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.
WEIGHT TRAINING INJURIES
Improper weight-training techniques can lead to weight training injuries. The most common areas to be injured are the back, shoulders, and knees.
Back sprains and strains most commonly result from improper lifting technique when performing exercises such as bench presses, deadlifts, and rows. Sprains involve stretching of ligaments while strains involve stretching of muscles or tendons. Initial treatment involves the R.I.C.E. method (i.e. Rest, Ice, Compression, and Elevation). Assessment and treatment by your physiotherapist are also valuable. At Saanich Physio your Physiotherapist can help you minimise the risk of obtaining weight training injuries.
Training Tip: The risk of back injuries can be reduced by maintaining a neutral spine and avoiding flexing or extending the lower back under heavy load.
Lifting weights overhead incorrectly can lead to injuries such as shoulder impingement syndrome and rotator cuff damage. Shoulder impingement syndrome is when swelling and inflammation of structures in, and around the shoulder results in pain in the front and side of the shoulder/upper arm. Rotator cuff damage causes pain and weakness of shoulder movement. Treatment for these conditions may include physiotherapy and anti-inflammatory medication in minor cases; and cortisone injections and potentially surgery in more serious cases.
Training Tip: The risk of shoulder injuries increases with excessive repetitions. Ensure you also train other body parts to give your shoulders adequate recovery time between training sessions.
Repetitive knee exercises such as squats, lunges, deep knee bends, jumps, knee extension and leg lifts can cause pain at the front of the knee. Injury to the patellar tendon (the tendon that connects the kneecap to the shin bone) can occur with overuse. Small tears develop in the tendon leading to pain just below the kneecap. Treatment in the form of physiotherapy and a patellar tendon strap often helps to reduce symptoms and your doctor may also recommend anti-inflammatory medications.
Training Tip: Ensure that your kneecap tracks correctly (i.e. over the outside of the foot) during squat and lunge exercises.
If you feel pain from weight lifting in the gym seek treatment and corrective strategies from us at Saanich Physio. The longer you keep training with an injury or small niggles that can turn into bigger injuries, the longer your recovery time will be. Seek help early and keep yourself in the gym – there is no need to suffer from weight training injuries.
Aasa U, Svartholm I, Andersson F, et al. Injuries among weightlifters and powerlifters: a systematic review. Br J Sports Med 2017; 51:211-220.
Kerr ZY, Collins CL, Comstock RD. Epidemiology of weight training-related injuries presenting to United States emergency departments, 1990 to 2007. Am J Sports Med 2010; 38(4): 765-71.
Mazur LJ, Yetman RJ, Risser WL. Weight-training injuries. Common injuries and preventative methods. Sports Med 1993; 16(1): 57-63.
Siewe J et al. Injuries and Overuse Syndromes in Competitive and Elite Bodybuilding. Int J Sports Med 2014; 35: 943-948.
Siewe J et al. Injuries and Overuse Syndromes in Powerlifting. Int J Sports Med 2011; 32: 703-711.
Weisenthal BM, Beck CA et al. Injury Rate and Patterns Among CrossFit Athletes. The Orthopaedic Journal of Sports Medicine 2014; 2(4): 1-7.
Tendinopathy TOP TEN By Jill Cook PhD
Tendon pain and dysfunction are the presenting clinical features of tendinopathy. Research has investigated many treatment options, but consistent, positive, clinical outcomes remain elusive. We know that treatment should be active (eg, exercise-based), and that a consistent and ongoing investment in rehabilitation is required. It is important to maximise this investment by understanding (and conveying to patients) treatments that do not help. The following 10 points high- light treatment approaches to avoid as they do not improve lower limb tendinopathy.
1. Don’t rest completely.
Rest decreases the load tolerance of tendon, and complete rest decreases tendon stiffness within 2 weeks.1 It also decreases strength and power in the muscle attached to the tendon and the function of the kinetic chain,2 and likely changes the motor cortex, leaving the person less able to tolerate load at multiple levels. Treatment should initially reduce painful, high tendon load (point 2) and intro- duce beneficial loads (eg, isometrics3). Once pain is low and stable (consistent on a loading test each day), load can be increased slowly to improve the capacity of the tendon.4
2. Don’t prescribe incorrect exercise.
Understanding load is essential for correct exercise prescription. High tendon load occurs when it is used like a spring, such as in jumping, changing direction and sprinting.5 Tendon springs must be loaded quickly to be effective, so slow exercises even with weights are not high tendon load and can be used early in rehabilitation. However, exercising at a longer muscle tendon length can compress the tendon at its insertion.6 This adds substantial load and should be avoided, even slowly, early in rehabilitation.
3. Don’t rely on passive treatments.
Passive treatments are not helpful in the long term as they promote the patient as a passive recipient of care and do not increase the load tolerance of tendon.Treatments like electrotherapy and ice temporarily ameliorate pain only for it to return when the tendon is loaded.7
4. Avoid injection therapies.
Injections of substances into a tendon have been shown to be no more effective than placebo in good clinical trials.8 Clinicians who support injection therapies incorrectly suggest they will return a pathological tendon to normal. There is little need to intervene in the pathology as
there is evidence that the tendonadapts to the pathology and has plenty of tendon tissue capable of tolerating high load.9 Injections may change pain in the short term as they may affect the nerves, but should only be considered if the tendon has not responded to a good exercise-based programme.
