Treating and Preventing Meniscus Injuries - Part 5

Exercise

If the injury is not severe enough to warrant surgery therapy can usually begin almost immediately. If surgery is warranted, exercises can usually begin within a short period of time [depending on your surgeon’s advice].

Initially, patients with meniscus injury tend to do better with non-weight-bearing activities that do not cause compression. Especially in cases of more severe injury it is important to progress to weight-bearing functional activities.

If you’ve had a posterior meniscus injury you should keep your knees ranges of motion limited while performing exercise. This will help to ensure that further injury does not take place. It is also important to avoid any rotational movements of the knee, especially in weight-bearing positions.

In cases of surgery it may be necessary to avoid any type of flexion exercise for up to two months. Exercises that include twisting activities or squats may need to be avoided for up to 3 to 6 months. Depending upon the degree of injury it may also be necessary to limit athletic activity for 4 to 6 months after surgery.

The following exercise recommendations are only general in nature for individuals who do not need surgery, or have been cleared by their surgeon to perform these exercises.

Initial Phase of Exercise

The objectives during this phase are to decrease swelling [RICE], prevent further injury [bracing may be necessary], prevent muscle atrophy and maintain overall strength. During this initial phase which is can be several weeks depending on the degree of injury, four weeks if post operative, further injury must be prevented. During this stage appropriate exercises would include:

1. Isometric exercises for the Quadriceps (especially the VMO)
2. Range of motion exercises [passive and active if appropriate]
3. Stationary cycling - single leg cycling only using the uninjured leg

Intermediate stage of exercise (Patient can now flex and extend knee)

The objective of this stage is to return to full weight bearing on the injured leg and to increase muscular endurance. It is important to combine soft tissue mobilization with exercise to avoid scar tissue formation. During this stage appropriate exercises would include opened chain kinetic exercises such as:

1. Limited open chain resisted tubing exercises of the ankles knee and hip.
2. Stationary cycling with no or only minimal tension.
3. One leg stands - in this exercise you alternate standing on one leg for approximately 20 to 30 seconds, shifting your weight back and forth. This can only be done if you are able to tolerate weight-bearing.
4. An upper extremity weight training program
5. Deep water running program
6. Stretches should include the: Quadriceps, hamstrings, hip rotators, iliotibial band, and calf muscles.

As the patient progresses Open Kinetic and Closed Kinetic Chain resisted exercises can be used.

Advanced stage of exercise (Patient now has full range of motion)

1. Begin running at 50 to 60% of effort.
2. Step ups, onto box.
3. Jumping and hopping exercises. These exercises must be performed completely pain-free.
4. Eventually exercises should simulate activities performed by the sport or activity the individual wishes to return to,
5. Balance and stability training on a gym ball can be used at this stage.

Conclusion:

In many cases meniscus injuries can be prevented. Active Release Techniques has been proven to be a viable option in removing meniscus entrapment’s before the actual tear occurs. Once an actual injury has occurred manual therapy and exercise should be implemented as soon as possible. Therapy must always consider key kinetic chain relationships to prevent an ongoing cycle of injuries. In addition to therapy exercise is essential without the correct rehabilitative strategy the probability of ongoing injury is almost 100%.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Treating and Preventing Meniscus Injuries - Part 4

OK… I am finally back at my meniscus blog…delays due to having a blast dancing at the Calgary Salsa Congress. The next Calgary Salsa Congress is April 2012 - and if you are in town…then be sure to go to this. The workshops and performances from around the world are amazing. But now, to the matter at hand…your meniscus injury.

What to do when a meniscus injury has occurred?

You should seek medical attention immediately if you show indications of a meniscus tear as it is extremely important to determine the severity of the injury. The severity of your injury will determine the type of strategy that must be implemented to rehabilitate your meniscus tear. It is important to stop all further activities that may cause further damage to the knee until you have completed this assessment.

Upon initial onset of the meniscus injury – RICE IT!

No matter what the severity of the injury is, at the initial onset of a meniscus tear, follow the RICE (rest, ice, compression, and elevation ) procedure.

• Rest - Avoid putting excess stress on the knee. If necessary, use crutches, and a neoprene brace that keeps the knee locked in extension.
• Ice – Apply ice to the knee for 20-30 minutes, every 2-3 hours, until the swelling is reduced.
• Compression - An elastic tensor bandage on your knee may also help to reduce swelling and can be used in conjunction with the ice.
• Elevation - Elevating your knee helps to reduce swelling. Place your knee on a blanket or pillow.

