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What Can Be Done About Meniscal Tear?

by Pain Doc | Sep 11, 2010 | Knee Pain

Capsule of right knee-joint (distended). Poste...

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The meniscus is a shallow bowl shaped piece of cartilage that is attached to the lower leg bone, or tibia. There is a medial meniscus (inner half of knee) and a lateral meniscus (outer half of knee).

The end of the femur (upper leg) bone has two protuberances called the femoral condyles, which rest on top of the meniscii (plural). In the standing position, the meniscii bear the full weight of the body above the knee. They serve as a cushion and shock absorber and protect both of the ends of the tibia and the femur. The meniscus also guide the action of the femoral condyles as you bend and extend your knee.

The knee is obviously a highly utilized, weight bearing joint. It has the largest suface contact area of any joint in the body as it has to bear most of the body’s weight and on top of that, absorb shock from walking, running and jumping. It is held together by several strong ligaments, the primary being the anterior and posterior cruciate ligaments (ACL, PCL), the medial and lateral collateral ligaments (MCL, LCL), and the patellar tendons. It is a synovial joint, which means it is totally encapsulated and lined with synovium, a specialized tissue that secretes synovial fluid to lubricate the joint.

The slightest alteration in the inner workings of the knee will lead to problems. A common one is a meniscal tear. The two basic types are a radial meniscal tear and a vertical meniscal tear. A radial tear that expands forms what is called a “bucket handle” tear (3rd set in the below image- top and bottom).

types of meniscal tears

Meniscal tears are caused by excessive pounding forces to the knee, which weaken the meniscii over time. Eventually a tiny tear forms, which grows in length as the individual continues to engage in the offensive activity (running on hard pavement, weight lifting, playing basketball, etc.), much like how a tiny crack in a car windshield grows into a long crack over time . If a small piece breaks free, it floats inside the knee space, suspended in the synovial fluid. Like a grain of sand in a watch, it interferes with the moving parts and can cause the knee to swell and become stiff.. Pain is felt deep inside the knee and is worse with prolonged standing and transitioning from sitting to standing.

Meniscal tears increase the chances of accelerated knee osteoarthritis, as “bone on bone” contact occurs between the ends of the femur and tibia.

TREATMENT: Diagnosis is made with a knee MRI and arthroscopy. Meniscal tears will most likely require arthroscopic surgery involving repair to the tear. If you have a gradual onset of deep, focal knee pain accompanied by knee stiffness that doesn’t go away, see your doctor.

Prevention, as always, is the key. I advise against sports that involve consistent and prolonged pounding forces to the knee. This includes long distance running and frequent hard court basketball that involves jumping. Consider doing functional exercises that combine cardio and strength instead.

Most leg exercises will strengthen the knee. Do mostly closed kinetic chain exercises where the foot is immobilized. This includes squats and lunges.

Intermittent jumping exercises are ok as long as they are controlled and are not the focus of an exercise session. Power jumps and related plyometric exercises fall into this category.

Most meniscal tears grow too large to heal on their own by the time the patient seeks medical help. This is why surgery is the only option. The surgeon stitches together the tear, but thanks to the forces the knee has to endure, the tear often returns.

Some patients do not get surgery, and let the tear become chronic. When it’s chronic, there is less acute pain, and more of a broad, dull pain in the knee. In this scenario, the knee joint will experience accelerated degeneration, leading to knee osteoarthritis. Eventually in the later years, knee replacement surgery is needed.

I made a general Knee Pain Rehab instruction video that includes things one can do to help deal with early stage knee pain.

How to manage lower back strain

by Pain Doc | Sep 9, 2010 | Low Back Pain

Low back pain is said to be the most common cause of lost work days, after the common cold. Most everyone has experienced an episode of lower back pain at some point in their life; millions suffer from chronic (ongoing; unending) lower back pain of some form.

The low back, or lumbar spine, is comprised of the last five (5) vertebrae in the spine. These vertebrae are the largest as they support most of the body’s torso weight. Like the cervical spine; i.e. neck (the first 7 bones of the spine), there are no rib attachments in the lumbar spine to limit movement, making the lumbar spine more moveable than the thoracic spine (torso), but less flexible than the cervical spine due to its larger, heavier vertebrae.

This unique lumbar spine design offers advantages and disadvantges. The obvious advantage is flexibility–you can bend (flex) your low back forward, backward, sideways, and can rotate it a few degrees to either side. The disadvantage is that with more movement, there are more opportunities to stress the joints of the lumbar spine (more moving parts) and therefore more chance of injury and pain. This includes potential injury/ trauma to the surrounding ligaments, joint capsules, cartilage lining the small joint surfaces; small facet joints, intervertebral discs, and the lumbar vertebrae themselves.

