or call 111.

References

1. Poulsen E, Goncalves GH, Bricca A, Roos EM, Thorlund JB, Juhl CB. Knee osteoarthritis risk is increased 4-6 fold after knee injury: a systematic review and meta-analysis. British Journal of Sports Medicine, 2019;53(23):1454-1463. doi:10.1136/bjsports-2018-100022
2. Whittaker JL, Losciale JM, Juhl CB, et al. Risk factors for knee osteoarthritis after traumatic knee injury: a systematic review and meta-analysis for the OPTIKNEE consensus. British Journal of Sports Medicine, 2022;56(24):1406-1421. doi:10.1136/bjsports-2022-105496
3. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews, 2015;(1):CD004376. doi:10.1002/14651858.CD004376.pub3
4. National Institute for Health and Care Excellence. Osteoarthritis in over 16s: diagnosis and management. NICE guideline NG226, 2022. nice.org.uk/guidance/ng226
5. Lo GH, Vinod S, Richard MJ, et al. Association between walking for exercise and symptomatic and structural progression in individuals with knee osteoarthritis. Arthritis and Rheumatology, 2022;74(10):1660-1667. doi:10.1002/art.42241
6. Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ, 2015;350:h2747. doi:10.1136/bmj.h2747