Knee pain can affect a large range of age groups, ranging from ‘growing’ pains experienced by young people to ‘arthritic’ pain in older persons, and everything in-between. In this Blog we will examine knee meniscus injuries, what causes them and how to treat these injuries.
What is the Meniscus of the Knee?
The meniscus are C-shaped structures in your knee joint which sit between your femur (or thigh bone) and your tibia (or shin bone). They are made of a type of cartilage called fibrocartilage, which is a little bit different to other form of cartilage in your knee called articular cartilage. Articular cartilage is often more affected with arthritis. Your knee has two menisci, the medial meniscus and lateral meniscus. The medial meniscus is located on the inside while the lateral meniscus is on the outside of your knee.
The menisci have a limited blood supply which rely on movement of the knee to keep it strong and healthy. The best thing you can do to prevent your meniscus from injury, is to keep active and keep the knee moving.
What does the Meniscus do?
The main role of the menisci is to help with absorbing and distributing forces through the knee joint. They work together with knee and hip muscles to act as a shock absorber when the knee is active. The menisci also increases the surface area of the knee joint, so it adds some extra stability to the knee.
How do you injure your meniscus?
The majority of meniscus injuries occur as people age (over 50 years). As you get older the limited blood supply to the meniscus becomes further reduced. As people age they develop wrinkles and grey hair. The aging process also occurs in the knee, the menisci begin to degenerate, lose some of their strength and become more prone to injury.
As the menisci become more susceptible to injury with age, the range and types of movements which can damage it become more prevalent. The majority of meniscus injuries occur when you twist your knee over a planted foot. – Sometimes it can be as simple, as turning to look over your shoulder or stepping off a ladder and putting weight on your foot and twisting your knee. You might notice the knee to slowly swell up.
Meniscus injuries in the younger ager group (under 30) are not as prevalent. Simple twisting movements to the knee are unlikely to cause menisci injury in younger persons. You are more likely to see menisci injuries occur with other knee injuries such as ligament damage caused through sport.
What should I do if I damage my meniscus?
So you have injured your knee and you are thinking, what to do next? Alternatively, you have had a scan on your knee and been diagnosed with a meniscus tear and wanting to know what is the best way to treat it?
A 2002 study involving people who had ‘degenerative’ menisci tears, compared the rehabilitation recovery rates of three groups. The first group had meniscus removal surgery (i.e. arthroscopic meniscectomy), the second experienced joint ‘wash-out’ (lavage) and third underwent ‘placebo’ surgery where the surgeon made skin incisions only. All groups undertook the same rehabilitation program. Amazingly they found no difference in between the 3 groups. All groups had the same levels of pain and function, and all improved at the same rate.
Since the initial 2002 study, further published studies have compared meniscus surgery with placebo surgery and physiotherapy treatment. These studies continue to confirm the same result, that is, there is no differences between all of the groups in terms of rehabilitation other than the surgery group having a higher cost of treatment!
The treatment for meniscus tears in the active, younger population (under 30) is more complex with some individuals needing surgery as soon as possible, while others can manage with physiotherapy and exercise.
What does this all mean?
Degenerative meniscus tears are more common as people age. In some cases people who not have any knee pain may have degenerative menisci and not be in any pain. In other words having a degenerative meniscus correlates poorly pain. The good news is, you might not need to have surgery at all if you are able to undertake a comprehensive physiotherapy rehabilitation program.
Will surgery provide you any benefits? Yes it will in the short term. However, arthroscopic meniscus surgery is associated with a ten-fold increase the risk of knee osteoarthritis.
Although most degenerative meniscus tears don’t need surgery, there are always some cases where surgery is going to be more effective than physiotherapy. Some menisci tears can either ‘stick-up’ into the joint or ‘break-off.’ In cases like these the tear can cause the knee to lock when trying to bend or straighten, and surgery is recommended to remove the tear.
What will my physiotherapist work on during my rehabilitation?
The first thing your physiotherapist will undertake is a full assessment of not only your knee, but your legs and even your back to see if you pain is coming from your meniscus or from somewhere else.
If you have hurt your meniscus recently your physiotherapist will start treatment aiming to reduce the swelling and begin to return it to its full range of movement.
