Meniscal Tears & Consideration of PT Instead of Surgery

   

By Greg Louie, DPT

The menisci lie between the tibia and femur. They stabilize the knee into flexion and extension, assist in joint lubrication and nutrition, and distribute compressive forces to reduce stress on the articular cartilage with load-bearing and load transmission.(1) Meniscal tears are quite common,the mean annual incidence of meniscal injuries are 66 for every 100,000 individuals.(2)

There are two classifications of meniscal tears: traumatic and degenerative. For a meniscus tear to classified as traumatic, the meniscus must be healthy and there must be an injury to the knee as a result of a forced movement.(3) These types of tears are higher amongst young adults because of an increased percentage of this population participating in high-level activities and sports.(4) A forced twisting movement with the knee bent is the common mechanism of injury for traumatic lesions. Degenerative tears occur in the absence of trauma and result from deterioration of the meniscus from abnormal loading forces to the knee.(3) Individuals with a body mass index greater than 25, those who are older then 60, and those who work in jobs requiring increased kneeling, squatting, and stair climbing are at a significantly higher risk for degenerative meniscal tears.(4)

Meniscus injures are often accompanied by other ligamentous injuries of the knee.(3) A combination of injury to the meniscus, medial collateral ligament, and the anterior cruciate ligament is known as the unhappy triad of the knee.(5)

In the United States, partial meniscectomies are the most common orthopedic surgical procedure(6) but does this mean everyone with a torn meniscus should opt for surgery? Several studies have found that surgery is not always necessary and that physical therapy should be considered prior to surgery. Sihvonon and associates found no difference in partial menisectomy compared to sham surgery.(7) Katz and colleagues found no difference in outcomes with arthroscopic partial meniscectomy combined with physical therapy compared to physical therapy alone.(8) Surgery should be considered as a last resort when all other interventions (including physical therapy) have failed.

A physical therapist will assess the severity of the tear and provide interventions to control the pain, inflammation, and swelling. As the knee beings to heal, they can help you regain full range of motion, get you back walking pain free, and build strength and coordination to prevent reinjury.

 Blog post written by Greg Louie, DPT Student from University of St. Augustine. At the time of publishing Greg was in a clinical rotation at Catz PTI. Follow him on Instagram @sportsperformancerehab

References:

1. Makris EA, Hadidi P, Athanasiou KA. The knee meniscus: structure-function, pathophysiology, current repair techniques, and prospects for regeneration. Biomaterials. 2011;32(30):7411-7431.

2. Hede A, Jensen DB, Blyme P, et al. Epidemiology of meniscal lesions in the knee. Acta Orthop Scand. 1990; 61:435–437.

3. http://www.physio-pedia.com/Meniscal_Lesions

4. Snoeker BA, Bakker EW, Kegel CA, Lucas C Risk factors for meniscal tears: a systematic review including meta-analysis. J Orthop Sports Phys Ther 43: 352–367. 2885

5. Sbourne K, Nitz P. The O’Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears. Am J Sports Med. 19(5):474–7.

6. Englund M, Guermazi A, Gale D, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008; 359:1108-1115.

7. Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013; 369(26): 2515–24.

8. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013; 368:1675-1684

Rotator Cuff Rehab Management

   

By Garrett Holle, DPT Student

The function of the rotator cuff is colossal in the performance of our athletes and everyday individuals.  So much so, in fact, it has formerly been called the kiss of death for the career of overhead athletes.  Rotator cuff injury in sports is climbing in part due to an increased emphasis on strength in college programs. Moreover, in a study of NCAA college football players, rotator cuff injury was the 3rd most commonly reported shoulder injury (1). This high rate of occurrence holds true in the general public as
this study showed that of a random sample, 20.7% of patients had full-thickness rotator cuff tears (3).

As you can see, the ability to treat rotator cuff injuries and treat them well is going to be a valuable skill in your practice. The rehab is not easy, but we can make a huge difference with our patients if we handle them correctly.

How to Avoid a Common Oversight of Rotator Cuff Rehab

When prescribing exercise for the small intrinsic muscles of the cuff, it can be easy to throw the typical 3 sets of 12 to a patient.  However, I think we should reconsider this.  In addition to the typical explanation that every patient is different, there is also physiological evidence that supports this notion. This study explored the fiber composition of the rotator cuff muscles, indicating a mixed composition of fast and slow twitch (2). Although 44% of rotator cuff fibers labeled positively as slow twitch, the remaining fibers lie somewhere on the fast-twitch continuum.

