The most read post on this blog deals with “Swelling, Effusion, Edema and Bruising – What’s the difference?”. I will take the concept one step further and discuss how knee swelling or joint effusions impact your ability to control your knee extension when you walk.
So, you injure your knee and develop swelling inside the joint. You may notice your knee giving way. That means when you transfer weight onto your injured leg the knee buckles. This is due to the quadriceps (front of your thigh) not contracting efficiently and hence not controlling the knee in extension. Knee extension is vital in walking because it stabilizes the leg to accept the transferred weight from the opposite leg when you are in stance phase of gait. If the knee is unable to go fully straight while stepping onto it you have difficulty swinging the other leg through to take another step.
This happens because of the swelling (and possibly pain too) within the joint. A neural reflex is set up by distension of the joint structures. It passes through the spinal cord and back to inhibit the quadriceps. It is then difficult to contract them at the right time and with sufficient speed during the gait cycle. Hence, unsafe walking and difficulty going up and down stairs, for example. You may notice immediate deterioration of your ability to contract the quadriceps following injury with a joint effusion.
To regain quadriceps function and hence to restore normal and safe walking you must control the swelling (see earlier post on this topic), avoid increasing it by careful activity modification and do specific exercises to regain normal quadriceps function. Physical therapists will instruct you in specific neuromuscular reeducation exercises to restore the quadriceps recruitment pattern. Such exercises may include seated quad sets, straight leg raises or short arc quad recruitment. These may be done with neuromuscular electrical stimulation (not TENS – that’s for pain and totally different type of current form) to facilitate recruitment of the muscle. In addition, you will be given terminal knee extension exercises in standing such as straightening the knee against a wall with a towel roll behind your knee against the wall or fully extending your knee against tension created by an elastic sports cord.
So, controlling swelling in a joint is necessary to regain function of the muscles moving that joint. This process is used in all knee injuries that result in joint effusions as well as in all postoperative rehabilitation, for example, following ACL reconstruction, meniscus repairs and debridement as well as total knee replacements.
What have you found helpful in the past?
What worked for you? What didn’t?
Post your comments here so other people can learn from your experiences. We would love to here from you.
A study by Burnett et al in the Journal of Bone and Joint Surgery (2006) documented an average time from injury to accurate diagnosis for hip pain due to labral tears as 21 months. People with this type of hip pain saw an average of 3.3 providers before definitive treatment was initiaited. In 17% of their study group of 66 patients, surgery was recommended on a different anatomic site. Once the correct diagnosis was made and the hip arthroscopy was performed, 89% of the patients were clinically better off than before surgery. That is positive.
Hip pain can originate from a number of structures and as a result can be easily misdiagnosed. Low back pain can refer pain to the hip area. Sacroiliac joint dysfunction can too. Hip pain can be due to bony problems such as impingement or due to damage to the cartilage structure around the socket, that is the labrum (similar to the shoulder – see an earlier post on this blog). It can originate from strain or tearing of the lignaments around the hip joint as well as from all the many muscles which control the hip joint. In addition, pain may originate from the pubic area where the abdominal muscles and the hip adductors attach, commonly called athletic pubalgia or a sports hernia. Finally, hip pain can be a consequence of referred pain from the leg.
Hip pain is typically localized to the groin area. It may also be felt laterally over the outside of the hip or in the buttock. There may be clicking, popping and snapping in the hip joint associated with the pain. Walking, running, ascending and descending stairs, putting shoes on (figure 4 sitting) and lying on the affected side may be challenging.
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Thank you for being part of Custom Physical Therapy. Here’s to your healthy hips!
To my fellow Boomers out there ….. How are your knees doing? We are an active sector of the population and we want to remain that way for the health benefits (and the fun!) thereof. Knee pain due to osteoarthritis, whether one or both knees, has a dramatic impact on a person’s ability to continue with their chosen active lifestyle and, if it gets painful enough, may impact activities of daily living such as getting into and out of a car or a chair, cooking a meal or simply walking.
WHY KNEE OSTEOARTHRITIS?