If you have full range of movement and no swelling in your knee joint your physiotherapist will begin an exercise program focused on strengthening the muscles around your knee, and from around your hip. Weak quadriceps muscle has been found to place a greater load on your knee joint and your meniscus. Strengthening these muscle groups can reduce the pressure on the meniscus during movement. Weakness in your bottom (gluteal) muscles can also affect your knee function. Weakness in the gluteal muscles is known to place more load through the inside of the knee, which is where the majority of medial injuries occur. Strengthening the quadriceps and gluteal muscles will contribute to reducing the pressure on the knee.
Degenerative meniscus tears areas common as wrinkles and grey hair as you grow older. Although surgery is sometimes required for some knee injuries it often is not the only or best option in most cases. For most knee injuries involving the menisci the best anti-aging medicine is physical activity and exercise.
Are our devices giving us neck pain?
There are millions of people right now looking down at their smartphone or tablet. Do you ever stop to think about what this might be doing to your neck and upper back?
At Saanich Physiotherapy and Sports Clinic, we are seeing a huge increase in the amount of neck, upper back, shoulder and arm pain which is all related to posture when using devices. From texting on the smartphone to watching TV on the tablet in bed, we are all guilty in some way. And sadly, we are seeing more and more children coming in with these issues too.
Consider how much your head actually weighs. On average, it weighs 4.5-5kg. When sitting or standing upright, this weight is supported by the lower neck vertebrae, intervertebral discs, muscles and ligaments. When you then lean your head forward when looking at your smartphone, the relative weight of your head on your neck muscles can increase up to 27kg! Just by looking down at your phone, you can increase the force on your lower neck by 5 times!
When maintaining this position for a period of time, the muscles will fatigue and stop working, meaning that the force of your head is now being held up by small ligaments, the neck joints and the discs in the neck. It is no wonder people are having more and more neck pain.
The term “Text Neck” is becoming more commonly accepted as a diagnosis for neck pain caused by prolonged use of smartphones and tablets. If left untreated, this massive increase in force in the lower neck and lead to headaches, increased arching of the spine, general pain and tightness and arm pain from irritating nerves in the neck. It can also cause weakening of the muscles in the neck which can lead to ongoing pain, stiffness, headaches or arm pain in the future.
With the increase in children having smartphones and even the use of tablets in school, there are becoming more and more postural issues arising which is definitely a concern for ongoing and long term neck and upper back problems later in life.
Text Neck can be treated. Your Physiotherapist may use joint mobilizations, soft tissue massage, taping or even dry needling to help restore normal movement within the joints and muscles.
However, it is imperative that you strengthen the muscles in the neck and upper back to prevent long term issues. Your Physiotherapist will tailor a program for you to complete at home or might even recommend core conditioning or yoga classes for a supervised strengthening program.
If you, your children or another family member or friend are guilty of using their smartphone or tablet too much and are noticing pain or discomfort in their neck, upper back or arm make sure you book an assessment with your Physiotherapist sooner rather than later!
Physical Therapist’s Guide to Knee Pain
Knee pain can be caused by disease or injury. The most common disease affecting the knee is osteoarthritis. Knee injuries can occur as the result of a direct blow or sudden movement that strains the knee beyond its normal range of movement. Knee pain caused by an injury is most often associated with knee cartilage tears, such as meniscal tears, or ligament tears, such as anterior cruciate ligament tears.
What is Knee Pain?
Knee pain can be caused by disease or injury. Knee pain can restrict movement, affect muscle control in the sore leg, and reduce the strength and endurance of the muscles that support the knee.
The most common disease affecting the knee is osteoarthritis, which is caused by the cartilage in the knee gradually wearing away, resulting in pain and swelling.
Knee injuries can occur as the result of a direct blow or sudden movement that strains the knee beyond its normal range of motion, as can happen in sports, recreational activities, a fall, or a motor vehicle accident. Knee pain caused by an injury often is associated with tears in the knee cartilage or ligaments. Knee pain also can be the result of repeated stress, as often occurs with the kneecap, also known as patellofemoral pain syndrome. Very rarely, with extreme trauma, a bone may break at the knee.