Therefore, low back pain can originate in one of several structures in the lower back:

the discs (strong fibro-cartilage ligaments that hold vertebrae together)
the facet joints (the “rear” joints of a vertebra, opposite the vertebral
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bodies)
the pars– the small extensions of bone to either side of the vertebrae that form the upper and lower borders of the intervertebral foramen, and end in the lumbar facet joints
the surrounding muscles
the surrounding fascia (muscle covering)
the nerve roots inside the spinal canal
the vertebrae itself (compression fractures; vertebral end-plate fractures)

Today we’ll address lower back pain due to muscle and fascia strain. I’ll refer to this a low back or lumbar strain. This is a common cause of lower back pain and is more manageable than pain due to deeper spinal structures.

In the many cases of lower back strain that I’ve treated over the years, the patient describes a sudden onset of pain after bending at the waist reaching for something. In other cases, the pain starts a day after doing something like weight lifting, running or rock climbing.

Medically speaking, a muscle sprain-strain occurs when muscle fibers tear during contraction and subsequently release inflammation.

The convention for naming soft tissue injuries is that strain refers to injury to a muscle and tendon while sprain refers to injury to ligaments, which connect bone to bone. Since muscles, ligaments and tendons typically get injured all at once in a typical injury due to their anatomical proximity to one another, doctors refer to these types of injuries as sprain-strain injuries.

Sprain-strain severity is described as Grade I, Grade II and Grade III, with Grade III being the most severe and refers to complete rupture of a tendon or ligament. Most lumbar strains are Grade I and II.

Inflammation is meant to contain/ quarantine an injury and is actually an important process in the healing phase (tissue regeneration). The problem is that it releases chemicals that irritate nerves and surrounding tissues, and stiffens adjacent muscles and joints. The inflammatory response can “overshoot” causing the patient to needlessly suffer.

If you go to your doctor complaining of lower back strain, and tests do not indicate damage to deeper structures (discs, facet joints, nerve roots, bone) then you will most likely be prescribed pain blockers (usually NSAIDs- non-steroidal anti-inflammatories), rest, and ice. Your doctor will likely put you on “temporary disability” which means no heavy lifting, bending at the waist, and other activities that put stress on the lower back. Sometimes muscle relaxants are prescribed, if there are complaints of spasm and stiffness. You will be told that it should resolve on its own, and most cases do.

TREATMENT:

At first onset of straining your back, apply ice for 20 minutes every two hours of the waking day. The easiest way in my opinion is to get a large freezer ziplock back, fill a third of it with ice cubes, put about a cup of water in the back and zip it closed (get as much air out as possible before closing shut).

Lie down so that your exposed (no clothing) lower back is directly on top of the bag. Bend your knees or put a pillow under them for comfort. This flattens the lower back and allows it to make good contact with the icepack. (Optional: put a neck roll under your neck for comfort). Do this for 1-2 days.

On the second day, you can introduce gentle stretches while you ice. After your 20 minutes of icing, try lifting your knees to your chest, pulling them gently towards you with your hands. Hold for 5 seconds; repeat five times. Then, keeping your feet together (you are still lying on your back), knees bent, let the knees fall to the right side, gently twisting the lower back; reverse sides. Do five times to each side. What these movements do is orient any scar tissue that develops, in the direction of contraction.

On the third day, assuming pain is still present, you can try using heat. I recommend an infrared lamp. This is radiant heat that penetrates deeper than a hotpack.

If you need to get pain free even sooner, I suggest using the 120 LED (Light Emitting Diode) wrap. This popular home therapy device used red light therapy + infrared heat, which goes beyond simply blood circulation increase. The red light diodes inhibit inflammation and increase cellular metabolism (energy production, waste removal) which means speedier tissue healing.

After a week, your lower back strain should be 60-90% better. If it is only 25% or so improved after a week, the injury is likely worse than originally thought; and deeper soft tissues may be involved. In this case, consider using Pulsed EMF to further enhance tissue healing.

Last thought: I believe that if someone strains his lower back by simply bending forward, it indicates that the back muscles, and probably core/abdominal muscles need better conditioning. It’s not all about strength, it’s also muscle coordination in response to varying loads; for example, picking up a piece of heavy luggage. Those with excellent muscle coordination (there are five major muscle groups that have to work together to move the lower back) are less likely to injure their backs like this. Interestingly, research shows that osteoarthritis, or degenerative joint disease in the lumbar spine, is related to poor lower back muscle coordination. And it makes sense– your muscles move and support your lumbar spine. Poor support and coordination between muscles (erector spinae group, abdominals, etc.) can cause your spinal joints to bear more stress than normal during every day movements.

