Could Sit Ups Make Your Back Worse?

Hey, guys!

It’s Dr. David here at El Paso Manual Physical Therapy

We hear from clients all the time that they’ve been told by somebody somewhere down the line that sit-ups are bad for your back and they’ve probably felt pain when doing sit-ups or after doing sit-ups.

The thing is it’s not that sit-ups are bad for your back. Its that the way you might be doing sit-ups is bad for your back.

We want to clear it up for you guys.

Here is the right way, one of the best ways to do a sit up and it’s not the only way.

There are tons of ways.

An important thing to know about the way that you’re doing sit-ups is that there are three primary muscle groups that you use to accomplish a sit up or any type of ab exercise.

There’s upper abs, lower abs and then your hip flexors which are in the front of the hip here into the thigh a little bit.

You use all those muscles to perform that sit up motion.

But, when you’re trying to help your back problem by doing sit-ups, you usually need to get the lower ab stronger, the ones that are right below your belly button.

There’s a quick little trick that you can do that cleans up a lot of bad form on sit-ups.

Let me show you real quick.

This is the way that I like to do sit-ups.

You’re just going to lie flat, arms all the way up, feet flat just like so and here’s the trick.

You got to flatten out your low back so you got to push down right here.

Then once you hold that down, then come up from right there and you would do as many reps or sets as you desire to do.

But you got to focus on feeling your lower abdominals below the belly button work harder than anything else.

Now the reason why I don’t like you to have somebody hold down your feet or pin your feet under something is because that forces you to use your hip flexors more because you’re using your legs to stabilize and makes you cheat on using your lower abs so you miss using your lower abs because you’re using your hip flexors.

If you always train like that, you do your ab work like that, you’re actually training your hip flexors and it can definitely lead to a back problem.

Guys, if you’ve got a low back problem and you’re looking to do some ab exercises, some core exercises to treat the back problem, make sure you target those lower abs.

I hope this helps, guys.

Have a wonderful day.

Meniscus Tears – Everything You Need To Know

May 20, 2020/in Podcast/by dmiddaugh

Hey there El Paso! Welcome to the Stay Healthy El Paso Podcast. My name is Dr. David Middaugh, Physical Therapist, and I'm the owner of El Paso Manual Physical Therapy. I wanted to talk to you today about meniscus tears. We have had lots of clients in the clinic, over the past few weeks coming in with knee problems, and they specifically have meniscus involvement.

Now I'm going to use a bunch of different words, talking about the meniscus. I'll try my best to make sure I delineate the differences between them all. So when I say meniscal involvement, for example, that's just any problem related to the meniscus, because there are different types of ways that the meniscus can get injured, which we'll go into. But just follow me here. In case you are having trouble following all the different terms, don't worry, I'm trying to make this as simple as possible, for people that are not in the medical field and may not understand medical terms.

But I'll have to use a term every now and then just to make sure that I'm communicating clearly. I encourage you to go Google stuff and go look it up type in the word that I'm saying here, but like I said, I'm going to explain it as clearly as possible.

I'm going to tell you everything you need to know about meniscal tears. If you have one right now, you are going to probably find yourself in some of these symptoms I'm going to talk about, as well as some of the issues that are surrounding meniscal tears and treating them.

If you have never learned about a meniscal tear, let me just start with answering the question of what the meniscus is. I get asked this all the time. A meniscus is a chunk of cartilage that sits between your thigh bone and your shin bone. It's in your knee and you have two in each knee, you have a pair in each knee and the pair is differentiated by the inside one, and the outside one. In the medical field that’s called the medial meniscus. That's the inside one, and the lateral meniscus, that's the outside one.

The job of these two chunks of cartilage, in each of your knees, is to cushion the thigh bone on the shinbone, and make sure that movement happens. Normally in the knee, because if you ever look at the structure of the bones in the knee, they don't really sit on each other perfectly well. Well, the meniscus helps to fix that problem, it develops what's called congruency because the meniscus is cup shaped. They allow the end of the thigh bone to settle onto the top of the shin bone, the tibia.

The main job, like I said, is to cushion the femur onto the tibia, the thigh bone onto the shin bone, and of course what's above the thigh bone while the rest of your body your hips, your torso, head and arms. Because it's supposed to cushion it, it acts a lot like a disk in a spine. If you think of your spine or somebody's spine. There are chunks of cartilage between each of the bones in the spine, and their job is to absorb forces and cushion everything else above, and below it and allows certain movement to happen. So that's a meniscus.

The next question I usually get, from people coming in for treatment is, why does the meniscus tear? Why is my meniscus torn? How did it happen? Some people have an accident, maybe playing sports growing up, they were playing soccer or football or volleyball, basketball, one of those and they had a knee injury that went undiagnosed. They got better from it. They never felt like they had to go to the doctor. But they have never quite been the same from that injury there. They tend to avoid exercises that aggravate it. They just been babying it essentially for decades.

You do have some more extreme injuries where we are playing those same sports or something similar or car accidents or other accidents. People blow up their knee, they tear the meniscus, they tear the ACL, or other structures in the knee. They might end up having an operation afterwards because it was a massive injury. Those people can also end up with some meniscal injury later on in life.

There is another group of people that never had a sports injury growing up, never really had any injuries whatsoever. And then they get to middle age, they are in their 50s, 60s, maybe a little older than that, and they start having knee problems. They go to the doctor, get an MRI and find out that they have a meniscal tear. That's always a shocker for them because they are wonder how did they get this? They have never had any knee pain ever. They have never done anything that could have aggravated it, and they chalked it up to old age. They think well, I'm in my 60s now so I'm feeling older and this is what happens to old knees.

But let's talk about what really causes a meniscus tear. Those are just the perceptions that people have, the stories that people give here in the clinic. But when I look at a meniscal problem, somebody that is coming in and they are telling me about their knee problem, the way that the pain presents, I have to differentiate, is it more of an arthritis problem? Is it more of a meniscus problem, a ligament problem or some other cartilage in the knee? Because there is lots of cartilage in the knee.

There are other structures too, that that could be causing knee pain. Certain nerves can cause knee pain. There is actually a nerve that is called the saphenous nerve. It runs on the inside of your leg, and there is a massive branch off the saphenous nerve that lies right on top of the meniscus and could mask meniscus pain for some people. I have to be able to differentiate, is this a saphenous injury or a meniscus injury or is it both, and then decide how to treat that problem so that the person can get back to doing what they want to do.

But in a true injured meniscus, where there is a tear and there are problems with it, the structure of the meniscus is disrupted. A lot of these people can function without any problems. They may not even know that they have a meniscus tear.

Then there are some other people that have knee pain. They go get an MRI, they get checked out, and they are told that they don't have a meniscus tear. When we see them here in the clinic, they have knee pain, obviously, they may even have swelling and other problems that look a lot like a meniscus tear. But what I believe they actually have is an irritated meniscus, which you can't really pick up on an MRI or X-ray too well, and it's confounding for the medical field.

People don't know what to do with these types of patients that have knee pain, that doesn't show anything on any sort of imaging, any sort of MRI or X-ray. The way to think about a meniscus irritation is, just think of your skin, if you scratch your skin, not too hard, but hard enough to get it red, where you leave a red mark. That would be skin irritation. Your skin is just angry because you scratched it. That redness will go away within a few minutes, maybe at most, a few hours, maybe a day at most. It won't take long to recover from that before your skin will look normal again. But if you scratch yourself pretty hard and you break your skin, some blood comes out while you have an injury there, that needs to take some extra time to heal properly, and that's going to take you some more time.

In a true injury on your skin, you have to start the inflammation process, you have to send certain cells to the area, your bloods got to clot, you have to eventually form a scab, under the scab, over time, a scar will form the special cells to do that, that's called proliferation. And then over the course of a week or two, sometimes three, then the scab will fall off and you have a nice new little scar that formed to protect your skin and close it up. Now that's got to happen in just about every single tissue in the body. It just looks different depending on the tissue. That happens on bone, that happens on cartilage, on ligaments, on muscle, but obviously you don't see it because it's under your skin.

Whenever you look at your body, you are pretty much looking at skin everywhere. So, in a meniscus if you have a tear, it is really slow to heal, because cartilage is one of the slowest healing tissues in the body. I think in the meniscus, in my opinion, from my personal experience in treating people with this, this type of problem, it's the absolute second slowest, only second two discs in the spine. Discs in the spine can take a really long time to heal. But the good news about both discs and the meniscus inside the knee, the cartilage in the knee is that it does heal. If you put it in the right environment, you take the proper steps, it can heal. I've seen it happen many times and people are always super happy to reach that point.

The next question that you probably are wondering about, because you are thinking, well, do I have a meniscal problem or is it one of these other things you mentioned, arthritis, that weird saphenous nerve, other types of cartilage in the knee. Let me go the way that a meniscus tear feels in individuals. Whenever we spot them here I can, I can tell you exactly how they present. I categorize these people into three different types, mild, moderate, and severe meniscus tears.