Osteoarthritis affects 25 million North Americans and is symptomatic in 13% of people aged 55 years and older. It has been shown to be the most frequent cause of functional disability including being dependent on alternative forms of mobility due to the tremendous pain with walking. Ouch! The prevalence of osteoarthritis is rapidly increasing due to two main factors. Firstly, the aging of the American population (that includes us!) is increasing the share numbers of people older than 55 years. Secondly, the rapidly increasing obesity in our population is increasing the rate of joint degeneration. One study reported 83% of males who had knee osteoarthritis were obese compared to 42% of males without it. Wow! Now there is a statistic that says a lot and leaves nothing to the imagination as to what we need to do to address the issue.
WHAT IS IT?
Osteoarthritis is the joints response to structural damage caused by mechanical problems. It is the body’s attempt to repair a joint under unusual stress and often leads to a stable, pain free joint. If this process fails (is insufficient for the magnitude of mechanical stress placed on the joint) the knee becomes symptomatic and hence functionally debilitating.
MECHANICAL STRESS YOU SAY?
Pathological mechanical stress of the knee joint may be due to:
Obesity increases the overall load through the joint and overwhelms the joint tissues resulting in osteoarthritis. Being bandy or bow-legged reduces the weight bearing surface area in the knee joints (shifts it from throughout the knee to one side or the other of the joint) and results in excessive wear and tear of the joint on the outer or inner surfaces respectively. Sustaining a serious injury to the knee in which ligaments are torn and the joint surfaces are banged together in the injury may initiate the osteoarthritic “repair” process as well. Thus, when stress on the joint tissues exceeds their physiological tolerance breakdown ensues and osteoarthritis begins.
HOW CAN WE ADDRESS THE CAUSATIVE FACTORS?
Weight loss in an effort to attain a normal body weight for your frame is paramount in reducing the forces through the knees. Walking results in a force through the knee equal to 3 – 4 times your body weight each step. If you lose 20 – 50 pounds in an effort to attain your normal weight, you reduce the forces through your knees by 80 – 200 pounds each step you take! Talk about happier knees! An 11.2 pound weight loss over a 10 year period has been shown to reduce the likelihood of developing knee osteoarthritis by 50%.
For misaligned knee joints (those of you who are bandy or bow-legged) there are unloading braces to modify (increase) the load bearing surface and hence reduce stress to the one side of the affected knee.
In all osteoarthritic knee joints muscle weakness, joint stiffness and poor balance are factors. Muscles around the knee joint serve to cause movement in bending and straightening the knee, can reduce mechanical stresses to the joint by absorbing loads applied to the limb (e.g. cushioning during landing a jump or when skiing) and stabilize the knee joint during daily tasks of walking, running, lifting and carrying to name a few. Patients with knee osteoarthritis are 20% to 40% weaker in their quadriceps than people without the condition. As the disease worsens the knee muscle activation patterns become less efficient and less specific and joint proprioception (the brain’s ability to know what is happening at the joint and react accordingly) is suppressed. A well constructed, evidence-based physical therapy program will improve strength, range of motion and proprioception and result in improvements in physical function, pain and quality of life. Modifying the mechanical problems causing the osteoarthritis together with addressing the inflammatory and pain aspects of the disease process through pharmacological intervention from your physician can result in an 86% success rate in improving your function. Who would not like that!?
All our physical therapists at Custom Physical Therapy have undergone specialized training for treating osteoarthritis. The therapists work as part of a team comprised of you the patient, your physician and the physical therapist. Using physical therapy interventions to modify the mechanical factors impacting the progression of osteoarthritis together with the physician addressing the pharmacological aspects and the patient being compliant with an exercise and stretching program (see our very first post on this blog) as well as brace use, if prescribed, the team of patient-physical therapist-doctor minimizes the effect of the disease process on your function.
YOUR CALL TO ACTION!
You are encouraged to call Custom Physical Therapy to talk to one of our accredited physical therapists about your knee pain. You may be a candidate for this customized evidence-based program specifically developed to improve your function which deteriorated due to knee osteoarthritis.