So, the best strategy is to prevent getting lower back strain by strengthening AND conditioning (improve coordination of) your lower back muscles by doing functional exercises.

What is Causing My Heel Pain?

by Pain Doc | Sep 7, 2010 | Foot and Ankle Pain

Lateral X-ray of a Calcaneum demonstrating a spur.

Image via Wikipedia

Heel pain can be caused by a number of factors. One of the most common is a heel spur, medically referred to as a calcaneal spur.

A heel spur is an outgrowth of bone in the shape of a small spire. If it’s at the bottom or side of the heel bone (calcaneous), it can be painful to walk. It is thought that heel spurs form as a result of stress on a tendinous insertion into to the heel, but some heel spurs aren’t associated with the area where a tendon inserts into the heel.

Whenever offshoots of bone form (bone spurs), it is due to a history of stress to the bone, either gradual formation following a single impact trauma such as a car accident; or cumulative impact forces over time, such as from sports. For the foot bones, an example of the latter would be years of playing basketball or ballet dancing. The repetitive pounding on the joints of the foot can cause bone cells at the impact area to secrete more bone matrix as a compensatory response. In the spine and large weight bearing joints (knee, hip) they are called osteophytes.

In some cases, the heel spur stops producing pain; perhaps due to resorbption or even callous formation neutralizing its ability to press against tissue. For those that don’t, surgery can be done by a podiatrist or orthopedic surgeon to smooth down the heel spur.

TREATMENT:

In the meantime, avoiding impact trauma to the heel is important (running, jumping). You can buy special shoe inserts that help reduce pressure on the heel spur. Comfortable shoes are a must as well; make sure they are wide and have a thick rubber, shock absorbing sole. The Z-Coil shoe brand incorporates a large spring at the heel to minimize shock/ impact forces to the foot when walking.

Sitting in a chair and rolling a cold beer or soda can (unopened) under your foot can help stretch the foot and ease some of the pain. A golf ball can provide more focused massage to the bottom of the foot. Press downward with enough pressure to get a good stretch and massage, but not so much to increase the heel pain.

Image via Wikipedia

Lastly, consider exercising your feet by walking barefoot around the house and outside (walking barefoot indoors is not as effective due to the flatness of the floor; bumpy and uneven is better). Walking in shoes actually weaken the foot over time by preventing the intrinsic foot muscles and joints from exercising and experiencing their full range of motion. You can also consider getting the Vibram foot glove. This interesting shoe fits on your foot like a glove, allowing some independent movement of the toes.

Plantar fascitis is a condition where the plantar fascia (a wide, band-like ligament connecting the heel to the forefoot) pulls off a thin layer of periosteum (membrane lining the bone) from the heel and results in inflammation and pain at the front, bottom part of the heel. It can make walking very uncomfortable.

The best approach to treating plantar fascitis is to rest your foot for a few days: no running, no walking up hill; walk only on flat surfaces. Use Red Light Therapy and Pulsed EMF for 15 minutes, twice a day for 2-3 weeks to accelerate healing of tissues, and for reducing any inflammation that is causing pain. Red light therapy uses photobiomodulation to accelerate cell metabolism; thus accelerating healing of tissues.

Compression fractures and hairline (stress) fractures can also cause heel pain. If you think you’ve fracture your heelbone, have it X-rayed. You’ll likely get a foot cast, avoid impact to the heel for several months, and wait until the fracture heals (no pun intended).

If your heel bone fractures easily, it could be due to a bone cysts. See your doctor on solutions for dealing with bone cysts.

Carpal Tunnel Syndrome

by Pain Doc | Sep 6, 2010 | Hand and Wrist Pain

Image via Wikipedia

Carpal tunnel syndrome is a condition where one of the major nerves of the arm gets compressed in the wrist. It can lead to pain, numbness, and tingling in the hands. Advanced symptoms are muscle weakness in the hands, muscle atrophy (shrinking), especially of the thumb pad; and loss of motor coordination in fine dexterity skills, like buttoning a blouse.

The three main nerves that are responsible for controlling the arm are the ulnar, median, and radial nerves. The median nerve, like its name implies, travels down the middle of the arm. It passes through the carpal tunnel which is just above the crease in the wrist before splitting into branches that go to the thumb, index, middle, and inner half of the ring finger.

The carpal tunnel is a small diameter hole formed by the wrist bones and the transverse carpal ligament. It contains the tendons that flex the fingers (flexor tendons), and the median nerve. Pressure as light as a penny can adversely affect nerve tissue, so any pressure increase in the carpal tunnel will over time injure the median nerve.

