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.
Back Pain solutions with Saanich Physio
Back Pain Victoria – Back pain or back injury is a very common condition that we treat on a daily basis. Saanich Physio has a particular interest in treating your back pain by providing quality, effective hands-on Physio & exercise solutions for your back pain.
Back Pain Physio
Once we have your acute back pain under control with hands-on treatments we work with you to rehabilitate and restore the function of your back muscles and spine. All our Physiotherapists will work with you on exercises for your back pain, as we believe self -management strategies are key to the prevention of recurrent back pain episodes.
At Saanich Physio our approach to your back pain is holistic and your back pain physiotherapist will work with you on improving areas such as posture, sleep, lifestyle, work ergonomics, stress reduction, hobbies or your current sports or exercise regimes. We may also discuss the impact of additional factors like heavy schoolbags, lack of exercise or a sedentary lifestyle.
Back Pain – What causes it?
80% of the Canadian population will suffer from back pain at some point during their lives. It is the third most common reason people take time off work after colds and flu. Lower back pain can originate from many causes. Your back pain can originate from your lumbar spine discs, spinal facet joints, arthritis, back muscle strain, back ligament strain, muscle spasm, bony spurs or growths, pinched nerves, irritated nerves, osteoporosis, sciatica and stress just to name a few.
Back Pain – why do I have it?
Some of the most common reasons for back pain are incorrect lifting techniques, repetitive bending, poor posture, prolonged sitting as well as weakness in your core stabilising muscles
Back Pain Victoria – Signs and Symptoms
Back Pain can affect the lower, thoracic or middle back or upper back neck.
Back Pain is often described as one or more of the following:
- Local sharp pain, dull ache or burning pain
- Pain that radiates into your hip, groin or buttocks
- Pain that is aggravated by sitting, standing, bending forward or backwards, twisting or walking
- Pain that travels down your leg to your thigh, calf, ankle or foot
- Pins and needles or numbness travelling into your legs and /or feet
- Weakness of your leg muscles
- Pain associated with loss of bladder or bowel control
Back Pain Victoria – Will Physio help me?
Hands-on Physio treatment for back pain will vary according to the cause of your back pain. In addition to soft tissue techniques and joint mobilisations, we may use dry needling for back pain, taping or bracing to support your spinal muscles, heat or ice therapy and suggestions for medications for reducing your pain and inflammation. Your back pain Physio may refer you for appointments for x-ray, CT scans or MRI to assist in diagnosing your back pain if required. We can liaise directly with the radiologist for scans and or steroid injections.
Non-Specific Back Pain
Degenerative Disc Disease
Stiff Lumbar Joints
Discogenic Back Pain including-
Bulging Disc, Prolapsed Disc & Herniated Disc
Spinal Canal Stenosis
Thoracic-Upper Back Pain
Sacroiliac Joint Pain
Back Sprains and Strains
Pregnancy-related Back Pain
Physiotherapy to prevent relapses and worsening of symptoms
Make a booking today to get your back pain under control. Click our Book Now Button for an appointment today.
By Vanessa Service, Physiotherapist
What does my vestibular system do?
Your vestibular system’s job is to process sensory information that is required to control balance and eye movements. This means that information from the inner ear, the visual system, and from the muscles and joints is analysed by the brain. Integrating this information allows you to1:
– Maintain clear sight while you move your head,
– Figure out the orientation of your head in space in relation to gravity,
– Identify how fast and in which direction your are moving, and
– Make fast and automatic adjustments to your posture so you can maintain balance (stay in your desired position).
In other words, your vestibular system coordinates your movement with your balance, allowing you to navigate through and adapt to the world. It is this process that allows you to walk down the sidewalk, to step off a curb, to sit down and stand up again and to turn your head while walking. Anytime your head moves through space you’re depending on your vestibular system.
What are vestibular disorders and what are the symptoms?
If the vestibular system encounters disease or injury, such as a viral infection or head trauma, the result may be a vestibular disorder. However, aging, some medications, and genetic or environmental factors may also cause vestibular conditions.
Symptoms of damage to the vestibular system may include:
– Vertigo (a sense of the world spinning around you)
– Dizziness (feeling lightheaded or floating/rocking in space)
– Imbalance and special disorientation (stumbling, staggering, drifting to one side while walking)
– Difficulty with changes in walking surfaces
– Tinnitus (ringing or buzzing in the ears)
– Discomfort in busy visual environments (such as the grocery store) or when looking at screens/television
Examples of vestibular disorders include:
- Benign paroxysmal positional vertigo or BPPV (a common condition where loose debris or “crystals” collect in a part of the inner ear)
- Vestibular neuritis or labyrinthitis.
- Migraine associated vertigo
- Endolymphatic hydrops
- Acoustic neuroma
- Meniere’s disease
How can a vestibular physiotherapist help?
The effect of a vestibular condition on a person’s life can be profound. Dizziness and balance problems are often a barrier to activities of daily living, to independence, and to engaging with the community. This negative impact on daily function and socialization may also contribute to anxiety and depression. As such, appropriate management of vestibular conditions is an essential component to improving quality of life for individuals and families affected by vestibular disorders.
A vestibular therapist will interview you about the history of your symptoms and perform a series of vestibular, balance, and visual tests. Treatment will depend on what is found in the assessment. For example, if you are diagnosed with BPPV, your therapist will perform a manoeuvre to reposition the associated crystals. Other vestibular disorders are treated with specific exercises and strategies that your vestibular therapist will teach you and help you progress through to reach your specific goals.
Although for most people a vestibular disorder is permanent, an exercise based plan can be designed to reduce dizziness, vertigo, and balance and gaze stability problems1. This is made possible by your brain’s incredible ability to adapt its other systems in order to effectively compensate for an improperly functioning vestibular system. Vestibular rehabilitation is a non-invasive and drug free intervention that helps to promote and maximize the amount of compensation that occurs. Current research supports the use of vestibular rehabilitation in the management of vestibular conditions2, demonstrating reduced dizziness, balance issues, and increased independence with regard to activities of daily living 3. Additionally, no adverse effects associated with vestibular rehabilitation have been reported2. As such, vestibular rehabilitation can provide a pathway to improved quality of life for those living with a vestibular condition.
1. About Vestibular Disorders (n.d) Retrieved from https://vestibular.org/understanding-vestibular-disorder
2. Hillier SL et al., Vestibular rehabilitation for unilateral peripheral vestibular dysfunction, Cochrane Database of Systematic Reviews 3, 2011.
3. Cohen HS, Kimball KT Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg 2003 Jan;128(1):60-70
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.