Total joint replacements surgeries tend to increase towards the end of the year because insurance deductibles have been met and out-of-pocket expenses tend to be less. An additional cost to the patient is the rehabilitation after the surgery, which also tends to impact insurance deductibles.
The most frequent type of joint replacement that needs the most rehabilitation is the total knee replacement, also known as total knee arthroplasty (TKA). So what does the rehabilitation process involve?
The first thing to understand is that 50% of a successful outcome is the caliber of the surgery. If you have done your due diligence by being an educated healthcare consumer (see my very first post on this blog) and asked the best surgeon to do your total knee arthroplasty, you should be pretty confident that the actual prosthesis is the right size and was put in correctly. That is the easy part of the process; after all you slept through it!
Then you wake up and realize your knee hurts. It is swollen, stiff, and the muscles in your thigh (both quadriceps in the front and hamstrings in the back) do not contract well despite you attempting to make them to work. You have difficulty transferring from supine (lying on your back) to sitting and then to standing. Now you have to walk with a walker, another foreign experience. After 3-5 days, the doctor may send you home from the hospital. Now you need to get into the car to be driven home. This requires you to bend your new knee, another daunting thought. Once home you need to do the right thing to keep your progress going and prevent complications such as deep vein thrombosis (DVT: a blood clot) in either one of your legs, arthrofibrosis (excessive scarring from the surgery) and infection.
Physical therapists now become your best friends and should be for a number of weeks to months following the surgery. You will be guided through a steady progression to return you to full function.
FIRST INPATIENT PHYSICAL THERAPY:
You will have inpatient physical therapy to get you ready for returning home i.e. avoid DVTs, know how to take care of your surgical wound and, you need to learn how to walk safely with a walker. You will also need to ascend and descend stairs, You should return home with enough active range of motion (AROM) to get into and out of the car and be instructed in transfers from supine to sitting to standing as well as how to get in and out of a chair. Detailed instruction should be given regarding how to control the postoperative swelling.
Avoiding DVTs: perform the embolic isometric contraction sequence of the calf, quadriceps and gluteus musculature (in that order). Also, do ankle pumps.
Surgical wound care: keep it dry, no showering – I have had one patient, 13 years ago, who decided to shower before the surgical wound was healed sufficiently. The knee became infected and was never the same again. Luckily it was not a TKA and the infection, therefore, did not enter the bone. It is worthwhile doing it right and accepting you will be a little dirtier than usual!
Walking: The majority of TKA patients start walking with a front wheel walker, day one or two after surgery. The large base of support gives the individual more stability. You must use an assistive device as your quadriceps (muscles comprising the front of the thigh) are not contracting efficiently. This is because of the incision and the pain impacting the function of the extensor mechanism (quadriceps + patella + patella tendon). As a result, you have difficulty straightening your knee and controlling it in full extension. When you transfer weight to the leg, the knee will have a tendency to give way (knee buckles under the weight) and you may fall.
Negotiating stairs with your walker: The inpatient physical therapist will teach you the correct technique for going up and down stairs with and without the walker. All homes have at least one to three steps to ascend from the garage to the house or at the front door. Just remember: the nonsurgical leg does all the work so you lead with it up stairs and lower your surgical side down with it when going down stairs.
AROM: Immediately you need to start working on getting your new knee straight (OUCH!) and getting it bending (OUCH!). The inpatient physical therapist should show you simple but effective exercises such as passive knee extension, hamstring and calf stretching to get it straight. They will also instruct you in heel slides to regain knee flexion. If you leave the hospital with full knee extension (straight knee) and 90° of flexion, you will be ahead of the game. With 90° of flexion you can get into and out of as well as sit in the car that will take you home.
Transfers: Inpatient physical therapists are the gurus at instructing in transfers under a variety of circumstances, all in an effort to get you more functional and independent. You should leave the hospital knowing exactly how to do a variety of transfers e.g. change positions in bed, sit to stand, in and out of a car, the commode, avoiding low chairs like a couch. You walker is your friend here to and you must focus on safety in all your mobility.
