Do you suffer from knee pain?

Do you “suffer” from knee pain? 

“Within this new paradigm, overweight and obesity contribute to OA through biomechanical (increased joint load) and inflammatory mechanisms.”

​There is newer research that indicates body fat can release inflammation. Think about this, inflammation can cause pain and there has been the old wives tale that being overweight can be the cause of pain, but now there is research to back up the claim that excess body fat can be a factor in having increased pain.  

“Years lived with disability due to high body mass index have also increased markedly for males and females aged 15-49 years since 1990, emphasizing the potential contribution of rising obesity levels to global OA (osteoarthritis) burden among younger people”

​Being obese takes a toll on health. This is not a surprise. The heavier a person is, the more energy and work required in order to just move. Pair this with increased pain sensation and movement may actually decrease over time.  

“Research has shown that the greatest risk factor predicting the development of knee OA in young an middle-aged people is a previous traumatic knee injury”.

​If you injure your knee traumatically, the research covers ACL surgeries and meniscus surgeries, then there is a high likelihood of developing knee osteoarthritis.  

“Radiographic findings are not well correlated with symptoms and are unlikely to alter the management plan or predict future disease progression”

​THIS MAY BE THE MOST IMPORTANT MESSAGE FOR PATIENTS TO UNDERSTAND. Just because an X-ray shows “degeneration”, “osteoarthritis”, “joint narrowing”, “bone spurs”…so on and so forth…doesn’t mean that this is causing pain. What we now is that these findings are common as we age. There’s an analogy that these findings are similar to wrinkles on the skin, they are just wrinkles on the inside. Not too many people worry about skin degeneration in the form of wrinkles. The same should hold true regarding some of the results of an X-ray or MRI.  

“Overuse of MRI is costly for health systems and may lead to unwarranted surgical intervention.”

​The most important part of this is that MRI’s may lead to surgeries that aren’t needed. Let’s go back to the wrinkle analogy. Just because something doesn’t look young and supple…like it does in the textbooks, doesn’t mean that everyone should have a surgery to remove wrinkles. The same holds true for wrinkles on the inside.  

“…comprehensive assessment of young patients should include 3 key components: 1. A patient-centered history; 2. Physical examination, including performance-based tests; and 3. Administration of appropriate patient-reported outcome measures (PROMs).”

​I challenge this sentence in that it is only limited to young patients. This 3 step process should be performed on every patient, REGARDLESS OF DIAGNOSIS! Every patient should be treated as an individual and not as a diagnosis. Everyone has a different story. Every patient has different needs. Every patient has different goals that are specific to that patient in front of you. The only way that this can be learned by the therapist is by performing a patient-specific evaluation.

​The only way that we know if a patient is actually improving, aside from simply asking them, is to perform tests and measures. When your internet isn’t going as fast as we think it should, we can always run an internet speed test. This is an unbiased way to test the thought that it is running slow. We need the same types of tests and measures in physical therapy. These should be performed by your PT within the first 2 visits.

​Finally, there is a patient reported outcome. This is a way for the patient to answer questions in order to determine if the patient actually believes that they are better or not. The questions have been validated by some research and the form should be universally known.  

“…education about the neurophysiology of chronic pain and contribution of emotional and social factors to the pain experience may be relevant for some patients.”

​Many people still believe that an injury happens and therefore there must be pain. It doesn’t quite work this way. The brain can overcome any of those “inputs” that theoretically can cause pain. For instance, we’ve all heard the story of a person performing feats of strength like lifting a car off a child, but few people hear about the injuries that tend to happen after this feat of strength. The brain can overpower the body’s ability to feel pain. On the flip side, the brain can cause pain without injury. This is a little known fact by many PT’s unfortunately. This type of pain requires a completely different type of treatment than someone that is actively experiencing an injury. This is more complex than can be described in this article, but there will be future posts to describe this phenomenon.  

“…exercise can reduce pain and improve physical function for knee and hip OA…Muscle strengthening can play a role in managing symptoms…Neuromuscular training programs can address sensorimotor deficits often associated with knee injury, including altered muscle activation patterns, proprioceptive impairment, functional instability, and impaired postural control”

​This is a mouthful. To summarize, there is rarely a reason not to “get stronger”. Being strong enables people to do more than being weak. Don’t get me wrong, there are multiple ways to get strong, but there are also multiple ways to get injured while getting strong. Please, if you have little/no experience with strengthening exercises, see a PT or CSCS in order to obtain quality information prior to starting the program.