In mild, there might be a little bit of swelling, these people tend to still be active, they get pain. Not every day, it's more so a couple times a week, and it tends to be associated when they are very active. A lot of these people are younger usually, they are in their 40s, sometimes 30s. You see some older people with it too. These are the people that are definitely in better shape and haven't had any injuries, and they tend to get a mild meniscus injury later in life. But they eill be running or playing sports. Being active with families. Some of them just like to go walk their dog and they will push their activity a little too much and that will set off their knee problem.

They will come in saying, I've been walking or jogging for years, and I started to train for this event where I had to do extra and then my knees started to swell up. But I gave it a day or two, the swelling went away, I felt fine again, and then I went back to do that exercise, and my knee swelled up again. And it's just concerning me because I'm getting older, and I want to be able to do this activity. I've never had any problem and I don't want to have to stop doing this exercise because it's keeping me in shape.

That's the typical mild presentation for a torn meniscus, or it could even be a meniscal irritation in these people. In fact, a lot of these people don't get MRIs. It's not that bad for them. Some of them barely get any attention from doctors though. They might go see him for a visit and then get sent straight over to physical therapy. They never actually get an MRI. Which is a good thing in my opinion, because if you have a tear, it leads you down a path that may not be the nicest. Ignorance might be bliss in this in this situation.

Plus, they get better once they come into the clinic and get treatment. They start improving, they don't feel like they need a MRI, or any sort of imaging, because they are happy with the results.

One person in particular, we had a woman in her 50s come in, she's ran for years and years, three, four or five times a week she runs on a treadmill at home. She is not into competition or anything like that. She just runs for her own benefit. She does other exercises as well some aerobics type of exercises. But she started to have knee pain all of a sudden, during and after running. Then she was flared up for a week or two. Nothing that stopped her from doing what she wanted to do. But she had to think twice about getting back on the treadmill because she knew that she would flare up again.

After we address certain things in her hips and her muscles around her legs, we even had to go up into her back, and down into the foot as well. She got back to running and she didn't have any problems at all, it stopped the swelling, we got it back 100%. So that would be a case of a mild meniscus injury. The people that come in at that point, I think are super-duper smart because they are definitely getting ahead of the problem. Ideally don't want to wait until it's more moderate or severe. But I'm going to go into moderate and severe next.

If you find yourself in one of those categories, don't take it the wrong way. Our medical field is just crazy if you have any injuries. We'll talk about it just let's keep going here.

Let's get into the moderate part. If you have a moderate meniscal problem, you think you might have a torn meniscus, the way this is going to present, you are going to definitely have swelling, you are going to definitely have limits on your activity, the problems might present daily. These people to tend to complain about going up and down stairs, usually going downstairs is rougher than going upstairs, and they started having trouble sleeping at night. Because of the knee problem. They also tend to say that mornings are pretty rough. They don't like to wake up and get up out of bed in the morning because those first few steps, getting up out of bed to head over to the bathroom. The knee feels stiff, it doesn't want to move well, it might pop and click a lot. It takes 15 minutes, 20 minutes, and some people closer to an hour to kind of loosen up the knee and kind of get back to normal.

When it's at that point, these people typically have stopped exercising. They are concerned that they are getting unhealthier. They are putting on weight and that's feeding into the knee problem as well. A lot of times they've been seen a doctor already, they might have had some sort of treatment that just didn't work out for them. They might be using a brace or something like that, and we'll talk about what to use, and what not to use here in a second but just bear with me.

If you think that you have a moderate knee meniscal tear, it usually is still salvageable quite a bit, you can usually get in the 90s, as far as percentage improvement, if we are talking, zero to 100%, these people tend to get 95% better, 97% better. They tend to do really, really well, they might just have some very mild limitations that they might not even worry about. Most importantly, they don't need to have a surgery or some sort of invasive procedure, and they can stay healthy the rest of their lives.

Let's talk about a severe meniscal tear. These people will have all the symptoms of the moderate meniscal tear, the ones that just covered, their swelling will tend to be constant. Of course, going up and down stairs is a nightmare for them. They avoid it at all costs. I've had people come in and say I sold my two-story house because I could not go upstairs anymore. And I live in a one-story house now and I avoid stairs at all costs. I always use the elevator the escalator. These people tend to walk with a limp. They have changed their walking pattern over time. Some of them will use a cane, they tend to be older because this has happened over time.

One of the classic symptoms that severe meniscal tear will have is joint locking. What this looks like is their knee will get stuck. They will sit down, or go to get up, and of course you have to bend your knee during that process, and when they are about to transition either into sitting down or getting up, their knee will get stuck. They are sitting down, their knee won't want to bend all the way. Most people, when they sit in a kitchen chair, your knee will bend about 290 degrees, and it'll get stuck at 20 degrees or 30 degrees and they feel like they can't bend it to 90 degrees, it's painful, and it just feels stuck or locked. Usually they can shake it a certain way, kind of wiggle it around, and then it'll make a noise, it'll pop and unlock. Then they can bend their knee just fine.

Then the opposite will happen when they stand up, they will go to stand up and the knee will kind of stay bent. They usually have trouble balancing once they stand up, and they shake their leg around, and move it around, and then it'll pop, and then it'll go straight, and they can walk normal again. By normal i mean they are normal which is painful and with a limp and with swelling and all that. The thing behind this is that there are a flap of the meniscus that's impeding motion within the joints. That's why these people can shake it loose and twist and turn their knee and it'll move better.

But if it's that bad, you have a severe meniscal problem more than likely. Now, the way that the meniscus will feel in most people, as far as pain, is that they tend to have pain on the inside of their knee. If you were to reach down and you feel your kneecap and then slide your hand towards the inside of your knee, there are usually some bumpy spots there, depending on how much tissue you havegot, and that's where it tends to hurt for people.

Some people do have pain on the outside of the knee as well, and some people report pain on the back of their knee. There are something called a baker's cyst that can develop at the back of the knee. When you hear the word cyst people, I think the mind picture that most people get is like a bubble that needs to be taken out or drained. The way I think of this is the joint is just very swollen inside the knee, there are an active inflammation process happening, and extra fluid is being developed to deal with it.

Sometimes, I think the body is trying to build some cushion inside the knee as well. So, it's generating fluid, and it's a genetic thing. In my opinion, I think some people are just predisposed to react that way to different types of the injuries including a meniscal tear. That Baker cysts is a problem, because they will have trouble bending their knee and it's unsightly for some people. If they get really big, they just get really concerned with it. But the problem needs to be addressed, the meniscus problem needs to be addressed, and usually the baker cysts will reduce or become less of issue.

The medial meniscus, the inside knee meniscus is the one that tends to get affected more often. But you do see the lateral meniscus problem happen to a lot of people as well, and there are ways to test both here in the clinic. But regardless of which one is affected, the treatment options are typically the same, and we are going to go into all that here in a second. But what you'll see with a meniscus problem is, there are usually other knee problems happening at the same time. You'll typically see some knee arthritis developing, it's called osteoarthritis. There are usually some cartilage problems in the back of the kneecap, on the front of the femur, the thigh bone, and there could be some ligament problems as well.

There are some major ligaments inside the knee. I'll just go over them really quick. One of the top four are called the ACL, PCL, MCL and LCL. And these are structures that connect the bones to each other and hold the bones together. These four ligaments, their job is to make sure that the thigh bone stays attached to the shin bone. If they get elongated or torn, then that can cause stability problems in the knees. The connection between the two bones won't be as stable as it should be, which can cause the meniscus to get irritated because the meniscus will take some weird forces.

Let's talk about what happens to an untreated meniscus tear. We got lots of clients coming in here, of course they are getting treatment and some of them delay a long time on getting treatment, and the symptoms kind of worsen. And then we have the ones like I was telling you about earlier, where they come in when it's mild, and they haven't had any major limitations yet, and they haven't had a chance with all this other stuff to develop. But what tends to happen in people with untreated meniscus tears, of course, the meniscus problem gets worse over time. They move from mild to moderate to severe, and with all the problems that develop they will progress through arthritis way faster than normal.

About arthritis, arthritis is happening, and everybody constantly think of it as aging just like you get gray hairs and wrinkles on the outside of your body. The thought process osteoarthritis is that you get it on the inside of your body as well, and you age on the inside of your body as well, and it looks like osteoarthritis, so the joints change a bit. You might get different little structural changes in other tissues as well. For some people, they start developing small bone spurs. They start developing the cartilage might thin out, they get spots on their cartilage, the joint surfaces looking even, and it might not actually be painful at all.

In older people, I think, I'll have to dig up the research again, but it's in the 90s. I think once you are over 80 years old, it's like 93% chance that you are going to have some sort of arthritic change, or disc herniation in your back. I haven't seen the research on knees, but the rates go up. Of course, when you are younger, you still have a chance of having all that stuff happening, but it is painless and a lot of people. But if you have a meniscus tear, and you have other issues on top of that, like loose ligaments or cartilage issues in the kneecap, and you havebeen moving inappropriately for a while, you haven't been exercising like you probably should be, because this knee problem is slowing you down. Then it's going to allow for a faster progression.

Just think of it like your overall health. If you don't take care of your health, you are going to probably not live as long as somebody who does take care of their health. Your joints are the same way. If you don't take care of your joints, they are not going to last as long as if you do take care of them. People with meniscus problems in their knee, they tend to eventually develop hip problems. They can develop hip arthritis, they can get pain in the hip joint itself or around the hip joint. They will also get lower back problems. A lot of times we get ankle and foot issues as well. The foot changes the strength in their foot is usually affected and that can cause toe problems like hammer toes, bunions, other issues with the foot that that can be prevented.