Control the swelling: This is a vital component of regaining full range and quadriceps function and should be a major focus immediately following surgery. (read the second post on this blog which discussed this topic in detail). Make sure you get iced in the hospital for 45 minutes at a time, all around your knee at least 4-6 times a day. You, the patient, must be vocal about this to get it done. You will be glad you followed this procedure. Recognize you will have bandages around your knee so it will take a while for the cold to penetrate them. Do not get the bandages wet (see paragraph above on infection!). Once the bandages are removed (7 to 10 days after surgery) you will ice for 30 minutes.
Now you are home. Feel better already, albeit a little beaten up I am sure. Out patient physical therapy now takes over. (if you are frail, you may get home health physical therapy but make sure they follow the following guidelines).
OUT PATIENT PHYSICAL THERAPY:
The other 50% of a good outcome is dependent on a good relationship between you and your physical therapists. Here is where the hard work really starts and you must be dedicated. Focus on the right things and you will get a great result.
Note: There is no need for the physical therapist to aggressively bend or straighten your knee. This may inflame the joint and increase the likelihood of arthrofibrosis. I typically set my patients specific goals to attain each week and it is their responsibility to achieve the range required. I measure at the beginning of each physical therapy session to track progress. If they struggle to improve at the agreed upon rate (typically 10° to 15° of active flexion per week), then I will step in and stretch their knee gently.
Rehabilitation is typically broken down into phases. Transition from one phase to the next is dependent on specific criteria such as degree of pain and swelling. Progression is not based purely on a timeline.
Phase 1: Post op days 1-10
Phase 2: Weeks 2 – 12 post-op
So, there is a lot of work to do in recovering from a total knee replacement. It is not rocket science but it does require focused dedication. Focus on the right things based on your discussion with the physical therapist and be dedicated with your home exercises as well as those in the physical therapy clinic.
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Thanks for reading this.
Tendinitis is the inflammation of a tendon and of tendon-muscle attachments i.e. where the tendon attaches to the bone (insertional tendinitis). It is an overuse phenomenon, can be excrutiatingly painful and functionally debilitating. Treatment should focus on addressing the cause of the tendinitis, reducing the inflammation and the pain, and remodelling the tendon through a controlled exercise progression.
Most frequently seen diagnoses in our physical therapy clinic are rotator cuff tendinitis (supraspinatus tendinitis), posterior tibial and peroneal tendinitis (pain in the foot and ankle), tennis elbow (lateral epidondylitis), achilles tendinitis, patella tendinitis and iliotibial band syndrome. Interestingly, we have recently been seeing an increase in tendinitis of the guteus medius (hip abductor muscle). We see golfer’s elbow (medial epicondylitis) less frequently than tennis elbow.
Despite tendinitis occuring in tendons all over the body, the approach to treating the condition remains the same for each structure involved. You treat the tendonitis by following a specific intervention progression. The exercises are different for the different tendons but the principle remains the same:
Treat the cause of tendinitis.
It does not matter what tendon is involved, the cause is most frequently overuse. Overuse means the stress the tendon has had to endure, as a result of the force it is being asked to apply (both intensity and frequency), results in microtrauma to the tendon structure and hence inflammation. If the tendon is not given rest, it does not have the opportunity to recover. Examples of activities which can result in tendinitis include typing, repeated gripping on a production line, fly fishing, overhead lifting or repeated jumping. Ankle sprains may cause tendinitis in the posterior tibialis and peroneal tendons of the foot.
So, the first line of attack is to decipher what the causative activities are and modify them. For most rapid resolution, these should be stopped completely to avoid the continuous trauma to the tendon. Sometimes this is not possible and a program of relative rest must be designed by the physical therapist:patient team.
Treat the inflammation.
Part of controlling the inflammation is reducing the stress on the tendon. The physical therapist will address this with you in detail. As mentioned above, rest gives the tendon the opportunity to recover from the microtrauma (as noted above). Non-steroidal anti-inflammatories or even streroids may be prescribed by your physician at the same time. Physical therapy interventions to control inflammation include ice in the form of an ice pack or even ice massage and, iontophoresis – the administration of an anti-inflammatory, dexamethazone, to the tendon utilizing electrical currenct to faciltiate the passage of the medication through the skin (Yes! No needles!).