​Neuromuscular training can be replaced by balance activities. This can teach patients how to utilize the “somatosensory system”, which is the communication that takes place between the muscles, bones and brain in order to remain in a certain position.  

“…neuromuscular exercises can improve knee cartilage quality (glycosaminoglycan content) in middle-aged adults following partial meniscectomy.”

​Every once in a while I learn something new when reading orthopedic research. (just kidding, I am learning every day from the stuff I read). This is a new concept to me. This means that by performing balance training, we can improve the quality of the knee cartilage (meniscus). This is huge because as a health professional, we were always taught that the cartilage has poor blood flow and we can’t really impact healing of this tissue. Who know that balance and exercise were good for you?

“..combining strengthening exercise with exercises aimed at increasing aerobic capacity and flexibility may be the best exercise approach for managing lower-limb OA”

​This has been challenged in the research lately. There is an article by Richard Rosedale (JOSPT 2014) that demonstrates that using MDT can provide superior results. The original advice of diet, exercise and balance is probably still the best advice until more research comes out to show that specific exercises are better than others.  

Hope this synopsis was helpful. If you are experiencing knee pain or have been told that you have arthritis, there are options. Come see me at FTR in Joliet, now a member of the Goodlife Family.  

Dr. Vince Gutierrez, PT, cert. MDT

903 129th Infantry Dr.

Unit 500

Joliet, IL 60435

815-483-2440

QUOTES TAKEN FROM:

Ackerman IN, Kemp JL, Crossley KM, et al. Hip and Knee Osteoarthritis Affects Younger People, Too. J Orthop Sports Phys Ther 2017;47(2): 67-79.

THAT JUST CHAPS MY ARSE!

101_1749THAT JUST CHAPS MY ARSE!

 

MORAL: We know a little more than we did 10 years ago, but we didn’t know much then either. We now know that we have been calling trochanteric bursitis by the wrong name. WHOOPEE! We think we know how to treat hip pain (isometrics progressing to loaded movement), but we aren’t completely sure yet. Don’t you love evidence-based medicine? I know I do. I feel smarter after reading this article (shaking my head no at the same time).

 

  1. “Gluteal tendinopathy is though to be the primary cause of lateral hip pain”

 

Gluteal, otherwise known as buttock, tendinopathy (a dysfunction of the tendon) is a major cause of lateral hip pain. Of course before we go here, the therapist or physician should rule out the spine as a cause of your symptoms. If he/she does not know how to do this, go to find a MDT therapist.

A long time ago (couple of years ago actually) there was this common diagnosis that we would get as a referral…trochanteric bursitis. It would make patients feel so smart that they remembered this term for their entire lives, because at some point a doctor may have told them that this is what is causing their pain. In 2 out of 10 patients with hip pain (outer border of the thigh), this diagnosis may be correct. If so…you are such a smarty pants. For the other 8 of 10, this article will apply to you (see below).

 

  1. “While this condition has traditionally been referred to as trochanteric bursitis, gluteus medius and/or minimus tendinopathy is now accepted as the most prevalent pathology in those with pain and tenderness over the greater trochanter…of 75 individuals…only 8 had bursal involvement”

 

This to me is awesome! Think about it…the medical profession has been around as long as prostitution and yet we still don’t know what we are selling. At least the other profession knows its product.

 

The research on this diagnosis is relatively new…the past 15 years, but I didn’t hear about this while going to PT school. I’ll tell you what I did learn about though…trochanteric bursitis. It’s a shame that the research is not making it into the school system. If your doctor/therapist/chiropractor/naturopath/neighbor calls it trochanteric bursitis it means one of two things, or both: 1. They don’t read current research 2. They graduated from a school that doesn’t teach current research. I know that it is semantics, a rose is but a rose and all, but a name is important. If we are treating trochanteric bursitis, we are assuming from the name that it is an inflammatory issue of the trochanteric bursa (fluid filled sack that hurts like heck when irritated). If we are treating gluteal tendinopathy, then we are treating a muscle tendon dysfunction. These are treated totally different based on tradition and current research; so the name matters.

 

  1. “While a number of risk factors for the development of gluteal tendinopathy have been proposed, few have been validated”

 

In other words, we think we know what places you at risk, but we can’t be sure. Modern science is awesome. Everyone wants information, but also needs to understand that we don’t have crystal balls. This whole evidence based practice thing is fairly new…considering the overall length of time that medicine has been practiced. It will take a long time in order to obtain answers. All we can give you at this point in time is our best guess.