Loss of arches in people that leave this untreated for a long time meniscus problem and then the arthritis gets out of hand, they will eventually likely get an knee replacement because the knee problem will continue to get worse. Of course, once they have that locking, like you get in severe meniscal tear that completely changes the mechanics, people really slow down. They don't want to move as much because of the locking and that makes arthritis progress way faster. If years go by, decades go by, then it's just a matter of time before they start getting told by their doctor that they need a knee replacement.

If it's that bad, if they've had joint locking for a long time and in their knee doesn't even move and have all the motion that is supposed to have a knee replacement a fantastic option for those people. The only concern I had is how are you going to move after that. You have to make sure you take care of your leg health, and get your activity back so that you can keep your body healthy, and make sure you don't have to have another knee replacement in a matter of time.

Now we are heading into the final part of this podcast here, we are going to talk about what treatment options there are for a meniscus tear. We will also go through the entire list of things that I see people do, and probably all the options that you are thinking of as well. I'm happy to entertain more if you leave us a comment on this podcast or get in touch with us. Let us know what other options are out there, I want to get a comprehensive list going.

Prior to getting any sort of medical treatment, we often see people trying home remedies.

The top things that people try, which is the easiest one, is just giving it time. They just rest it, they avoid moving a whole lot. They will avoid walking more than they need to, just to rest their knee. This is a very short-term solution, especially if you got an irritated meniscus it's going to feel better with off time. It absolutely will usually feel better because you are not standing on it, you are not putting weight through it, you are not using the meniscus like it's supposed to, so it has a chance to heal.

The problem is, if you haven't fixed the underlying problems that got to the meniscus tear, the meniscus problem in the first place. As soon as you get up to move again and you get active again, because you are feeling better, you are going to flare up again, we see people do that all the time. That's why they have the often symptoms where they say, Well, sometimes it flares up, and then a couple weeks later, I'm okay. Then another two or three months after that, it flares up again, and then it goes away. And then it flares up and it goes away. And eventually after going through this cycle enough times the pain gets worse and it stays more constant, or you don't get as much relief from the rest, because the original root problem hasn't been addressed.

The other things people will try at home, will be over the counter medications. Things like Ibuprofen, Tylenol, and Naproxen. There are a bunch of different medications you can get at the pharmacy over the counter. A lot of people try anti-inflammatory medications. The idea is to reduce the inflammation in the meniscus so that it can help with healing, and it's a pain reliever as well.

This is good for most people in the short term, they do get some relief. But after a while the drugs can become dangerous and this is not a good long-term solution. Ibuprofen is known to affect the lining of stomachs instantly, and for most people they can tolerate it pretty well, but I think the cutoff is six to eight weeks. If you are using ibuprofen consistently around the clock. After six to eight weeks the rate of people having major stomach problems, they get a hole in their stomach lining that spikes tremendously, which can lead to internal bleeding, which for a lot of people, they they need to go to the hospital for that. In some severe cases there is deaths that occur, especially in older populations, which is the people that tend to get these knee problems anyway.

If you are at home right now and you have been taking ibuprofen for a while, I strongly suggest you find an alternative, or take a break, or talk to your doctor about it and see what other options you have. Make sure you start to build a long-term plan to treat this miniscule problem because over the counter pain medication is not a long term plan.

Other things that people try are pain creams, you got your BenGay, Icy Hot, Biofreeze the rub that stuff all over their knee, and that tends to work pretty well in the short term as well. It's a pain reliever, it's not fixing the root problem, which we'll talk about here in a second.

The other the last most common thing that we see is people try knee braces. They will go to the store and buy a sleeve that slides over their foot and ankle and comes all the way up to their knee. These sleeves usually have a little opening for the kneecap to tell you where to line it up and leave some space for the kneecap. Some of these braces will be a little more heavy-duty, where they have metal brackets that are on the inside or the outside of the knee. A lot of people report that they have relief with these knee braces.

If you haven't tried a knee brace yet, and you are looking at trying to just get some relief, go for the knee brace that's definitely a way to get off the pain medication, if you havebeen using pain medication for a long time. It still is not going to solve the long-term problem, but I love the knee brace because it's not that dangerous for you to use. It's a safe way to get some instant relief, and most people report a little less swelling, they can sleep a little better at night.

But it only lasts so long because the problem is, knee braces tend to make your muscles weaker. Your body is smart, it can sense stability coming from the outside. The muscles will get lazy and you start to atrophy or lose muscle over time. A knee brace is just a short-term solution, you have to figure out a way to eventually not have to rely on the knee brace.

The other thing about knee braces is their main job, especially the heavy-duty ones, the ones with the brackets, their main job is to stabilize the knee and if you don't have a ligament problem, then it's not going to make a huge difference for your meniscus problem. You might need to get that checked out by an expert to know if you have more of a ligament problem, or meniscus problem, and get proper advice on how to use the knee brace. Because what I see a lot of people do, that come in where they need brace. I ask them this question I say, well, who gave you the knee brace first of all? Was it just on your own that you got that, or did somebody recommend that you use one? Was it a medical professional? And then what's your long-term plan for this knee brace because, if you are in your 50s or 60s, wearing a knee brace right now, I would not want you to be wearing a knee brace into your 70s and 80s or beyond, you eventually need to get out of that thing, but you need to have a plan.

The last step in your plan cannot be I'm going to be in this knee brace the rest of my life. Those knee braces are uncomfortable, they slide down, they get stinky, you have to wash those things everyday probably, especially in the summertime, and they just don't allow for normal movement. Ideally, you want to be without the knee brace as soon as possible, but you have to get to a point where you can wean yourself off and be able to do your everyday functions without a knee brace.

Okay, let's talk pain medications, prescription strength pain medications. Let's say you have gone to the doctor for this knee problem, they will usually recommend some sort of prescription strength pain medication. There are a ton of different types out there. It depends on which doctor you see, what their specialty is, and what their background is. They will recommend all kinds of pain medications, and these are all short sighted, for the most part, they are just doing their best to help you out with the pain that you are dealing with right now.

Understand that medications do not make your muscles stronger, they do not make your cartilage healthier, or your ligaments healthier, or your meniscus healthier as far as the actual structure. In fact, a lot of these anti-inflammatory medications, they are stopping the first stage in healing. Inflammation is actually a normal thing. That's why our bodies do it. It's the very first stage in healing, and it needs to occur in order for proper healing to happen.

If you are relying on anti-inflammatory medications, like some doctors will prescribe a steroid pack which limits inflammation. It's an anti-inflammatory medication, it is stopping the healing process in your entire body, and that's why they can't give you too much of it, because they know the long term effects of it, but it may provide you some quick relief, which most people are looking for that are visiting the doctor.

That might be a good thing for you, especially if you need to just kind of get through the week or get through the month. Or you don't want to be mean or grumpy with people because of your knee problem because that tends to happen, and you just want people to sleep at night, you are losing a lot of sleep. There are definitely some benefits to using some high-power pain medications, but they cannot be your long-term solution. You cannot rely on those for the long term, you are only going to get worse in your meniscus problem.

The next way the doctors will help out with medications is they will give you injection medication. The most common injection that people get is a cortisone injection into the knee, sometimes they'll do two or three all at once. It just depends on the doctor and how they do it. That is pain medication injected directly into the joints space, or the space where the meniscus is. They tend to be pretty effective in reducing pain. A lot of people have this sensation where they feel instantly better, after the injection site heals, maybe a day or two.

They might need a few days to recover from the injection, but then they feel massive relief. They feel like they can walk again, be active again, do all the things that they want to do. But you have to keep in mind, if you just got an injection, or you have had one not too long ago, or you are going to go get one soon. You have to keep in mind that it is not healing your meniscus. In fact, it's preventing your meniscus from healing. It's just masking the pain and you have got to make a plan to fix this meniscus for the long term so that you are not relying on injections for the long term, or other pain medications.

They will limit you on how many injections you can get per year, especially these cortisone injections. Because the doctors are very aware of the research, insurance companies are very aware of the research. If you get more than three or four per year, I think that's usually the limit. I'm not a physician, I'm a physical therapist, if I'm off, if you are in the medical field, or you know about all these limitations, and you are like, this guy doesn't know what he's talking about. You are probably right. I don't keep up with that part of the medical field. I keep up with my specialty very well.

I'm giving you the information that I hear from doctors and what I learned going through school, and what I keep up with here and there. The laws change, and the best practices change over time, and that's completely normal. But what I hear clients saying is, they limited me to three, they limited me to four. I'm like, good, you shouldn't get more than that because it's going to mess up your meniscus in the long term or other similar structures. So, you cannot rely on those cortisone injections.

Other things that people will get injected is PRP that stands for Platelet Rich Plasma. This is part of the newer, I think they call it functional medicine or it's non-medicinal, and it's supposed to be the natural stuff. They are injecting you with platelet rich plasma, they have to take some blood from you. They put it in a centrifuge, one of those things that spins really fast, and they pull up the plasma from your blood and it's got tons of platelets in it. Which is a sum of certain structures that are in your blood, and they inject that into your knee and the idea is that it helps your knee cartilage heal faster. I've seen mixed results with people getting these. I've heard some people say that it definitely helped out their pain, and then other people say didn't do a thing.