REST

Depending on the severity of the injury it may be necessary to rest your knee completely for several weeks in order to fully recover. Keeping the injured knee in a locked position, in full extension, will take about 50% of the compressive load off the knee.

Initially, you should avoid any activities that involve flexion of the knee. The act of flexing your knee creates tension in the popliteus and semimembranosus muscles. These structures connect into the meniscus, resulting on increased stress in this area.

Resting the injured leg does NOT mean avoiding all physical activity. Exercising your lower extremity on the non-injured leg will help to maintain overall muscle mass. By exercising the opposite leg, there will be some neurological crossover, which helps keep the muscles on the injured side from atrophying. Electrical stimulation, such as inferential current, can also aid in preventing muscle atrophy of the injured leg, and do so without additional stress on the meniscus.

Manual Therapy

Once you have the go-ahead from your physician, you should start manual therapy and exercise as soon as possible. Waiting too long to start treatment will only prolong a meniscus injury.

There was an interesting study that was done in 1988 by Timm about the effectiveness of combining rehabilitative exercises with arthroscopic knee surgery. Those patients who received no rehabilitative exercises showed a zero success rate in recovery (did not recover). Those individuals who received a comprehensive rehabilitation program showed a 92% success rate. This study was conducted on over 5000 subjects.

Manual therapy can help to prevent what is referred to as a flexion or extension contracture. This refers to the inability of the knee to fully straighten or bend due to pain, stiffness, and adhesion formation. A flexion contracture is the most common type of contracture. If an individual is not able to properly straighten their knee, then they will have difficulty in increasing strength or developing stability in the knee.

Types of Therapy

There several forms of therapy that can help to speed the healing process, with the most effective being Active Release Techniques, Graston Technique, massage therapy, fascial manipulation, and joint mobilization. During each stage of recovery from the injury, the patient can greatly benefit from these procedures to maintain active range-of-motion and speed the healing process.

Active Release Techniques

Active Release is a great way to speed the healing process, as well as prevent meniscus injuries (by removing adhesions and impingements in the area). Active Release treatments often involve removal or release of numerous soft-tissue restrictions above, below, or in direct contact with the meniscus. For example, as we mentioned in our earlier blog, the popliteal muscle and the semimembranosis muscle both attach to the meniscus. Active Release Techniques can remove restrictions in these structures, thereby improving meniscus function.

You can locate practitioners trained in Active Release Techniques at www.activerelease.com. When checking over qualifications, make sure you select a practitioner who is certified in working with lower extremity protocols. Of course, if you are in Calgary, Alberta - please come see us at Kinetic Health.

Graston Techniques

Graston Techniques uses specially designed stainless steel instruments to specifically detect and remove soft-tissue fibrosis caused by chronic inflammation. This technique was originally developed to be used on athletes.

With menisci injuries, Graston Technique (GT) proves quite beneficial since:

• GT increases the rate and amount of blood flow to the injured area. Since the menisus generally have decreased blood flow, any increase in circulatory function is helpful in the healing process.
• GT re-initiates the healing process in many areas where fibrotic scar tissue has formed. It does this by increasing cellular activity in the injured region, especially that of fibroblasts and mast cells.

You can find trained practitioners in Graston at www.grastontechnique.com and at our clinic in Calgary – Kinetic Health.

Registered Massage Therapy

Massage therapy can be very beneficial when treating a meniscus injury. Massage therapy helps to preventing flexion and extension contractures of the knee. In addition massage therapy can be an effective approach for managing pain.

Make sure you look for therapists that are educated and trained to accurately assess and treat meniscus injuries. It is important to remember that not all massage therapist receive the same level of training. Check the credentials of the selected massage therapist. Some massage therapists may also have received additional training in Active Release Techniques and will combine this treatment with their standard massage techniques.

