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meniscal tear

Health, Knee pain

Meniscus Tear: Heal Strong and Fast

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Meniscus tears are one of the most common injuries in sports and lead to a lot of time out from sports, swelling and pain. Here is what you can do to help your knee heal strong and fast and even avoid surgery.

Meniscus tears are, without a doubt the most common injury in the knee and the 5th most common injuries that present to sports medicine clinics.(1) With this in mind, we think it is important that you know:

  • What the meniscus is and how they get injured
  • What is better surgery or physio?
  • What are the best exercises you can do at home to heal strong and fast.

So let’s cover these three…


What is the meniscus:

meniscus tearThere are two meniscus in each knee, which are horseshoe-shaped and thicker on the outside to give a nice cup for your thigh bone to sit in. These give stability for your knee by adding a cup for the thigh bone to sit in and guiding the joint as it moves. The
meniscus also offer some padding between the two bones.

Meniscus blood supplyIt important to mention blood supply of the meniscus because this directly affects healing times. Only the outer 3rd of the meniscus has blood supplied to it, meaning in general healing can be slow for meniscus, particularly in the inner 3rd where there may be no healing response. In general, allow 12 weeks healing for meniscus tears.

How do they get injured:

Meniscus tears often happen with combined twisting and flexion, such as when you land and pivot on your leg after catching a ball or step out of the car and twist at the same time.
Think of it like this; Your meniscus sits between your shin and thigh bones. If your foot is planted on the ground and you are turning your body and pivoting way, this puts a huge amount of torsion through the meniscus. This combined with you body weight can often lead to a meniscus tear in many fast-moving ball sports – Makes sense right?

Common symptoms to look out for:

  • Pain on either the inside (more common) or outside of the knee-joint
  • Swelling, often a lot above the kneecap
  • Popping, clicking and catching
  • Locking of the knee joint, indicates a significant meniscus tear

What is the best treatment approach?

There are two main approaches for meniscus tear

  1. Surgical repair via arthroscopic surgery
  2. and conservative treatment which generally involves physiotherapy and strengthening exercises

There was a groundbreaking study done in 2002 which really made a lot of health professionals and surgeons take note. They took a group of patients with degeneration in their knees (arthritis) and split them up so that some of them had arthroscopic surgery, but some of them just got incisions in their skin so that it looked like they had surgery. The outcomes between the groups were no different.(3)

Since then a lot of further studies have been done, looking at meniscus injuries and whether surgery is better than conservative rehab and this is what they found:

  1. There is no significant difference in functional outcome between Physio and surgery (4)
  2. For degenerative meniscus tears, there is no difference between surgery and placebo (5)
  3. Arthroscopic surgery and strengthening is no better than strengthening alone in degenerative meniscus tears (6)

Conclusion: We really need to split meniscus tears into 2 groups; there are degenerative tears which are due to wear and tear and then there is acute meniscus tears which occur from one accident/incident. We can safely say that for degenerative mensicus tears surgery is not the answer and should be looked at only if conservative rehab fails – even the American Academy of Orthopaedic Surgeons state: “We are unable to recommend for or against arthroscopic partial meniscectomy in patients with osteoarthritis of the knee with a torn meniscus.”(7)

When it comes to acute meniscus tears though, it gets a bit more complicated. Surgery definitely can help here, but as a general rule, only if there is:

  • Instability – Knee giving way and you can’t trust it
  • Locking up
  • Or if conservative rehab does not have good results after 6-12 weeks.

So if you have a meniscus tear, whether degenerative of acute and have no instability or locking up, then the best thing for you is to get onto a good rehab and strengthening programme and give it a good shot before jumping to the scalpel.

Follow this link for the second post in the series which details a simple home-exercise programme for you to follow.


Health, Knee pain

ACL tear – Do you really need surgery?

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ACL tear non contact
When can I play again? Do I need surgery? These are the questions emotionally asked after anterior cruciate ligament injury. In this post i am going to answer these questions and more!

Torn your ACL and now wondering, do you really need surgery? The simple answer is: No – Only if you are a high level athlete, wish to return to pivoting/high demand sports OR have an unstable knee.

In this first post we will explore the difference in outcomes between surgery and conservative treatment and what that means for you: 

How do you know if you have an ACL tear?

If you heard a pop, snap or tear, the injury should be suspected as a ACL tear until proven otherwise. You may have felt something pop out or move  in the knee, this is sometimes confused for patella/knee cap dislocation but is most often an ACL tear.

You may or may not also feel clicking and locking which would indicate meniscal damage. Meniscal injury occurs in at least 40% of all meniscal tears(1).

Swelling will occur within an hour of injury, if swelling occurs a few hours later it points more towards meniscal tear.

But it is always best to get it thoroughly assessed by your local Sports Physiotherapist – It is not worth relying on Doctor Google or hoping it will go away!