How Does it Feel?
You may feel knee pain in different parts of your knee joint, depending on the problem affecting you. Identifying the location of your pain can help your physical therapist determine its cause.
How Is It Diagnosed?
Your physical therapist will make a diagnosis based on your symptoms, medical history, and a thorough examination. X-ray and magnetic resonance imaging (MRI) results may also be used to complete the diagnosis.
To help diagnose your condition, your physical therapist may ask you questions like these:
•Where exactly on your knee is the pain?
•Did you twist your knee?
•Did you feel a “tearing” sensation at the time of injury?
•Do you notice swelling?
•Have you ever felt like your knee joint is “catching,” or “locking,” or will give way?
•Do you have difficulty walking up and down stairs?
•Do you have difficulty sitting with your knee bent for long periods, as on an airplane or at the movies?
•Does your pain increase when you straighten or bend your knee?
•Does your knee hurt if you have to twist or turn quickly?
The physical therapist will perform tests to find out whether you have:
•Pain or discomfort with bending or straightening your knee
•Tenderness at the knee joint
•Limited motion in your knee
•Weakness in the muscles around your knee
•Difficulty putting weight on your knee when standing or walking
The physical therapist also is concerned about how well you are able to use your injured knee in daily life. To assess this, the therapist may use such tests as a single-limb hop test, a 6-minute walk test, or a timed up and go test.
How Can a Physical Therapist Help?
Based on the evaluation, your physical therapist will develop a customized rehabilitation program, including a specific set of knee exercises, for you.
If you already have knee problems, your physical therapist can help with a plan of exercise that will strengthen your knee without increasing the risk of injury or further damage. As a general rule, you should choose gentle exercises such as swimming, aquatic exercise, or walking rather than jarring exercises such as jogging or high-impact aerobics.
Consult your physical therapist about specific ways to maintain your knee health following injury or surgery. Your physical therapist has the relevant educational background and expertise to evaluate your knee health and to refer you to another health care provider if necessary.
Depending on the severity of your knee problem, your age, and your lifestyle, the therapist may select such treatments as:
Strength training and functional exercises, which are designed to increase strength, endurance, and function of your leg muscles (quadriceps and hamstrings). This in turn helps support the knee and reduce stress to the knee joint.
Your physical therapist can determine just how much you may need to limit physical activity involving the affected knee. He or she also can gauge your knee’s progress in function during your rehabilitation.
How Can a Physical Therapist Help Before & After Surgery?
Your physical therapist, in consultation with your surgeon, will be able to tell you how much activity you can do depending on the type of knee surgery (such as total knee replacement) you undergo. Your therapist and surgeon also might have you participate in physical therapy prior to surgery to increase your strength and motion. This can sometimes help with recovery after surgery.
Following surgery, your physical therapist will design a personalized rehabilitation program for you and help you gain the strength, movement, and endurance you need to return to performing the daily activities you did before.
Can this Injury or Condition be Prevented?
Ideally, everyone should regularly get 3 types of exercise to prevent injury to all parts of the body, including the knees:
•Range-of-motion exercises to help maintain normal joint movement and relieve stiffness.
•Strengthening exercises to keep or increase muscle strength.
•Aerobic or endurance exercises (such as walking or swimming) to improve function of the heart and circulation and to help control weight. Weight control can be important to people who have arthritis because extra weight puts pressure on many joints, including the knee.
To keep knee pain and other musculoskeletal pain at bay, it’s important to maintain an overall healthy lifestyle, exercise, get adequate rest, and eat healthy foods. It’s also important for runners and other athletes to perform physical therapist-approved stretching and warm-up exercises on a daily basis—especially before beginning physical activity.
Real Life Experiences
At age 56, Monica was in very good health—eating right, maintaining her weight, and exercising daily at home. One day she fell off her exercise equipment and twisted her knee. The pain was excruciating. Even though she could walk short distances, using her sore leg during her daily activities soon became impossible. Monica made an appointment with her physical therapist. The therapist reviewed her medical history, conducted a thorough examination, and consulted with Monica’s physician regarding the need for a series of X-rays to ensure no bones were broken in the fall.