Treating Menisci Injuries – see the next installment of this blog for more information about how you can treat menisci injuries with exercise. For more information about other types of knee injuries, visit the following sites:

• · Resolving Meniscus Injuries of the Knee
• · Ligament Injuries of the Knee
• · Illiotibial Band Syndrome (ITBS)
• · Resolving Knee Pain
• · Release Your Body

Treating Meniscus Injuries Part 5

For more information about our clinic in Calgary, Alberta - please visit www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2010 – ALL RIGHTS RESERVED)

Treating and Preventing Meniscus Injuries - Part 3

Meniscus Injury Prevention – ART and the Denver Broncos

The last Lower Extremity Active Release Techniques (ART) course that I helped teach was in Las Vegas. At this course I learned some rather remarkable facts about ART and the Denver Bronco’s football team. Over the last last three years - a remarkable thing has occurred. Ever since Dr. Leahy (developer of ART) has worked on them, the Denver Broncos have not required any meniscus surgery (that I know about). This is an astounding statistic as apparently, in previous years, it was common to have six or more meniscus surgeries per season within the team. (If anyone out there has more accurate statistics about this, please let me know!)

This is a remarkable reduction in overall injuries. This is especially important for professional teams where there is a direct correlation between the injury rates and their standings each season. The higher the injury rates, the more poorly the team will perform, due to key players being benched.

As I mentioned in the earlier segments of this blog, most meniscus injuries occur during contact activities, usually when the knee is bent, with the foot planted on the ground. These sport-related factors cannot be altered. However, you can deal with a functional factor - meniscus entrapment – long before the tear occurs. If these meniscus entrapments are released before the traumatic event occurs, then many menisci injuries could be avoided.

More technical details…read on!

In the last blog we talked about how Murray’s and Ege’s tests use flexion and extension with internal and external rotation to locate the location of the meniscus tear. During treatment, ART uses these same active motions in combination with joint palpation to determine and clear the site of the functional entrapment.

Research has shown that joint line palpation is 89% percent accurate for the diagnosis of a meniscus tear with an MRI (the gold standard) being 98% accurate. An 89% accuracy rate is nothing to balk at; especially when one considers how fast and inexpensive joint line palpation is when compared to the costs of an, MRI.

Karachalios T, Hantes M, Zibis AH, et al. J Bone Joint Surg, 2005;87-A(5):955-62.

Biomechanically, we know that the meniscus of the knee follow the motions of the bones to which they are attached:

• Above the knee joint, the bones of the femur [femoral condyles] pulled the menisci forward [anterior] with knee extension, and pull them backward [posterior] with knee flexion.
• Below the knee joint, as the tibia rotates internally or externally, it pulls the meniscus with it. As the tibia rotates to the outside - the lateral meniscus is pulled forward while the medial meniscus moves back. If the tibia rotates to the inside - the medial meniscus moves forward and the lateral meniscus moves back.

A functional meniscus entrapment occurs when any of these motions are restricted. This is easy for the ART practitioner to observe during examination since the patient will experience a sharp internal pain of the knee when executing specific motions. The patient may also notice a locking of the knee in certain positions. Patients that show these symptoms are extremely susceptible to a meniscus tear.

It’s about more than just the meniscus

Once the exact site of meniscus entrapment has been determined, it is important to consider that many other structures are also involved. Dr. Leahy has mentioned numerous times “that virtually every tissue the crosses the knee joint must be considered in a knee injury”. (Mike…please feel free to correct this quote!) In the last segment of this blog, I mentioned the popliteus and semimembranosis muscles and how they have direct connections to the meniscus. In addition to these, there are many other structures that also influence menisci function including: knee capsule, medial collateral ligament, and popliteal ligaments. Bottom line, to effectively treat or prevent a menisci injury, you must address each involved structure.

The actual procedures that the Active Release Techniques practitioner uses always varies depending upon the combination of involved structures. But in general terms, once the position of entrapment has been identified, the practitioner will put the knee into the position of entrapment then use physical pressure to release that entrapment.

Getting your meniscus treated

Fortunately, you don’t need Dr. Leahy on your team, or in your clinic, to achieve some of these same results. Practitioners certified in Lower Extremity Active Release Techniques are trained to use the same procedures that Dr. Leahy uses with the Denver Broncos. These practitioners can find the specific site of entrapment, and then use specific ART procedures to open the joint space between the femur and tibia to release the meniscal entrapment.

So if you are looking to prevent meniscal injuries, you need to find an ART practitioner who is trained in Lower Extremity protocols (www.activerelease.com). It is important to remember that not all Active Release Techniques practitioners are trained in the protocols and techniques for the Lower Extremity. Make sure that your ART practitioner is currently certified for this area. Of course, if you are ever in Calgary, you can see us at Kinetic Health and we will do our best to release any of your entrapments.