 

  1. “…the prevalence of lateral hip pain (likely gluteal tendinopathy) in people with low back pain has been reported to be as high as 35%…Importantly, treating the tendon-related pain has been shown to improve the function of those with low back pain, suggesting an interaction if not a causal relationship”

 

Okay…the authors of this journal article just made some big boy claims. First, to say that the lateral hip pain is likely tendinopathy is biased and absurd. We can not say this until the spine has been ruled out as a cause of lateral hip pain. Lateral hip pain is just that…pain in the outside portion of the hip. Until we rule out the spine as a cause of the pain, we can’t even say that the pain is coming from the hip. To make a claim this bold is arrogant. KNOW THIS: MULTIPLE JOINTS CAN REFER PAIN TO THE LATERAL HIP. If there is a problem in the back, it can show up at the lateral hip, which as the authors say is very common to have both back pain and hip pain simultaneously. If the SI joint is causing you problems, it could also show up at the lateral hip (not as common, but at least we can test for this). Finally, if the hip joint is causing problems, this can also show up as pain at the lateral hip. This is all before even talking about the gluteal tendons! The above statement is arrogant.

 

The second statement that is a stretch is to say that gluteal tendinopathy is the cause of low back pain. If you truly believe that, then you should buy this bridge I’m selling. It overlooks the bay in San Fran. Treating the hip tendons (also knows as core stabilization) is shown to be helpful in a small category of patients with back pain. To say that the hip caused the back pain is just as absurd as making a broad statement as the back caused the hip pain. Neither can be said until the patient is evaluated by someone unbiased.

 

  1. “Many orthopedic hip tests can be used for diagnostic purposes for more than 1 condition”

 

This is like saying there are many tests that can be used to measure water pressure, but none of the tests can tell you where exactly the problem is coming from. The tests only tell us that you hurt when we do these tests. There is a good article by Jeremy Lewis, PhD called something along the lines of “Special tests aren’t that special”. This means that as much as we would like to hinge our decision making process on special tests…they don’t tell us much.

 

  1. “…signs of local soft tissue pathology at the greater trochanter are common in imaging of those without lateral hip pain; thus, diagnosis should not rely solely on imaging studies”

 

Holy mouthful Batman! I think that the authors just said that imaging doesn’t tell the whole picture. Healthy people…without pain healthy people…can have the same exact picture as you, only they have no pain! IMAGINE THAT! We know so much more now than 10 years ago, but some of our new knowledge just works to muddy the picture of the pathoanatomical model (saying that we know which tissue is the problem).

 

  1. “In studies of patients with clinical symptoms of lateral hip pain…atrophic changes in the gluteus minims and medius in 40% of the hips”

 

If your hip hurts, you may not use it as well (otherwise known as limping), which may cause a further problem with the muscles. This is just speculation, but the authors already speculated that hip pain causes back pain…so I feel justified.

 

  1. “The authors of a recent article have demonstrated that five 45-second isometric quadriceps contractions held at 70% of a maximum contraction provided almost complete relief of patellar tendon pain, immediately and for at least 45 minutes”

 

I find this study fascinating because based on MDT principles, maybe it wasn’t the force or the prolonged hold, but simply straightening out a knee that is typically bent. I’ll have to find the study and see if the authors of that study actually tried to classify the patients before giving the treatment.

 

  1. “Increases in night pain may indicate that the load has been too high and needs to be adjusted. Once each level of tensile load is well tolerated, the load should be slowly increased and the response monitored to maximize structural change in the musculotendinous unit, while avoiding or minimizing pain exacerbation. “

 

DON’T BE A MEATHEAD! Hi…my name is Vince and I am a meathead. I say this with love. If you do too much, you will create a chemical response in your body called INFLAMMATION (read it with the menacing voice like in the commercial for heinous diseases…like erectile dysfunction). If you do too much, you will hurt. The funny thing is that you won’t know you’ve done too much until you’ve actually done it. It’s like a new graduate not getting a job because they need 3 years of experience. The only way to get there is to get there.

 

EXCERPTS TAKEN FROM:

 

Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and clinical Features in Its Management. J Orthop Sorts Phys Ther. 2015;45(11):910-922.