The other thing that people get injected with is, and this is less popular, but it's up and coming are stem cells. You might have done some research because maybe you have a meniscus tear. You have known it for a while. You had an MRI a while back, and maybe you have been dodging surgeons, because they've been wanting to do an operation on you, and you are thinking of alternative solutions. I'm sure stem cells has probably crossed your mind once or twice. It's still controversial, the source of where they get the stem cells is very controversial. I won't go into that. Even the efficacy or the likelihood to be helpful for you, is mixed.

I have had some clients, that said that they had stem cells injected, and said that it made a big difference. And I have had others that said they had it injected, and saw only minor difference, or no difference. It's so new that we don't know much about it. Right now, there isn't much research. Not many people are doing it, and that that's all we know about it right now.

What I can tell you regarding all these injections is, they are not fixing the strength of the muscles, which usually needs to be addressed. They are not dealing with joint mobility, how well the joint moves, the quality of motion, the way that you move overall, the way that you walk and move. But that's something we fix here in physical therapy, which I'll talk more about in a second. There are still a lot of root problems that are not being addressed with these injections, and I think that's why people get mixed results because they get some relief instantly. But they continue to be weak and continue to not move well, and that sets them up to have the pain return. It's not a good long-term solution to the problem.

Okay, two more things. We are to talk surgery next. A lot of people get a surgery to fix their meniscus, they will do a meniscectomy, often a partial meniscectomy, which means that they take out a piece of the meniscus, usually a flap or a torn chunk. The idea is that the tissue is not going to heal, so they cut it out, get it out of the way. Because the assumption is that that is what's causing the pain. But what we know about the meniscus, as far as its ability to generate pain, the outer edges of the meniscus, where tears are less likely to happen. The outer edges are where you have the most nerve endings and where it's likely to be more painful. The inner edges are where you have much fewer nerve endings and that's where the tears tend to happen. It's a little controversial right now doing these partial meniscectomies, because there are actually a few studies coming out of England.

England, they have a national health care system, where it's run by the government, it's socialistic versus here in the US it's capitalistic. But as a result of them being of England being a national health care system, the government is very into figuring out what works and what doesn't, because they want to save costs. So, what they are what they are doing is something called placebo, partial meniscectomy.

What is happening is, they are getting people that have known meniscal injuries, they get them through MRIs, they get their MRIs done, and they find them meniscal tears, and they are putting them into these studies where they split them in half. Half the group goes into where they get normal surgery done. They are the normal partial meniscectomy be done, and then the other group goes into the placebo, partial meniscectomy. Both groups have surgeries. There are interesting words in the studies, they say they even move the knee the same way in the placebo, they have the same tools, they put them under anesthesia, the same people are there, they take the same amount of time to try to account for every variable possible to make it exactly like a normal surgery. But the one difference is that they do not actually cut the chunk of the meniscus out that they were looking at cutting out.

They leave the torn meniscus alone. Then they close them all up, and after the course of six months, up to a year, what they found was that there was no difference in improvement between both groups. Both groups improved a bit, but not one group improve more than the other. Now they are thinking well, is this meniscus surgery even doing anything? Now they haven't done studies like that in the US, but I think it'll be interesting if they ever do.

For those people that have meniscus surgeries, what I would consider if this surgery even needed? Is that the best place to go? You open yourself up to a bunch of risks possibly, if you ever have a surgery, there is a chance for infection. You have all kinds of risks, and for some people, it is the best thing. I'll even tell some clients that this this is pretty bad, I can't help you with this, you need to go talk to a surgeon, ad I'll be straightforward and honest. But for a lot of cases, coming in a lot of people with meniscus problems, I'd say you know, 9 out of 10. What I'll tell them is I can help you out, and if it's real severe, I'll say well, let's give it a month with treatment., and if you are improving some, maybe you'll be happy with that level of improvement, we'll have a good idea for how much you can improve. Because you might be okay with getting 70% better if that's your max because at least you can walk around and do your normal things. 100% improvement may not be realistic for you, even if you had a surgery, who knows.

If you are out there and you have already had a meniscectomy, a partial meniscectomy, and it didn't improve, and you are one of those cases, unfortunately. Or if you are thinking about getting a meniscus surgery, or you are just learning about this for the first time, and you even know there was a meniscus surgery out there. Let me tell you about the outcomes of this.

A lot of people will improve, they get better, but then over time, they tend to regress, they get worse again. What we know for sure in the research is people that get meniscus surgeries are more likely to have osteoarthritis develop quicker in their knee. I think it's for obvious reasons. There is a chunk of your meniscus missing. So, the knee joint just doesn't move normally again, and it's going to age faster. It's really a short-term solution in my opinion to get a knee surgery, it might be the best decision for you depending on your situation. You have to weigh all those problems with you all those all those risks, all the factors to make the best decision moving forward.

But what the surgery is not fixing. Let's talk about that. Next is your strength, your joint mobility, the way that you move, the how you sit, how you stand. There are a lot of things that we look at here in physical therapy. Here at the clinic, we go into extreme detail about what you are doing, that led up to this meniscus injury. Because that's the question that needs to be answered. If we can fix the problems that led up to this meniscus injury, then you have an excellent shot at recovering for the long term. Even if you have had a surgery, you are going to have a surgery. It allows you to stop using the pain medications. avoid having to get injections. Stop having to worry about your knee all the time, you can get your sleep back, you can be able to go up and down steps just fine.

I'll tell you a story. We recently had a woman who came in for her hip. She actually had a hip surgery that didn't go too well but was having knee problems, and it looked like a moderate meniscus injury. In figuring out what was going on with her hip, and what we found in her was that her glute muscles are very weak. She just was not using them well. And it's counterintuitive because she's got a big butt. You would think she's got lots of glute muscle, and she has some pretty good strength, but she just wasn't using it well, and the strength that she had wasn't enough for the activities that she was doing. She was on her feet quite a bit, walking around every day for her job.

She doesn't have adequate strength to do what she needs to be doing throughout the day. And then she also isn't walking the best, so we had to figure out how to teach her. We taught her how to walk better way to figure out the problems there. We taught her how to strengthen her glutes better, and how to progress and to what level to progress to, and it's been amazing to see the benefits, we are five weeks in, now this week's upcoming is a sixth visit.

She is already sleeping better. She's walking much better. She stopped relying on insoles. She used to get insoles all the time. She feels like she doesn't need them anymore. The number one thing that we talked about recently though was, she's got a two-story home, and she was saying that she has to grab the rails to pull herself up with her arms to take weight off her legs, her hip and her knees. Because it was hurting so much. That was the first visit that I saw her. She flies up those steps now and can go down the steps with little to no pain, and she's still got tons of improvement to make.

This woman is set on getting back into the gym and doing the treadmill, being able to jog, being able to lift weights, and I think she's going to be very capable doing it. We just got to go a little farther and her progress to get to that that level.

So that's the root problem that we are fixing in here, we have got to find out where you are weak, where you are strong, there are usually something called a muscle imbalance happening. Muscles on one side of the body will be relatively strong, and on the other side of the body, they will be relatively weak. That stuff you can't pick up on an MRI. You can't see it on an X-ray, physicians aren’t trained to fix that or even identify it.

I think some doctors will have an idea of that happening, but they are not sure what to do with it because their specialty is medications, surgery, injections, those kinds of things. And that's cool. You need that sometimes. But if you are looking at fixing your movement, your strength, getting that long term, natural cure, because you take that with you, you can only get medication for so long and injections, and you ideally don't want to have more than one surgery. You are going to get one, you want to be going back for surgery all the time, doctors won't even let you do that.

You want to have fixes that you have control over, and that's what we teach here. It's heavy in education. We teach you what to do, and how to do it, when to ramp it up, or when to ramp it down, how to read your body, how to know what's normal, and what's not normal as far as sensations, and what you should be doing. We coach people through that process so that they can get to the point where they feel super confident that they are doing the right things, and that it's only helping their knee and not harming their knee.

There you go, guys. We talked about everything there is about meniscal problems. We covered what it is, what the meniscus is itself. How does a meniscus tear? What does it feel like to have a meniscal injury? We went over the mild, moderate and severe levels of meniscal tears, and what happens to an untreated meniscal tear. Of course, more issues are going to happen up in the hip and down in the foot. Then also the treatment options. We covered everything from what people try at home, and then what you can get done using the medical field, and what's going to help you for the short term, and what's going to help you for the long term. I hope this podcast was helpful for you. If you know of somebody that's got a meniscal injury, please share this with them. I want everybody to have the best information possible so that they can make the best decision about their own health moving forward. And I hope you have a wonderful day. Have a great day. Buh bye.

The Top 6 Tips For How To Heal A Rotator Cuff Problem Without Surgery

May 14, 2020/in Blog/by dmiddaugh

Top 6 Reasons For Knee Pain and 4 Ways To Fix It

May 13, 2020/in Podcast/by dmiddaugh

Hey everyone, welcome to the stay healthy El Paso podcast. I'm your host, Dr. David Middaugh, expert manual physical therapist, and I'm the owner of El Paso Manual Physical Therapy.