Brief anatomy:

acl anatomuThe knee is formed by three bones, making up two joints. One joint is where the patella (knee cap) glides on the femur as you bend your knee. The other is formed by the tibia and the femur – This is the main joint that the ACL is in the middle of.

There are four main ligament that connect the femur and the tibia together and form this large hinge-like joint. These are the medial collateral(MCL), lateral collateral(LCL), anterior cruciate(ACL) and posterior cruciate(PCL) ligaments.

The ACL is right in the middle of the knee and prevents the tibia sliding forward on the femur and prevents excessive rotation.

Between the smooth articular surfaces of the tibia and femur and the menisci – the lateral and medial meniscus act as the shock absorber of the knee to prevent body injury, absorb shock and offer a smooth, rounded surface to move on.

Causes of ACL tear:

ACL injuries occur when the bones of the leg twist in opposite directions under full body weight, either during contact, or non-contact:

Non-contact ACL injury makes up about 70% of all ACL injuries, The two main mechanisms of non-contact injury are:

  • acl mechanismHigh impact jump-landing with a under-flexed (too straight) knee or valgus position (knee going laterally)

 

 

 

 

 

 

  • acl non contact 2Forceful rotation of the knee with the foot planted on the ground. This often happens when turning, side-stepping, pivoting etc.

 

 

 

 

 

acl tear contact

Contact ACL injuries:

The other 30% of ACL tears are due to contact and so are more random and due to a less preventable mechanism – There are often just plain unlucky.

 

 

 

 

Risk factors for ACL injury:

  • Poor sports specific conditioning
  • Muscle imbalance – The main one here is a low hamstrings-to-quadriceps strength ratio
  • Poor technique and awkward body movement
  • Poor neuromuscular coordination and balance

Risk factors that are hard to change:

  • Female gender
  • Joint laxity
  • Reduced ACL size and strength
  • Increased female sex hormones

 

Prevalence:

In the USA alone, about 250 000 ACL injuries occur annually. This translates into a 1 in 3000 chance that a member of the general population will injure their ACL.(2)

And over half of these injuries are full ruptures of the ACL!

So that means an estimated 175 000 ACL reconstructions costing over US$2 billion each year.(3) That is a huge cost – especially if extrapolated world-wide! Unfortunately I can’t get a number on this but I’m sure you can appreciate that it is absolutely gargantuan.

This represents a huge financial cost for the health system AND for you with nearly half of ACL injuries undergoing surgery!

So imagine if it was found that there was no significant difference in outcome between surgery and conservative rehab?

Conservative rehab Vs Surgery – What are the outcomes? 

Re-Injury rate after reconstruction:

One of the big concerns following surgery is re-injuring the ACL or surrounding structures (e.g. meniscus or cartilage) upon returning to sport. This is because the re-injury rate IS HIGH – studies looking into this have found it can vary from 2.3% to 13%.(4) The reason for the reasonably large range here is because it does depend on the sport or activity that the player returns to.

The re-injury rate is in the higher spectrum if playing a pivoting sport. The re-injury rate is 12% when playing a pivoting sport such as rugby and football/soccer – This is an unacceptably high rate giving an almost 1 in 8 chance of re-injury!

Risk of Osteoarthritis:

Often patients are recommended surgery so that the risk of osteoarthritis (OA) is reduced, but this is simply not true.

The rate of return to sport, treatment method or how much loading the knee takes in the years after injury are not the main factors contributing to OA – The initial injury itself is the important factor contributing to OA. This is due to bleeding within and inflammation of the joint after injury that, although your symptoms resolve gradually (pain, limited range etc) and tears can be repaired surgically, trigger a remodeling process. This chronic remodeling triggered in the cartilage and other tissues in the joint leads to OA in the majority of cases.(7)

This results in roughly half of all ACL inured knees showing OA after 10 years and nearly 100% after 15-20 years.

Some studies have actually found that following re-construction there is more OA. Kessler et al 2008 found that although there was better knee stability after a re-con, there was significantly more OA when compared to conservative treatment (42% vs 25%).(6)

It is also worth mentioning that sports participation itself – without prior injury moderately increases the risk of hip or knee OA.

Conclusion: There is NO evidence to suggest that ACL repair prevents future arthritis.

So when is surgery called for?

People who SHOULD under-go reconstruction are those that:

  • Have on-going symptomatic instability, eg knee giving out
  • Are elite athletes

Or

  • Wish to return to high-risk sports (pivoting sports)

The main reason for ACL reconstruction is to give an athlete a stable knee – So do not rush off to the surgeon if you do not have an unstable knee!

Follow this link for great information on:

 

Please Like, Share and Comment to let me know how you go and check out the below link to check your hip stability! Your hip controls the knee so this is very important!

 

 


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