Consultation with an orthopedic surgeon confirmed that there were no broken bones and no need for surgery. Monica’s physical therapist developed a program of strength training and functional exercises to increase her hip, knee, and ankle muscle strength and endurance. The physical therapist also recommended electrical stimulation of the knee to increase her quadriceps (thigh) muscle strength.
By following the physical therapist’s regimen, Monica decreased her knee pain, and her mobility improved dramatically. Regular ongoing strength-training knee exercises—and more careful use of her exercise equipment—have helped Monica remain free of knee pain.
What Kind of Physical Therapist Do I Need?
Although all physical therapists are prepared through education and experience to treat people with knee pain, you may want to consider:
•A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems
•A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship FCAMPT in orthopedic physical therapy, giving the therapist advanced knowledge, experience, and skills that may apply to your condition
General tips when you’re looking for a physiotherapist:
•Get recommendations from family and friends or from other health care providers.
•When you contact a physical therapy clinic for an appointment, ask about the physical therapist’s experience in helping people with TKR.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
A blog by Amy Mathews Amos- See below
My symptoms started in January 2008, with deep pain in my bladder and the sense that I had to urinate constantly. I was given a diagnosis of interstitial cystitis, a chronic bladder condition with no known cure. But in the following months, pain spread to my thighs, knees, hips, buttocks, abdomen and back. By the time my condition was properly diagnosed three years later, I had seen two urogynecologists, three orthopedists, six physical therapists, two manual therapists, a rheumatologist, a neurologist, a chiropractor and a homeopath.
What was wrong? Something completely unexpected, given my symptoms: myofascial pain syndrome, a condition caused by muscle fibers that contract but don’t release. That constant contraction creates knots of taut muscle, or trigger points, that send pain throughout the body, even to parts that are perfectly healthy. Most doctors have never heard of myofascial pain syndrome and few know how to treat it.
In my case, trigger points in my pelvic floor — the bowl of muscle on the bottom of the pelvis — referred pain to my bladder. Points along my thighs pulled on my knee joints, creating sharp pain when I walked. Points in my hips, buttocks and abdomen threw my pelvis and lower spine out of alignment, pushing even more pain up my back. The pain was so severe at times that I could sit for only brief periods.
“Why didn’t anybody know this?” I asked my doctor, Timothy Taylor, soon after he correctly diagnosed the reason for my pain. “Because doctors don’t specialize in muscles,” he said. “It’s the forgotten organ.”
‘There’s no wire’
Most medical schools and physical therapy programs lack instruction in myofascial pain, in part because it involves referred pain, according to Robert Gerwin, an associate professor of neurology at Johns Hopkins University. Gerwin, who is also president of Pain and Rehabilitation Medicine in Bethesda, says that medicine has only recently come to understand this type of pain.
“I remember a long conversation with a neurosurgeon saying that [referred] pain is impossible because there’s no connection, there’s no wire, no string, no blood vessel, there’s no nerve, there’s no nothing connecting these two places,” Gerwin said. Of course, the surgeon was “not realizing that the mechanism of spread is through the spinal cord.”
Pain signals from taut muscle fibers travel to specific locations on the spinal cord that also receive signals from other parts of the body. Referred pain occurs when pain signals from muscles register in the nervous system as if they came from elsewhere.
Although physicians increasingly recognize referred pain today, diagnosis and treatment of myofascial pain often takes more time than most physicians can provide, according to Taylor. Practitioners need specific training to recognize trigger points. And they must examine and palpate patients carefully to identify and locate these taut bands of muscle fiber.
In a 2000 survey, more than 88 percent of pain specialists agreed that myofascial pain syndrome was a legitimate diagnosis, but they differed over the criteria for diagnosing it.
Norman Harden, the medical director of the Center for Pain Studies at the Rehabilitation Institute of Chicago, conducted that survey. He believes that practitioners need clear, validated criteria for diagnosing myofascial pain and identifying effective treatments. He recently conducted another survey to determine if the level of recognition among pain specialists has changed. Preliminary results suggest it has not.
According to Gerwin, myofascial trigger points often cause or contribute to problems such as chronic back pain, headaches and pelvic pain. Trigger points can form anywhere in the body after an injury or if muscles brace against pain or trauma for a long period. They also can result from chronic overuse of muscles due to stress or to poor posture that puts constant pressure on muscles not designed to withstand it.