I am going to talk to you today about the top six reasons for knee pain and four ways to start fixing it. We see knee pain here in the clinic all the time, and if you haven't had any sort of trauma, such as an accident where you fell, somebody fell into you, then you developed knee pain.

Usually, for most people it comes on without any sort of reason, it comes on what we call insidiously. That's what they say in the medical field. But all that means is that there wasn't a clear reason why you started to have knee pain, it just came out of nowhere. Oftentimes, people say it's related to their age, they say “I hit 50, I hit 60, and my parents had the same problems as they were getting older. Now that's why I'm getting issues too, it's just age catching up with me.” But we are going to talk through some of the main causes of knee pain that comes on without any sort of reason and dispel some of the myths along the way.

Let me just talk about age right away. As you age, of course, time passes in order for you to age, and one of the things that you have to keep in mind, that sure your body won't heal as fast, and you have put more wear and tear on it over the years. But what is affecting people, that are older, is that they have put more wear and tear on it in a bad way. In other words, if you think of a car, the longer you drive it, the more maintenance you have to do on it.

You have to fix your tires, get your oil changed, you get other things changed out and repaired, and all that tune-ups. But if you make sure that your tires are properly aligned, if you go get your tires rotated, if you manage your tires, they will stay good for a long time. But if you don't go get your tires checked out, then they start balding. In other words, the treads start to disappear and that's because you wore down the tires, the rubber on the outside of the tires way faster than you should.

Same thing happens inside the body. We are talking specifically about the knees today. If you are doing things that are harmful to your knees, unknowingly most of the time, then it's going to wear down your knees faster, and it's not a function of age.

An interesting thing that we see is, people that are just generally more active, they are very into running or cycling, they are just getting lots of reps. They get knee problems younger than somebody who is less active, just like if you were to, put 200,000 miles on your car really fast, you are going to go through more tires. But if you aren't as active as other people, maybe you are not into running or cycling or heavy exercise. Maybe you are more of a leisure exercise person you like to work out, walk and do other things.

Those people that still tend to get knee problems will get it later in life, like 60s, 70s or beyond. It's just a matter of how many reps they put their body through the bad reps, reps that affect their knee joints improperly. I just wanted to dispel that myth really quick. We will go through more here in a second.

Let's get into the top six reasons that knee pain happens.

Reason number one, worn down cartilage.

It's along that same thread that I was talking about. There is cartilage right behind your kneecap. If you feel your knee right now if you reach down and feel the front of your knee, there is a little bone that is called the kneecap and it sits against the end of your thigh bone.

The thigh bone, it's called the femur, it is the longest bone in the body, and it is the top half of the knee. The knee joint, and that little kneecap slides up and down against the end of the thigh bone. And between the surfaces of the kneecap and the thigh bone, there is layers of cartilage. That cartilage is supposed to allow for frictionless movement.

In other words, the bones are supposed to slide on each other real nice and easy, without any sort of grinding, without any sort of noise. Of course, if you have any children around or youngsters, they probably never complain about knees cracking and popping, as they bend them or straighten them. But your knees might make noises, and that's usually because you have worn down cartilage somehow, some way.

The cool thing about the human body is that we have nice thick layers of cartilage, that take a long time to wear down all the way, to where it's harmful for you. If you are concerned right now, because you find that your kneecaps are crunchy, they make noises whenever you bend them and straighten them out. As long as it doesn't hurt, you are okay. It is a sign that you have worn down your cartilage to some degree. I would get concerned to make sure you manage it because it can lead to other problems that we will talk about in a second.

You have to make sure to keep your cartilage healthy. Now, how to keep your cartilage healthy? That depends on a lot of things. The most basic level of advice I can give you, on keeping your knee cartilage healthy, the one right behind your kneecap and on the end of your thigh bone, is to make sure that you get some form of regular consistent exercise.

Some interesting facts about cartilage are that it's a very active tissue. A lot of people think it doesn't have a blood supply, it doesn't have much of a nerve supply, and that's true, but that doesn't mean that it doesn't do anything. It's a cushion in the cells inside the cartilage, cartilage cells, they respond to how much force you put through them, and if it's the right amount of forces, it can actually start fixing itself and fortify itself, make itself more dense, so that it's protective against wearing down too fast, and appropriately so that you don't have any problems later on in life.

Regular exercise stimulates these cartilage cells to behave normally and protect themselves against bad stuff happening to your knee cartilage. Regular exercise depends on your fitness level, your ability. If you haven't worked out in a long time, that doesn't mean start running three miles every day. You got to do a little bit at a time and work your way up. Of course, you have to figure out what works well for you.

That's number one, worn down cartilage. It is probably one of the most common reasons that we see people here in the clinic with knee problems and it's very fixable. There are a few things that need to happen, and they all tend to get better. The noises don’t go away completely, but it doesn't hurt and it's not getting worse. That’s the most important thing.

Number two is loose ligaments.

You have a bunch of ligaments in your knee. Some are very popular. A lot of people get surgeries on these. Just to make sure that everybody's on the same page here. A ligament connects a bone to a bone. In the context of the knee, there are four main ligaments, I'll mention a fifth one as well, but the four main ligaments that connect the thigh bone to the shin bone, the thigh bone is the femur, and the shin bone and the tibia. You have the ACL anterior cruciate ligament, the PCL posterior cruciate ligament, the MCL, the medial collateral ligament, and the LCL, the lateral collateral ligament.

The ACL is probably the most commonly torn one or affected one. That's the one that you hear about in sports. High school kids might have their ACL torn or affected somehow. If you ever watch basketball or football, knee injuries are commonly stemming from some sort of ACL injury. If you have a completely torn ACL, it's actually possible to function without one. But you have to make sure that you are very strong, and that you learn how to move properly. But that is a surgery that is commonly done for knees.

If you have a torn ACL, there are great surgeons out there that can go into your knee and repair it. There are a bunch of different ways to repair it, and those surgeries work out pretty well. The rehab is not fun. In order to get all your knee motion back and strength back, it typically takes about a year. But most people returned to sports just fine, as long as they don't have too many other associated injuries.

Because usually, when you tear your ACL, there are other things that get affected too. In the context of this podcast, we are talking about knee injuries that come on without any sort of trauma or accident. If you had a sports injury, and tore your ACL, then this wouldn't count.

But let's say that you are in your 50s, 60s or older, and you had some old high school injuries, or you fell once or twice or more, and kind of tweaked your knee and it's never been the same since. We hear that story here in the clinic so many times and they will tie it back to “Yeah, this one time I was coming down the stairs and took a bad step, kind of stumbled down and my knee has never felt the same since.”

When we see people here in the clinic, one of the first things we go to check is their ligaments, because we can actually feel here in the clinic, how lose their ligaments are or how tight they are. They should be tight. They shouldn't really move. Ligaments are not stretchy structures, they have a certain length and they are supposed to remain that length all the time. They do have some plasticity. In other words, that's what they call it in the medical field, but that just means that over time, they can stretch and shorten, but they should normally have a good amount of tightness to them so that it keeps your joints together properly.

But in some cases, we have people that have a loose ACL, or a loose NCL, or other ligaments as well, ad that can start affecting the knee really badly. They will get alignment issues in their knee, meaning the shin bone doesn't line up properly with the thigh bone. That's because the ligament is loose, it's just not as tight as it should be. Over time that causes other issues, usually the ligament itself doesn't hurt a whole lot. It's the side effects of having that loose ligament.

The cool thing is, if you have a loose ligament in your knee, like an ACL, or an MCL, or one of these other ligaments, you typically don't need surgery. You actually need to brace it, you need to put a knee brace on. The hard part with it though is how long to wear the knee brace, when to wear the knee brace, and how do we not have the knee brace. There is a whole treatment approach to this, that we walk our patients through here in the clinic, because it is very confusing.

The information out there, on the internet or even for medical professionals, they really by and large don't know how to feel that these ligaments are loose, and how to guide somebody on how to wear a knee brace properly so that it keeps the knees stabilized long enough to let the ligament scarred down and shrink to its normal size, so that it keeps the position of the thigh bone in the knee bone in its proper alignment.

If you think that you have a loose ligament injury, if you feel like you fit into one of those stories, that could be a reason for your knee problem.

Let's go on to number three…

Next, we are going to talk about a torn meniscus.

This is very common here in the clinic. In our clinic here at El Paso Manual Physical Therapy, we focus on helping people avoid unnecessary surgeries, injections and medications. Some cool research that came out with the meniscus, and before I go into the research, let's talk really quick about what it is the anatomy of it.

You have two meniscuses in each knee. You have four in your body. You have two in each knee that column, the medial meniscus in the lateral meniscus, a meniscus on the inside of your knee, and a meniscus on the outside of your knee. These are huge chunks of cartilage, and they act like a cushion a lot like the discs in your spine. They are shaped differently, and they are a little different in their makeup.