The most common cause of increased pressure in the carpal tunnel is thickening of the flexor tendons due to long term repetitive use of the fingers such as in typing. Over time the tendons press the median nerve against the rigid transverse carpal ligament. The nerve loses oxygen and it starts to malfunction. Left alone, the damage will be permanent as nerves have a limited ability to regenerate.

Other possible causes are prior injury to the wrist that narrows the carpal tunnel and arthritic or other pathological changes in the wrist bones that cause them to occlude the tunnel.

Pregnancy and thyroid conditions may mimic symptoms of carpal tunnel syndrome.

TREATMENT:

Image via Wikipedia

If the symptoms are advanced (pain, numbness, tingling especially at NIGHT and loss of hand coordination and muscle atrophy) see your doctor. The doctor should refer you to a hand specialist who may order a nerve conduction test to diagnose carpal tunnel syndrome. If your test is positive, you may be referred for physical therapy, which will involve mostly stretching and hand exercises. If that doesn’t work, you may be offered a cortisone injection and exercise prescription, a wrist brace and orders to avoid prolonged hand usage. The last option is carpal tunnel release surgery, where the transverse carpal ligament is surgically cut to relieve pressure in the tunnel.

If your condition is not advanced, do the following:

If your job or hobby requires lots of finger and hand activity, there is a good chance that this is the cause of your symptoms. Check your work station set up and ensure the following:

a. Keyboard should be low enough so that your fingers are at the level of the keyboard when:

your upper arms and shoulders are relaxed; your upper arms (above the elbow) are to the side of your body almost touching;
your elbows are bent 90-100 degrees
your wrists are straight or even bent slightly downward

The most important part is having your shoulders relaxed. To see if you are doing it right, using your right hand press the top of your left upper shoulder, from the neck down to the shoulder joint. It should be relatively soft. If it is not, you are unconsciously contracting the neck and upper trapezius muscles and lifting the arm.

If you find you can’t accomplish the above, due to your desk being too high, you need to get an adjustable keyboard tray and install it under your desk. Place the keyboard on this tray and lower and angle the tray so that you can meet these requirements (see video below on how to do this).

b. The top 1/3 of your monitor screen should be at eye level. Use phone books or a monitor lift to get it to this position. Place the monitor close enough that you don’t have to bend your neck forward to see text on your screen, or adjust your screen settings to magnify the text.

c. The mouse and frequently used equipment should be close so that you don’t have to reach forward for them. Your keyboard tray should have an attached mouse pad; use it.

d. Remember to keep your head in a position where your ears are directly over your shoulders.

e. Every few minutes, relax your hands and wrists for 20-30 seconds.

f. Every hour do the wrist, neck and shoulder exercises in the video.

g. When symptoms are gone, you can do wrist strengthening exercises.

Exercise for Thoracic Outlet Syndrome

by Pain Doc | Sep 5, 2010 | Hand and Wrist Pain

The thoracic outlet is an “opening” at the base of the neck, on both sides, where the nerves and artery that service the arm on that side exit through as they descend into the arm. It is formed by the anterior and medial scalene muscles, the first rib, and the clavicle (collar bone).

If the thoracic outlet narrows in any way, due to one or more of these structures, neurovascular compression is possible (compression of the nerves and artery). This can result in shoulder pain, neck pain, weakness in the affected arm and hand, numbness and tingling in the arm down to the hands, especially the last three fingers; and in some cases swelling of the arm. Carrying something like a heavy bag on the affected shoulder makes the symptoms worse.

In thoracic outlet syndrome there is usually a history of prior injury/trauma to the shoulder girdle, such as a car accident or sports injury. People with long necks and long arms are said to be more predisposed to this condition as the weight of the arm and length of the neck tend to put more stress in the thoracic outlet area.

Left alone without resolution, it is possible to develop permanent nerve damage resulting in chronic pain, weakness in the arm and hand, and reduced sensation in the inner arm area.

What to Do if You Suspect You Have Thoracic Outlet Syndrome

If you suspect you have thoracic outlet syndrome, see your doctor or an experienced chiropractor. There are some simple orthopedic tests that can be done to see if you likely have TOS. An MRI study can help visualize the thoracic outlet and identify if there is swelling; and needle electromyograph (EMG) can determine if the arm muscles are getting the proper amount of nerve flow.

If the diagnosis is confirmed, physical therapy exercises are usually prescribed to help open the thoracic outlet space. In some cases, imaging studies show a fibrous band responsible for compressing the neurovascular structure; in these cases surgery may be an option. This involves the scalene muscles — three, short muscles that connect the lower neck vertebrae to the ribcage.

In the meantime, try doing this exercise. It is designed to create more space between the collar bone and the ribcage. If this is where your compression is occurring, it may help.