Bottom line, it is always much easier to prevent an injury than to treat one. Whether you are involved in running, triathlons, basketball, football, soccer, or any other sport that involves high velocity lateral motions, it is well worth having your knees checked for existing meniscus entrapment

One final note: The information that I presented here is quite remarkable. Unfortunately, there has been no definitive large-scale study conducted on this procedure. It is my hope that with these impressive results, new research will be conducted on a larger scale. Integrating these ART procedures into the general healthcare system could save the system a remarkable amount of money.

Treating Menisci Injuries – see the next installment of this blog for more information about how you can treat menisci injuries. For more information about other types of knee injuries, visit the following sites:

• · Resolving Meniscus Injuries of the Knee
• · Ligament Injuries of the Knee
• · Illiotibial Band Syndrome (ITBS)
• · Resolving Knee Pain
• · Release Your Body

Treating Meniscus Injuries Part 4

For more information about our clinic in Calgary, Alberta - please visit www.kinetichealth.ca

(COPYRIGHT KINETIC HEALTH 2011 – ALL RIGHTS RESERVED)

Treating and Preventing Meniscus Injuries - Part 2

In our previous blog (link) we discussed the causes and structural components of the knee and its menisci. Now…lets look at how we can treat injuries to the menisci.

Degree of Injury

Injuries to the menisci can range from minor, moderate, to more severe. Pain and swelling are the most common symptoms of a meniscus tear. With more severe menisci injuries, a person may notice some degree of “locking of the joint” accompanied by considerable instability of the knee. If “locking of the joint” occurs, it is imperative to immediately obtain medical attention from a sports physician, or some other medical practitioner who works with physical medicine. Your specialist should perform a physical examination on you to determine the severity of the injury.

Common Examination Findings

The following are common examination findings, which can indicate the presence of a meniscus injury

Effusion: Caused by an increased level of fluids in the synovial cavity of the knee joint.

Joint Line Tenderness: This is tenderness in the space (line) directly between your thigh bone, femur, and your shin (tibia). This line runs horizontally on both sides of your knee - from the front to the back.

Positive Orthopedic Test:

• McMurray’s Test: This test is performed with the patient lying on their back, while the examiner flexes the patient’s knee. A positive finding of a suspected meniscus tear occurs when a click is felt as the knee is brought from full flexion to 90 degrees of flexion.
• Ege's Test – In this test the patient is asked to squat in two positions, once with the feet rotated outwards (to detect a medial meniscus tear), and once with the feet rotated inwards (to identify a lateral meniscus tear). A positive finding of a suspected meniscus tear occurs when an audible click is heard (or a palpable click is felt) over the meniscus line.

Atrophy of the quadriceps or decreased quadriceps strength: The quadriceps muscle often starts to shut down shortly after a meniscus injury occurs. Considerable atrophy of the quadriceps can be noticed within one or two weeks after the injury.

The best and most accurate diagnostic results are achieved with an MRI (Sagittal images – fat suppression) - providing a 90% accuracy when diagnosing a meniscus injury.

Symptoms of Menisci Injuries

The following gives you a basic idea of the symptoms associated with the severity levels of menisci injury. Please be aware that these are general guidelines, to make a definitive diagnosis a medical professional should be consulted.

Symptoms of a minor meniscus tear:

• Only minimal pain - you are still able to walk.
• Some degree of swelling with increased pain when squatting.
• Most of these symptoms should diminish within 2-3 weeks of initial injury.

Symptoms of a moderate meniscus tear:

• Pain directly at the site of the meniscus (along the lateral or medial line).
• Sharp pain with any type of squatting or twisting motion of the knee.
• Considerable stiffness.
• If these symptoms are ignored and rehabilitation is not implemented it could take several months to a year before they go away.

Symptoms of a severe meniscus tear:

• Immediate sharp pain, swelling, and stiffness in the knee.
• The knee may lock into position.
• The patient is often unable to straighten the knee.
• This is often a case for surgical intervention.

Differentiating a Meniscus Tear from other Knee Injuries

There are several subjective factors that can help you to differentiate a meniscus tear from other types of knee problems.

• A meniscus tear is often caused by sudden trauma and compressive twisting motions. Other knee problems often take time to develop, with no clearly identifiable cause.
• A meniscus injury will often create symptoms directly between the joint line of the femur and the tibia (shinbone).
• Meniscus injuries can often create a locking of the knee. Other knee problems cause dull, aching pain, grating sounds, or crepitation.
• Meniscus injuries often result in severe, sharp pain with any type of sharp angular maneuvers of the knee. Other knee problems only generate pain when the person is coming into or out of a squatting position.