As far as what the tissues actually made of. It is a type of cartilage, but they are different because your knee joint has to bend and straighten, and you have to be able to walk and run and go up and down stairs and all the things that you normally do. The meniscus in your knee are really interesting structures. There are a lot of people that don't know that they are not solidly attached to your bones. They are attached to your tibia, the shin bone, the very top of it where it connects to the thigh bone. They are loosely attached so they are attached by the ends.

They have the ability to swivel and shift, and move around in order to accommodate the femur, the thigh bone sitting on top of the shin bone. If you have had a meniscus injury, then likely you had a knee alignment problem that has caused the thigh bone to pinch the meniscus. That's what usually causes a tear.

A torn meniscus happens over time, most of the time, it doesn't happen right away. There are a lot of people that say “Well, I had this accident and I tore my meniscus.” But you have to always consider, how do you know it wasn't torn before and maybe it just didn't hurt at that time. Either way, if you have a torn meniscus, what you will feel in the knee is usually a pretty loud clunk or click. That happens when you bend your knee at the same angle every time. In other words, if you look down to your leg and you are sitting right now, and you straighten out your leg, and at the same angle, you feel a little bump or a click inside your knee. That could be a torn meniscus.

There are a lot of other things that could be too. But here in the clinic we have special test to find out is this more of a meniscus problem, or some other cartilage, like the kneecap and thigh bone. If you do have a meniscus problem, typically you will get swelling along the joint lines, where the thigh bone meets, the shin bone, and it's associated with a lot of pain.

People will be in pain for days at a time when it flares up. That's another concept these meniscus injuries will flare up so they can get better. When they are not flared up and then you do something, you are too active, you are on your feet too much and then it flares up. You get swelling, and it hurts, and usually you lose some motion too, where you can't bend your knee or straighten your knee out all the way. In extreme meniscus injuries, you get locking, where you lose a lot of motion and you feel like you can't straighten it or bend it all the way.

Some people will force it and then it'll pass that restriction it'll unlock, it'll pop loose. Or they feel like they have to shake their knee or twist their foot and get the right angle and then their knee will move all the way. The idea with that is that there might be a flap, or a section of the meniscus that is in the way of the of the motion of the knee and it blocks it.

Whenever you have a torn meniscus, the common medical procedure is to go get a surgery to clean up the meniscus, where they called a meniscectomy, and what that means is they will go into the knee with the scope, so they will just make tiny incisions, and they will clip off the pieces that are torn and in the way of normal motion.

I think that's definitely necessary for some people, depending on how effective their meniscus is and other factors. You will have to talk to your surgeon about that. But there are some interesting studies that are coming out of the United Kingdom, the England area, where they have done placebo meniscus surgeries. What they did is they took people that had meniscus tears that were diagnosed via MRI, so they had an MRI, they found the meniscus tear, and half of them had a normal meniscus surgery where they cleaned up the meniscus. The other half had a placebo surgery. They actually did make cuts on them and they went in, they did everything they normally would, except they did not cut off the chunk of the meniscus that they needed to cut off. They left the meniscus alone. What they found is that in the recovery, in the months after having the meniscus surgery, both groups of people that had a normal meniscus surgery, and the people that had the placebo meniscus surgery, recovered the same. All improved, they all got better, and they all had a good outcome.

But now the question is, how necessary is that meniscus surgery? Because, of course, that costs more money and the rehab associated with that it takes more time. They are looking at ways to make sure that they heal meniscus injuries without surgery.

One more thing before we leave the meniscus topic, because it is very common, and we see it here in the clinic all the time. We have people that have the swelling issues, they have limited motion. It looks like a meniscus injury, but then they go get an MRI and find out that it's normal. The MRI showed that there is nothing wrong with their meniscus. Now there are problems with MRI, sometimes they don't show everything that's happening. There are times where the doctors go in and they realize that they do have a tear just didn't show up on the MRI, or the opposite can happen where they see a tear on the MRI and then they go in and it's fine.

This is guru level stuff. I don't have any research to back this up. But based on my experience with patients and how they improve pretty quickly, sometimes I think that there is such a thing as an irritated meniscus. Now, follow me here. Think about skin for a second. If you look at your skin, say look at your hands right now. If you were to scratch your skin lightly, but enough to irritate your skin, where you get a red mark, that is irritation, and it goes away within minutes, at most a day. But if you were to scratch your skin so hard that it cuts it open and you start bleeding, that's a skin injury. That's different from irritation.

Because what needs to happen in order for your skin to heal from from a cut that opens it up and you bleed from, you need to go through the normal healing process which requires you to get a scab and develop a scar, and that takes a week or more at times. It's a longer recovery time for your skin versus just a light scratch that causes some redness.

I think the same thing can happen in a knee meniscus, a medial or lateral meniscus in the knee, where you can irritate your meniscus, not necessarily tear it because you didn't have any findings on the MRI. The reason why I believe that happens is because normally, cartilage takes months to heal. You are talking three to six sometimes 12 months, depending on how severe the injury is.

Yet, we have people here in the clinic that look like a meniscus injury, and they are better within a month or two. I have to think that it is an irritation, especially if they have MRIs with them, that show that there is no tear. After a month or two of treatment, their meniscus looks completely normal. I really think that it's an irritation, and that's excellent news for a lot of people, because when they come and get treatment for an irritated meniscus here, we'll tell them if it's irritated or more likely torn.

They can avoid having an MRI which can be costly, and not really give you the best information always. Then they can also avoid potential unnecessary meniscus surgery and injections, which often just mask pain, they don't really fix the problem for the long term. They can avoid having that as well. So there you go. There is all the details on why a meniscus can cause pain in your knee.

All right, we are halfway through all the reasons.

Let's go on to number four, arthritis.

There are different types of arthritis. The most common is osteoarthritis, osteo just means bone. And arth means joint. An itis means swelling. Bone joint swelling is what osteoarthritis is. There are other versions of arthritis, psoriatic arthritis, rheumatoid arthritis. There is more than that. But the most common problem that people have is osteo arthritis. This is the age-related changes inside your joints.

This is associated with a meniscal tear, usually a loose ligament, and you can also have worn down cartilage. This tends to affect people that are older. What happens in it. Let's go to the extreme what happens in extreme arthritis is you have a loss of motion on an X ray. You will see that the bone ends just look different than normal. There is been small, repetitive problems that have continued for a long time and never been fixed, and it has changed the joints so much that the joint does not move.

Normally, there is swelling associated with this sometimes, and getting better from extreme arthritis, you are not going to get 100% better. Likely you are looking at more like getting 50 75% better, and if it's not that severe, then I think you can get it in the 90s for sure. But there are usually some more permanent changes. I'm an advocate of the body is very malleable; the body can change. If you put it in the right situation, it can morph into a healthier situation. But when you have been working on some bad knee problems for decades, for 50, 60, or 70 years. You know how fast it's going to morph back into normal is questionable, if it's going to happen in your lifetime. I just always keep that in mind.

Let's talk about arthritis that's just starting. The way that this typically presents in somebody is, they will have some knee pain, they might ache and throb. They may or may not have swelling, sometimes they will get swelling, they will have grinding in their knee, usually clicking and popping, and they usually won't like exercising or moving. You won't feel good in their need to go for a walk. You won't feel good in there to even get on a bike or elliptical machine. Their knee just doesn't like to do stuff.

As a result, people with knee arthritis typically avoid doing exercise, because it's uncomfortable to do so. They tend to get stuck between a rock and a hard place, because they might be out of shape, maybe putting on weight, and they know that they need to go exercise in order to maintain their body weight and their fitness. But using their legs just flares up their knee. They get stuck in this vicious cycle of putting on more weight, being less healthy, and also increased knee pain. Then they start to think, well, it's my weight that's affecting my knee. That might be true. That's extreme, though, you got to be like 70-80 or more than 100 pounds overweight for it to really be affecting your knee.

But most of the time, if you can increase the mechanics in the knee, if you can improve the alignment, make sure the knees bending all the way, and straightening all the way, and strengthen certain muscles around the hip and knee. That usually creates more space within the knee joint, which allows for improved motion. Somebody that has more mild-to-moderate arthritis can usually recover quite well and get back to exercising and be able to manage their weight.

We have had people here in the clinic that come in knowing that they have arthritis, they have gotten an X-ray, and the doctors have told them, the classic is a doctor says you have arthritis in about 15 or 20 years, you are probably going to need a knee replacement, if you don't take care of this. And then many patients are thinking, “Oh my gosh, I'm following in the footsteps of my mom or my dad, who is in their 80s or 90s, and they had a knee replacement a while back, and I don't want to deal with that because, I want to stay active and healthy, and make sure that my knees are able to carry me into my 80s and 90s just fine.”

I can tell you right now that more often than not, people, elderly people in those situations have not been able to get the strength in the space needed inside their knee joint. They could have probably prevented being in a walker or having to rely on a cane. If back in their 50s and 60s, they properly addressed it and kept up a few things as they aged over time. I can't give you clear specifics on how to treat arthritis, the ideas that I can share with you about it are, that you need to stay strong, and you need to make sure your knee moves all the way. You might need help for that, or you might not. It just depends on your specific situation.

I'm definitely going to go on the side of get help, because it will. It will shortcut your time and make sure that you are on the right path to not allowing your arthritis to get any worse and possibly reversing it. But if you wait, you might flounder around trying different things that may or may not work all the way. Meanwhile your arthritis is just progressing over time. You are unhealthy over time, this could contribute to other side effect, health conditions like your blood pressure being too high, your cholesterol being too high, because you can't exercise because your knee hurts.