Taylor understands this as both a physician and a patient. His myofascial pain started in 2003 during his daily run. “I felt a sharp pain in my rear that felt just like when my brothers used to shoot me with our BB gun,” he recalled. He checked himself for signs of injury but found none, then limped home, assuming it was a strained muscle that would heal after a few days. It didn’t.
He sought treatment first from his general practitioner. He then went to a battery of specialists: neurologists, rheumatologists, orthopedic surgeons, osteopathic physicians, physical medicine and rehabilitation specialists, and physical therapists.
Found it on the Internet
After three years, a physical medicine and rehabilitation specialist told him the source of his pain was his piriformis muscle, a pear-shaped muscle that runs diagonally across the buttocks. The doctor prescribed stretching and strengthening exercises to resolve it, but they only made things worse. Eventually, the pain reached down to Taylor’s knees, up to his head and out to his fingers on both sides of his body.
But he finally had a useful piece of information. He did an Internet search for “piriformis muscle” — a common spot for trigger points — and “myofascial pain syndrome” popped up. “I had been to the bone doctor and the joint doctor and the nerve doctor and the rehab doctor, and none of them had really examined my muscles in great detail,” he said. And none of them identified trigger points. Taylor has since changed his focus from radiology to working toward understanding, diagnosing and treating the condition. When I met him in 2011 he had established a practice that specializes in pain syndromes.
A popular treatment is dry needling, which sounds like exactly what it is: Tiny needles are inserted into the skin to stimulate a twitch response in the heart of a trigger point, releasing it. Although similar to acupuncture, dry needling focuses directly on trigger points rather than on the meridians, or energy fields, recognized by Chinese medicine. Usually, each trigger point requires several treatments before it relaxes substantially. Between sessions, patients treat themselves each day by pressing the points against a hard surface with simple tools such as tennis balls and holding for a minute or two. Treatment also addresses posture-related strains on muscles and metabolic factors such as vitamin and mineral deficiencies, low thyroid and hormonal imbalances that can contribute to trigger points.
Though a few studies have been done, they have not adequately demonstrated the effectiveness of treatments for trigger points, according to a 2009 review published in the European Journal of Pain. Researchers at the Universities of Exeter and Plymouth and the British Medical Acupuncture Society reported that only one of the seven studies they reviewed found dry needling to be effective in reducing pain. Four other studies found no difference between dry needling and placebo treatment, and the two remaining studies had contradictory results.
The American Academy of Orthopaedic Manual Physical Therapists recognizes dry needling as a legitimate treatment. The group maintains that research shows that dry needling reduces pain and muscle tension and helps muscles with trigger points return to normal. Other studies are underway. Jay Shah of the National Institutes of Health and Lynn Gerber and Siddartha Sikdar of George Mason University are using ultrasound imaging to examine how dry needling changes the physiology of trigger points after treatment.
Gerwin says that proper training in finding the trigger points can lead to consistency in diagnosing them. He and physical therapist Jan Dommerholt of Bethesda Physiocare run Myopain Seminars, which help physicians and physical therapists learn how to diagnose and treat trigger points.
According to Harden at the Rehabilitation Institute of Chicago, without clearer diagnostic criteria accessible to general practitioners, experiences like mine will continue. “As awareness grows and doctors feel empowered to understand and make this diagnosis, then that endless and frustrating round of trying to find what I’ve got and what the answer is will stop,” he said.
Gerwin agrees that more research will help, but already he sees greater acceptance of trigger points in the medical community.
“I think the bottom line is simply that the
underlying pain physiology is understood now to explain why referred pain occurs, to understand why tenderness occurs,” he said. “And that explains a lot of what muscle pain is all about.”
In my case, through a combination of therapies, including dry needling, compression, stretching, postural changes and relaxation techniques, I feel much better. I no longer need dry needling, but I do need to practice the other techniques myself, regularly, to prevent trigger points from reforming or to release them myself when they do form.
Amy Mathews Amos, a science writer in Shepherdstown, W.V., blogs at amymathewsamos.com.