Preventing Menisci Injuries – see the next installment of this blog for more information about how you can prevent menisci injuries. See the following sites for more information about knee injuries:

• Resolving Meniscus Injuries of the Knee
• Ligament Injuries of the Knee
• Illiotibial Band Syndrome (ITBS)
• Resolving Knee Pain
• Release Your Pain

Treating Meniscus Injuries Part 3

For more information about our clinic in Calgary, Alberta - please visit www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2010 – ALL RIGHTS RESERVED)

Treating and Preventing Meniscus Injuries - Part 1

The word meniscus is derived from the Greek word that means “Crescent” as in a crescent-shaped moon. The menisci in your knee are crescent-shaped fibro-cartilaginous structures that provides stability, shock absorption, nutrition, and joint lubrication while acting to distribute your weight across your knee joint.

The bones of your knees are covered with a layer of very smooth cartilage. This cartilage allows for gliding, reduced friction, and freedom of motion. The menisci of your knees are located between these cartilaginous surfaces and act to provide stability and even weight distribution. Forty to sixty percent of the force in the lower extremity is transmitted through the menisci. Without functional menisci, the joints of the knees would soon degenerate.

Each knee has two menisci - a lateral meniscus and a medial meniscus. Both menisci have a concave shape on the top and are flat on the bottom to create a wedge shape. This wedge keeps your thigh bone [ femur] from slipping off your shinbone [ tibia].

The lateral meniscus has an anterior and posterior horn. The popliteus muscle attaches directly to the posterior horn of the lateral meniscus. Thus, any tension or restrictions in the popliteus muscle directly affects the function of the lateral meniscus.

The medial meniscus also has an anterior and posterior horn. The semimembranosus muscle (a tendon extending from the hamstring) attaches to the posterior horn of the medial meniscus. Any tension or alteration in function of the hamstring muscles affects the function of medial meniscus. Fibers from the anterior cruciate ligament (ACL) blends into the anterior horn of the medial meniscus. A medial meniscus injury often occurs when there is an ACL tear. The medial meniscus is injured 5 to 7 times more often than the lateral meniscus since the medial meniscus is less mobile than the lateral meniscus.

Menisci injuries

Meniscus tears often occur when playing sports such as football, basketball, soccer, or rugby. Quite often, the injury occurs during a torsional motion in which the player’s knee is flexed while the foot is planted on the ground. Essentially the meniscus is torn due to the compressive forces that occur with rotation when the meniscus are pinched between two bones (tibial and femoral condyles).

Meniscus tears can also occur due to the slow degeneration that occurs with aging when the meniscus becomes less pliable and is easily torn. This usually happens to individuals over 60 years old.

Meniscus injuries, on the outer edges of the meniscus, can be very slow to heal due to poor circulation in the area. Meniscus injuries that occur within the center of the meniscus do not have the ability to heal themself since the center of the meniscus does not have a blood supply - it is avascular - without circulatory input. Without a good blood supply, nutrients required for healing are not supplied to the area and waste by-products are not removed. In a severe meniscus injury, loose pieces of cartilage (articular cartilage) may actually break off within the joint. These pieces can cause considerable damage to the knee joint, and lead to degenerative arthritis.

Surgical solutions for Injuries to the Menisci

Sometimes meniscus surgery is necessary. When surgery is performed, most surgeons will remove only a part of the meniscus. Removal of the entire meniscus will soon result in the development of osteoarthritis since there will be 235% increase in the stress experienced by the bones touching each other at the knee joint (tibiofemoral contact area). Arthroscopic surgery (where they remove a small section of the meniscus) can be performed if the damage is confined to the peripheral rim of the meniscus. Complete removal may be recommended by the surgeon if the damage is to the center of the meniscus (non-vascularized area).

Treating and Preventing Menisci Injuries – see the next installment of this blog for more information about how you can treat and prevent menisci injuries. For more information about knee injuries, visit the following sites:

• · Resolving Meniscus Injuries of the Knee
• · Ligament Injuries of the Knee
• · Illiotibial Band Syndrome (ITBS)
• · Resolving Knee Pain
• · releaseyourbody.com

Treating Meniscus Injuries Part 2

If you would like information about our clinic in Calgary please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2010 – ALL RIGHTS RESERVED)