A lot of people just don't connect it that way. Osteoarthritis is one of the most common knee problems that people face as they get older because it just it builds up over the years. Now, the other way that I say this is muscle imbalances, that if you think of your knee joint, you have muscles on the front of your leg called the quads, the quadricep muscles, and then you have muscles in the back of your leg of your thigh called your hamstring muscles.

This is a really simplistic explanation. There is way more complicated things that we look at here in the clinic and in way more precise ways to fix this problem, but I'm just giving you the bird's eye view of things. If your quad muscles are way stronger than your hamstring muscles, it's going to change the way that your knee joint moves. It's going to yank on your patella more, your kneecap. Because the quads, move the kneecap, and it's going to shift the shin bone too far forward on the thigh bone. This could feel like your quads are always tight. It could feel like you get knots in your quads, you might get the cartilage in the knees wearing down quicker, you might get the meniscus problems, you might get all the other issues that I talked about. Arthritis could come in, and the ligament issues could feed into this as well.

If your thigh muscles are way too strong, that's what we commonly see. That could be causing knee pain right away. Some of the misconceptions that people have is they think, “Well, my knee hurts, so I need to get stronger quad muscles.” At face value, that seems like it makes sense. But if you look deeper into it, it's going to yank the shin bone too far forward on the thigh bone, and then it increases the pressure of the kneecap against the thigh bone. It just changes the forces in a bad way inside the knee. That's a simple way to put it.

Most of the time, the reason why people will get, where their quads are too strong, is they are doing exercises that dominate the quads, that make the quads a dominant muscle in the leg. The feedback is terrible because people think “Look at these massive quads that I've got. That means I'm healthy.” I see pictures online often if people show it off their quad muscles, and if you ever look at their hamstrings, or the glutes, or other muscles that contribute to this muscle imbalance, they don't have much there.

Exercises in the gym that I would definitely stay away from, if you are dealing with a knee problem right now, and you think that a muscle problem could be affecting it, are knee extensions. The way this exercise looks is, there is typically a machine, you sit in it, and it has a pad that goes in front of your shins right above your ankles, and then you straighten out your knees and it makes your quad muscles tighten up real hard.

A lot of people love doing this exercise because it's straightforward. It's easy. The machine is easy to operate, and there is usually a stack of weights and you put a pin in the weight that you want, and you do your exercise. It gives you that instant feedback that my quads are tight, they feel like they worked out, they are burning and it makes you think “Wow, I really got a good quad workout!” and then some people will go get on the hamstring machine and they can't lift nearly as much, or don't get the same effect that they get on the quad machine.

There is a huge muscle imbalance. This is a big problem over time. Typically they don't get knee pain right away. They will get knee pain as time goes on over the years, but it starts years before the knee pain comes on, and when they have been working on their quads a lot.

Another time that people get quad problems, or quad dominance issues, where they are working out their quads too much, is doing free weight exercises like lunges, squats, and deadlifts. Exercises that are intended for your legs they are missing working other muscles, and they are targeting inadvertently the quad muscles.

CrossFit is an amazing exercise in my opinion. I have a CrossFit background. I love doing weightlifting, powerlifting, all that stuff. I've worked with tons of coaches over the years. I work with some awesome coaches and some coaches that could probably brush up on their mechanics and anatomy and all that. I don't blame them. I think they are all the coaches have the best intent. They are helping out all their clients with the best knowledge that they have possible. But they just don't understand certain things at certain levels. Of course, you know, I'm an expert in this kind of thing.

They will have their clients do certain exercises like squats and lunges, for example, and the clients will report they will say, my field is working in my quads and everybody's smiling about it because they are saying great, you are getting an awesome workout, you are burning calories, you are going to get more fit, this is good. Little do they know over time, they develop these massive quads and they do feel healthier, they are more fit, their blood levels are normal as far as blood pressure, all that other stuff. Blood values that are important for your heart health.

Meanwhile, they are generating all these massive forces through their knee joint, and they are harmful for the knee joint. They are wearing down their cartilage. They are loosening up ligaments, they are messing with the meniscus. What typically happens, after years of doing these lifts that are quad dominant, where they keep working out their quads, then they have a knee injury that that kind of comes on abruptly and they are like, I just been doing my squats like I always do. I've just been doing my knee extensions, like I always do and all of a sudden, my knee just blew out.

That's how this develops over time. So watch out if you are out there exercising right now, and you have been focusing on your quads and maybe neglecting other leg muscles. Make sure that you have a more well-rounded exercise routine. Make sure that you fix your squats if you like squatting and dead-lifts as well. What you should feel on squats and deadlifts is actually your bottom muscles working out, the glutes should feel like they are getting more of a workout.

Okay, let's go into number six. This is the last reason that knee pain comes on for most people. And this is related to the squats and deadlifts bad movement.

Number six is bad movements.

A lot of people don't get that their knees should work in a certain angle relative to their body. If you are female, typically you might have wider hips than a male. It's not 100% true, but it just depends you have to adapt and figure out the way that your body should be moving, to get the right muscles to work to take pressure off your knees. This is something that we go into depth here in physical therapy, to make sure that everybody knows and understands how their legs should properly move, so that their knees are healthy for the long term. This is not something that's taught. Oftentimes when we go into movement patterns here in the clinic, people think to, well, I know how to walk. I know how to run. I've been running for years and years, I've ran marathons. In fact, I know how to squat. I've been doing CrossFit for years, and I can pick up hundreds of pounds, or I know how to bike. Another one is cycling that people say it's no big deal. You just get on the bike, whether it's stationary, or road bike, or mountain bike and you just pedal that's all there is to it.

There is definitely more precise mechanics that need to be considered., ad they are just small tweaks most of the time, that if we can fix that bad movement, it turns into good movement. Think about this. If you have spent years and years, decades of your life moving bad, little by little, you have been worsening your knees over time. If you make it as small as a few degrees, shifting your knee position, it all of a sudden turn into good movement and you can keep doing those things that you love without having any injuries down the line.

The way that you move is needs to be taken into consideration. I can't give you more details on how to move right now, because it depends on your genetics, it depends on your activity, there is so many variables that we have to take into account. When we give people advice here in the clinic, we would have already figured out what they like to do, what kinds of exercises they are looking to do once they get out of pain. If they are not looking to do exercises, what their activities are like at home and at work, we have to factor all these things in so that they can properly exercise.

Alright, let's go into the four ways to start fixing your knee problem.

These are general answers here. Like I said, it depends on your specific situation, but some preliminary things that you can look at, to make sure that you start to go in the right direction to fix any problem. We are going to go over four of those.

Number one is your footwear.

I think that you should be able to walk barefoot and be able to have normal knee mechanics. But if you are dealing with an active knee problem right now, having comfortable footwear helps tremendously. If you can, depending on your work environment, the people that you are around, the social context, all that stuff. Having comfortable supportive athletic shoes is a big deal, it will definitely help reduce your knee pain right away.

Wearing dress shoes, heels, or sandals as well can affect your knees. Let me just go through each of those dress shoes, because they tend not have a whole lot of support. If you are on your feet a lot, and you are wearing shoes that have minimal support, the impact isn't absorbed in the shoe, it's transmitted up into the knee. If you have already got an irritated meniscus, or bad alignment in your knee, or these other problems that we talked about, it can just make it worse. It can exacerbate the knee problem.

If you like to wear heels, even just a small heel, like an inch or two inches, of course people talk about the extremes, the big stilettos the four or five inch, six inch heels. Obviously, that's going to change your ankle position and your foot position, and it's going to influence your knees, and even hips and back. But even the small heals, if you are on your feet for a long time, that does put a small influence on your knee, and they can aggravate knee problems, the more that you are in your feet. If you are able to get into some comfortable athletic shoes, I would recommend doing that.

Now sandals tend to not have a lot of support either. Certain sandals don't wrap around the heel so they can slide off your foot really easily. And that can cause you to walk and move inappropriately. I think sandals are fine if you are not going to be on your feet a whole lot. But if you are going to go to the store, especially a big store that you have to walk around a lot, I would definitely wear shoes that have the wrap around the heel, so that you are not having to change the way that you walk.

The second way to start fixing your knee right away, exercising.

Find exercise that does not aggravate your knee. Typically, a light cardio exercise is good for you. If you can get some advice on how to proceed in exercising, of course, but if you haven't really tried exercise, if you don't know if it's going to hurt you or not, I would venture into some stationary cycling.

Go to a gym that has the bikes, the ones that you sit on and you can watch TV, something like that. Or you might have a bike at home, even if it's an outdoor bike, that could be beneficial for you. The idea with this is, if you have a cartilage problem, meniscus problem or ligament problem, light, repetitive motion, like you might have encounter on a bike, or an elliptical too can begin to heal those tissues.