5. Don’t ignore tendon pain. Pain usually increases 24 hours afterexcess tendon load. An increase in pain of 2 or more (out of 10) on a daily loading test should initiate a reduction in the aspects of training that are overloading the tendon (point 2). The overload is likely to be due to excessive spring-like movements such as jumping, running and changing direction.
6. Don’t stretch the tendon.
Aside from the load on a tendon in sport, there are compressive loads on the bone-tendon junction when it is at its longest length. Stretching only serves to add compressive loads that are detrimental to the tendon.10
7. Don’t use friction massage.
A painful tendon is overloaded and irritated (reactive tendon pathology). Massaging or frictioning the tendon can increase pain and will not help pathology.7 An effect on local nerves may reduce pain in the short term only for it to return with high tendon loads.
8. Don’t use tendon images for diagnosis, prognosis or as an outcome measure.
Abnormal tendon images (ultrasound and MRI) in isolation do not support a diagnosis of tendon pain as asymptom- atic pathology is prevalent. There are also no aspects of imaging, such as vascu- larity and ‘tears’, that allow a clinician to determine outcome.11 Pathology on imaging is usually very stable and does not change with treatment and reductionin pain, so images are not a good outcome measure.12
9. Don’t be worried about rupture.
Pain is protective as it causes unloading of a tendon. In fact most people who rupture a tendon have never had pain and do not present clinically, despite the tendon having substantial pathology.13
10. Don’t rush rehabilitation.
Tendon needs time to build its strength and capacity. So does the muscle, the kinetic chain and the brain. Although this can be a substantial time (3 months or more), the long-term outcomes are good if the correct rehabilitation is completed.14
The above 10 treatment approaches take valuable resources and focus away from the best treatment for tendon pain—exer- cise-based rehabilitation. A progressive programme that starts with a muscle strength programme and then progresses through to more spring-like exercises and including endurance aspects will load the tendon correctly and give the best long- term results.
Sports Injury Prevention for Baby Boomers
While there may be no single fountain of youth, you can slow down the aging process by staying physically active. Regular exercise enhances muscle and joint function, keeps bones strong, and decreases your risk of heart attack and stroke.
Here are some tips developed by the American Orthopaedic Society for Sports Medicine and American Academy of Orthopaedic Surgeons that can help you exercise safely.
Always take time to warm up and stretch before physical activity. Research studies have shown that cold muscles are more prone to injury. Warm up with jumping jacks, stationary cycling or running or walking in place for 3 to 5 minutes. Then slowly and gently stretch, holding each stretch for 30 seconds. Do not stretch cold muscles.
Just like warming up, it is important to cool down. Gentle stretching after physical activity is very important to prepare your body for the next time you exercise. It will make recovery from exercise easier.
Consistent Exercise Program
Avoid the “weekend warrior” syndrome. Compressing your exercise into 2 days sets you up for trouble and does not increase your fitness level. Try to get at least 30 minutes of moderate physical activity every day. If you are truly pressed for time, you can break it up into 10-minute chunks. Remember that moderate physical activity can include walking the dog, working in the garden, playing with the kids and taking the stairs instead of an elevator. Parking on the far end of a parking lot will increase the distance you have to walk between your car and your destination.
Take sports lessons. Whether you are a beginner or have been playing a sport for a long time, lessons are a worthwhile investment. Proper form and instruction reduce the chance of developing an “overuse” injury like tendinitis or a stress fracture.
Lessons at varying levels of play for many sports are offered by local park districts and athletic clubs.
Invest in good equipment. Select the proper shoes for your sport and use them only for that sport. When the treads start to look worn or the shoes are no longer as supportive, it is time to replace them.
Listen to Your Body
As you age, you may find that you are not as flexible as you once were or that you cannot tolerate the same types of activities that you did years ago. While no one is happy about getting older, you will be able to prevent injury by modifying your activity to accommodate your body’s needs.
Use the Ten Percent Rule
When changing your activity level, increase it in increments of no more than 10% per week. If you normally walk 2 miles a day and want to increase your fitness level, do not try to suddenly walk 4 miles. Slowly build up to more miles each week until you reach your higher goal. When strength training, use the 10% rule as your guide and increase your weights gradually.
Develop a balanced fitness program that incorporates cardiovascular exercise, strength training, and flexibility. In addition to providing a total body workout, a balanced program will keep you from getting bored and lessen your chances of injury.
Add activities and new exercises cautiously. Whether you have been sedentary or are in good physical shape, do not try to take on too many activities at one time. It is best to add no more than one or two new activities per workout.
If you have or have had a sports or orthopaedic injury like tendinitis, arthritis, a stress fracture, or low back pain, consult your Physiotherapist who can help design a fitness routine to promote wellness and minimize the chance of injury.