Now if that study is a little too far into the physiology for you, let me make this applicable.

This knowledge of fiber type composition allows us to better determine and prescribe exercise volumes and intensities that satisfy the demands for muscle development. This concept aligns with the strength and conditioning principle of specificity. In the training realm, if you’re working with a sprinter, you’re going to utilize high intensity, low volume and if you’re training an endurance runner, you will use lower intensity with higher volumes. This example applies to training of the rotator cuff as well.

This concept is no nuance in the strength and conditioning realm, and it is a great illustration of how we can successfully begin to close the chasm between our two professions.

 Garrett Holle is a DPT student at the University of Kansas Medical Center. You can find him on all social media platforms @Holle_Per4mance 

References

1. Kaplan, L. D., Flanigan, D. C., Norwig, J., Jost, P., & Bradley, J. (2005). Prevalence and Variance of Shoulder Injuries in Elite Collegiate Football Players. The American Journal of Sports Medicine, 33(8), 1142–1146. https://doi.org/10.1177/0363546505274718

2. Lovering, R. M., & Russ, D. W. (2008). Fiber Type Composition of Cadaveric Human Rotator Cuff Muscles. Journal of Orthopaedic & Sports Physical Therapy, 38(11), 674–680. https://doi.org/10.2519/jospt.2008.2878

3. Yamamoto, A., Takagishi, K., Osawa, T., Yanagawa, T., Nakajima, D., Shitara, H., & Kobayashi, T. (2010). Prevalence and risk factors of a rotator cuff tear in the general population. Journal of Shoulder and Elbow Surgery, 19(1), 116–120. https://doi.org/10.1016/j.jse.2009.04.006

4. Rotator Cuff Image: Henry Vandyke Carter [Public domain], via Wikimedia Commons

 

Groin Strains

   

By Ashley Pena, DPT

Groin strains make up 8- 18% of all soccer injuries and also occur in many other high intensity sports such as Ice Hockey, Football, Basketball, and more. They are typically found to occur during kicking, cutting, pivoting, changing directions, or when planting the lead foot. In a prospective research study looking at the athletic population, Serner et. al. found that in soccer players, kicking was the most common mechanism of injury at 40%. In other sports, changing directions was the most frequent mechanism at 31%. In addition, Serner found that 66% of these groin strains resulted in injuries to the Adductors (primarily Adductor Longus). Iliopsoas and Proximal Rectus Femoris were also found to be frequently injured with 15-25% of the groin strain participants sustaining these injuries.

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❗️Groin strains❗️make up 8- 18% of all soccer injuries and also occur in many other high intensity sports such as Ice Hockey, Football, Basketball, and more. ⚽️🏒🏈🏀 They are typically found to occur during kicking, cutting, pivoting, changing directions, or when planting the lead foot. 🎥🎥🎥⬆️ Here are a few frontal & transverse plane movements that integrate groin loading with the rest of the body. 💻Blog Post by @ashpena3r coming 🔜 to chrisbutlersportspt.com 🎙 🎵.rl

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Aug 10, 2017 at 8:14pm PDT

Some factors which have been found in past research to be related to an increased risk of groin strains include older age, level of competition or experience, decreased range of hip abduction and rotation, isometric adductor muscle weakness or high abductor/adductor strength ratio, and poor performance in vertical jump tests. Specifically, in a cohort study done by Moreno-Perez et. al. it was found that players with groin injuries showed weaker isometric hip adductor strength and smaller Adductor/Abductor strength ratios than those without groin injuries giving evidence that screening for adductor strength deficits or Add/ Abd. muscle imbalances may be helpful in avoiding groin injuries.