Let's say you go and try this, and you feel like it aggravates your knee problem, then it might not work out for you right now. But I would start there, you could start out with some easy light exercise. When I say light, you can still burn a lot of calories, you have to play around with the intensity. I wouldn't put any resistance on the machine to start off, and I would go for like 10 to 15 minutes at the very beginning. The first time you do this, if you feel okay, see if you can do another five to 10 more minutes. You could potentially get up to an hour or more and burn quite a bit of calories to improve your health, which will also improve the knee if it doesn't aggravate it.

You can start out with some light cardio exercise. But where I want to warn you, let's say this works out for you. You start going to go cycle, you start doing the elliptical, and you are like wow, my knees are actually getting better. They still hurt. There are still some things that I can’t do, but I actually feel better. The more that you cycle, and do cardio, like the elliptical machine, maybe even some walking in order to protect your knees even more, and make sure that you are reversing a cartilage problem a meniscal problem, or a ligament problem, you eventually need to get into strengthening. You need to make sure that the right muscles are strong.

A lot of people only make it halfway through this, they only work their way through the cardio and don't ever get into the strengthening, because they are afraid to they have associated knee injuries with squats or with using that knee extension machine or other exercises, lunges that have hurt their knees. Typically, those are good exercises, they just need to be done properly so that they are helpful for your knees rather than harmful.

Number three, and this goes in line with the strengthening, in about eight to nine out of ten knee problems, in order to improve the knee problems for the long term, essentially the cure, we are talking about the cure here, you need stronger butt muscles.

The glutes need to get stronger. The glutes are key, because they properly position the knee. If you think about your hip joints, which you know the glutes are on the back of your hip, they can rotate your knee in and out, and they can change the way that your knee is positioned. For normal everyday activities, like walking, maybe running or this exercise that we are talking about cardio, your glutes are key and making sure that you are able to position your knee properly.

Also, the stronger they are, they tend to set up your other muscles down your leg to operate properly. Now let's take this to the extreme. If you have a relative that's elderly, or you know somebody that's elderly, maybe yourself and they have a chronic knee problem. More often than not, they tend to not have a but, they just don't have muscle back there. We see it all the time, we see people that as they get older, they lose their poor butt muscles. That's associated with having increased knee problems. They will have other problems along with that. They will have back problems, hip problems, maybe even sciatica problems, sciatic nerve problems. But if you have any problems, and you are older, more often than not, we see that they are lacking some serious butt muscles.

When we rehab people, when we get people better from their knee, if we are going to go down the pathway of strengthen their glutes, a nice side effect is that they actually get more firm back there, and they sometimes even increase the size of their butt muscles, which is a good thing. I strongly encourage you to start working on your glutes. There are tons of different exercises out there. You need to eventually get into resistance exercises, the ones where you have to have some weights to make it challenging, and it doesn't take a lot of time. It just needs to be done right. Get help on working out your glute muscles.

Number four, here's the last and most secure way to make sure that you start to fix your knee problem. Get specialist help.

If you go find somebody that knows what they are doing to fix the problem, especially somebody that can do it without a surgery, without more injections, without pain medications, I think that is your best long-term bet. I'm not in any way knocking off doctors, physicians, people that give surgeries, injections and medications, because that is definitely very helpful in certain circumstances.

If you have a completely blown up knee, more often than not a surgery is recommended. There are cases here in the clinic where we see people for the first time and I say Hey, you got to go talk to the surgeon about this. Don't do it, they can help you out. This is beyond my help. But for milder to moderate cases, and in some extreme cases can be salvaged as well. We can help them out, and it's a process that takes time, in order to get them to the point where they know they are educated. They are also helped out, hands on wise, to make sure that they have full motion, and all the mechanics are restored in their knee. The strengthening is also done properly, the exercises done properly so that they are safely getting there.

Here in the clinic, we speed up that process big time, a lot of people like to go try things out on their own, and that's fine, of course. But they might try different things that don't work, things that don't help, things that actually make it worse, or they give up that they don't have that consistent feedback on if they are doing the right thing or doing the wrong thing. We try and dig here and make sure that everybody's on the right path to fixing their knee problem for the long term. The experience most people have, here in the clinic whenever we are helping them out with a knee problem, is that they get better little by little.

There isn't a big change right away on the first or second visit, they will notice more of a change after the first month. Then it gets even better into the second month, and if we need to go beyond that, the third or fourth month or beyond, we'll see them for that. What tends to happen is they are better for a long, long time. There might be a few things for them to keep up long term, as far as some exercises. But if that's easy, and that's simple compared to getting a surgery, injection, or having to rely on pain medications.

Let's talk about those for a second. If you go have a surgery, we have amazing surgeons out there, and surgeries have changed so much in the past decade in the past 20 years. They are amazing and they do a great job with doing meniscectomies, knee replacements, and ligament repairs and all that stuff. If you have to have that done, that's great. But surgeons aren't necessarily teaching you on how to keep your knee healthy for the long term. They help you if something's torn, if something needs to be repaired or cleaned up, and that will typically allow your knee to feel better right after the surgery.

But I always have to ask the question of how did you get there? If you have any sort of trauma or accident that injured your knee, if it just came on without any sort of major problem, there is something that you are doing or not doing that led up to this. If you don't address that, you are going to end up having that problem again, even if you had a surgery to repair something that was torn or worn down or replaced.

You need to make sure that you learn how to take care of your knee problem. Another way to think about this is think of liposuction. Let's say somebody who's heavyset, everybody knows that if you eat better, if you eat less, depending if there are any sort of hormone problem or thyroid problem. But if you are just overweight because you eat too much, and you don't exercise, and you know it. If you know that if you start exercising and if you start eating better, you are probably going to lose weight.

But some people like to shortcut it, they like to go get liposuction and that's fine. That's your personal decision. Once you have liposuction done, you will look thinner instantly right away. But if you keep eating the same way, if you don’t exercise, it actually does come back. You will put the weight back on and you will grow again.

It's the same idea with getting the knee surgery done. If you don't learn how to manage it, it's just a matter of time before you need another knee surgery, or you have some other knee injury. We commonly hear people say they went in for a meniscectomy because they had a meniscus tear or meniscus problem. The surgeon told them afterwards, after they finished all the therapy and the follow up. They said well, you might need a replacement in 15 or 20 years. You will probably need a replacement in 15 or 20 years, come and visit me again.

When that happens, and that’s just some thinking in my head, I hope you don't have to have another surgery, let's figure out how to fix it, how to move better, how to get stronger, how to improve your alignment, how to take care of your cartilage, so that you don't have to have any other procedures later down the road.

The other one is pain medications. Whether it's injected or you are taking pain medications, that eats up your liver, and other organs, your kidneys, and it doesn't teach you how to move better and get stronger. It just takes away the pain temporarily. If you get an injection, typically those the relief will last anywhere from a month to several months. Some people get cured because their irritation goes away, and they don't get back to that activity that got them there in the first place. They think the injection fixed it. But if the pain comes back after having an injection, it's because you are doing something to aggravate it.

Still, you can't expect the injection to cure the knee problem. Notice I said problem, not pain, because it will take care of the pain. But it won't take care of the problem that caused the pain. That's what we look to fix here in the clinic with manual physical therapy. Same thing with medications. Of course, those just last hours, maybe a day and you really can't rely on it. They have some serious side effects, addiction problems for the prescribed medications, you can have addiction problems and doctors will limit you nowadays on how much medication you can have.

Also, it affects your normal function. I mean, some people they say they feel like they are drugged all day. They feel like they can't operate vehicles, they can drive, they feel drunk, they feel like they can't work, they can't think clearly. That's not cool. Then the over the counter medications like ibuprofen, they can rip up your stomach, they can really cause some serious problems inside your guts. Some people feel it instantly, they will feel nauseous, they feel like they can't eat after taking ibuprofen. But some people don't feel anything instantly. I'm more concerned about those because if you are taking ibuprofen around the clock, like the bottle says every four to six or eight hours, depending on the dosage, and you go for weeks like this, then it can seriously mess you up.

Some people get hospitalized for this, some people even die from side effects of taking ibuprofen. It is not a good idea to be taking ibuprofen for the long term.

That being said, when people come into the clinic here, I'll tell them, hey, how's your home life? How's your work life if you are pretty grumpy because you are not sleeping enough because your knee doesn't let you sleep? Or you are just aggravated, maybe taking some pain medication or asking your doctor for an injection or pain medication is wise at this point. But please be sure that you are working on a plan to fix the long-term problems so that you are not having to Rely on injections or medications for the long term.

There you go guys, you have the top six reasons that people get knee pain, and I've also giving you four ways to start fixing it right away. I hope that this podcast was helpful for you. I hope that you are more knowledgeable and educated about why the problem is happening, what to do about it, and what next steps to take.

If you are thinking that you want professional help right now, I encourage you to reach out to us call us at 915-503-1314 and talk to us about getting help for your knee problem. If you are in the El Paso area, we are open here to help you out. If you want more tips more help go to our website at www.EPManualPhysicalTherapy.com and there are free resources on there, you can find our blog, we have tons of knee help there, as well as other body parts that we commonly see.

You can download a knee pain tips guide, it's a PDF document that you can get sent right to your email. As soon as you give us some details, your email information, all that stuff. We'll send it to you right away and you can begin to read through the knee pain guide so that you can learn more about other ways to help out your new problem. I wish you have the best day today and stay healthy and stay safe. Bye.

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