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​❗️Groin Strains❗️ A study by Moreno-Perez et. al. found that athletes with groin injuries showed weaker isometric hip adductor strength and smaller Adductor/Abductor strength ratios than those without groin injuries. 🏈🏀⚽️ Screening for adductor strength deficits or Add/ Abd. muscle imbalances may be helpful in avoiding groin injuries. 🎥🎥🎥 Above are some advanced SL bridge variations that can help with controlling hip Add/Abd & ER/IR control. 💻 Blog Coming 🔜 ❤️💬Share 📚📚📚 Moreno-Pérez et al. Comparisons of hip strength and countermovement jump height in elite tennis players with and without acute history of groin injuries. Musculoskeletal Science and Practice. 2017 🎵.rl

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Aug 12, 2017 at 8:27pm PDT

Blog Post written by Ashley Pena, DPT Student from Cal State Northridge. At the time of publishing, Ashley was in her final clinical rotation with me at Catz PTI.

References:

1. Elattar O, Choi H-R, Dills VD, Busconi B. Groin Injuries (Athletic Pubalgia) and Return to Play. Sports Health: A Multidisciplinary Approach. 2016;8(4):313-323. doi:10.1177/1941738116653711.
2. Moreno-Pérez V, Lopez-Valenciano A, Barbado D, Moreside J, Elvira J, Vera-Garcia F. Comparisons of hip strength and countermovement jump height in elite tennis players with and without acute history of groin injuries. Musculoskeletal Science and Practice. 2017;29:144-149. doi:10.1016/j.msksp.2017.04.006.
3. Serner A, Tol JL, Jomaah N, et al. Diagnosis of Acute Groin Injuries. The American Journal of Sports Medicine. 2015;43(8):1857-1864. doi:10.1177/0363546515585123.
4. Tyler TF, Silvers HJ, Gerhardt MB, Nicholas SJ. Groin Injuries in Sports Medicine. Sports Health. 2010;2(3):231-236. doi:10.1177/1941738110366820.

Brain Vandalism

   

By Nick Hannah, PT

I need to begin this blog by emphasizing a very important fact about your body: YOUR JOINTS ARE INHERENTLY STRONG AND STABLE! In the absence of rare circumstances like severe traumas (i.e. joint dislocations) and certain genetic disorders that can physically make your joints ‘loosey-goosey,’ the joints making up your body simply won’t go out of place from day-to-day activities.

However, there are times you could swear they really WERE out of place. Joints and body parts can feel shifted, “off,” “out-of-sorts,” wonky—sometimes as if they were no longer a part of you. These kinds of perceptions are NORMAL and many feel this way. Weird right? So how can it be that your joints FEEL out of place when in reality they’re rock solid? Let’s find out. 

Within your brain different cell groups build a DETAILED map of your body—a helpful analogy is to think of this body map in the brain like a detailed painting (every nook, cranny and unique aspect of your body is represented and accounted for). This means that certain brain areas control the movements and feelings of certain body parts. It’s more complicated than this but that’s the gist of it.

When we have pain in a certain body area (i.e. a hip), our body painting changes—that once crisp, clear image of the hip in the brain gets smudged. The actual brain tissue changes: we call this neuroplasticity. If the pain persists long enough, the brain’s representation of the hip gets even more distorted—the smudging grows and spreads to surrounding body parts of your painting (your once beautiful work of art is under ruin).

With time, this brain ‘vandalism’ alters how you perceive and control movement of the hip & surrounding body parts. THIS is why you feel weird, out of place, and ‘off.’ It also accounts for why pain spreads, and it can happen to any body part.

Side note: these changes aren’t unique to pain. Ask any seasonal golfer what their VERY first swing feels like after many ‘golf-less’ months in the winter—it feels weird! More smudging at work here.

So how do you improve your ‘brain vandalism’?

• First, find yourself a good physiotherapist (or another health professional—I’m biased of course). Education is paramount here: you must understand that the strategies adopted early on and meant to protect you—like fear avoidance, limiting painful movement, rest etc.—are now creating maladaptive changes in the brain and actually making things worse.
• Second, slowly but surely re-expose the painful body part to the normal movements and activities it once performed. This is called graded exposure—and the starting point for everyone will be different. In this way you start to re-trace what was smudged, and begin the process of re-painting the body part as represented in the brain.

Stop thinking you’re out of place. You might FEEL like it, but now you know why.

As always. Don’t sit still. Make moves.

Blog post written by Nick Hannah, PT.  Nick is the winner of the Blog Post Competition I challenged my Instagram followers with this July.  You can find Nick on Instagram @hannahmoves.