Treat the pain.
By following the above suggestions, pain should subside over time as the inflammation is controlled. If the pain is severe enough your physician may subscribe analgesics (pain killers).
Remodel the tendon.
Here is where the work is! Your physical therapist will teach you how to stretch the involved tendon as well as progress you through a specific exercise regimen which involves both concentric and eccentric exercises which will stress the tendon. A concentric exercise is one in which the muscle contracts and shortens at the same time e.g. the bicep contracts to bend the elbow bringing the coffee cup to your mouth. An eccentric contraction is one in which the contracting muscle is lengthening while it contracts e.g. the bicep contracts and lengthens as it controls the extending elbow to put the coffee cup back down on the table. An eccentric contraction places more tension on the tendon than a concentric contraction and can thus promote tendon remodelling. Eccentric exercises are more aggressive than the concentric type.
The goal of the stretching and strengthening progression is to stimulate tendon remodelling. This improves the flexibility and tensile strength of the tendon. This, in turn, improves the tendons ability to tolerate the original activity which caused the tendinitis.
Soft tissue mobilization? Deep transverse friction?
What about soft tissue mobilization and deep transverse friction? Soft tissue mobilization of the involved muscle belly and, indeed, of the surrounding musculature can be helpful in alleviating discomfort. It is less aggressive than deep transverse friction and is definitely more comfortable.
Deep transverse friction is used to stimulate blood flow in the involved tendon and break up any adhesions which may have developed as a consequence of the microtrauma of the tendinitis. It is done by applying significant pressure (up to 7/10 pain) over the tendon with the thumb or index finger and rubbing in a direction transverse to the direction of the tendon fibers. Sound like fun!? It is done in conjunction with the tendon remodelling exercises detailed above.
YOU CALL TO ACTION:
The International Association for the Study of Pain defines pain as follows:
“Pain is an unpleasant sensory and emotional experience associated with actual or potential damage, or described in terms of such damage.”
So what does that mean anyway?
Put differently, per Dr. Lorimer Moseley, Ph.D., a world-renowned pain researcher and clinician at the Prince of Wales Medical Research Institute in Sydney, Australia:
“Pain is the conscious correlate of the implicit perception of threat to body tissue.”
This suggests that pain does not originate in the tissue due to injury or a degenerative process. Instead, it is a very complex interaction between the peripheral tissues (e.g. torn muscle, knee arthritis, lumbar disc herniation, whiplash injury, broken bone) and the brain. The brain processes information as follows:
So pain is an output from the brain after the brain has processed all the above information as well as the nerve impulses coming from the injured area, called sensory input. Once it has synthesized the need for an output you will then “be told by your brain” if something is painful or not. Think about the person I spoke to a few years ago who had a motor cycle accident and felt minimal pain when she stopped skidding along the highway and noticed her leg 20 feet away from her! Why no pain then? The brain had compiled an appropriate response at that time that suggested she had more important survival needs and thus did not feel pain. When she was loaded into the ambulance and the emergency personnel took over (they were in charge of survival now) she began to feel pain.
So what kind of output from the brain results once it has decided there needs to be a response to the “painful situation?”
The most recent research into pain has changed the viewpoint from one of a noxious stimulus causing pain (i.e. a peripheral origin of pain) to one of the brain being the decision maker as to what is painful and what is not (i.e. a central origin of pain). How complicated is that! It is not as simple as treating the injured tissue to relieve the pain. Pain needs to be treated from multiple angles with a multi-disciplinary approach.
YOU CALL TO ACTION!
Sparks location: 775-331-1199
South Reno location: 775-853-9966
Northwest location: 775-746-9222
If you sprain your ankle severely you may hear your doctor and physical therapist mention the words swelling, edema, effusion or bruising. If you have surgery on your knee for a meniscus tear or a ligament reconstruction you will hear similar terms (and see them too!). What is that bruising and swollen area in the muscles in front of your shin (tibia) when you ding your lower leg on the corner of a coffee table?
The Definitions (Dorland’s Medical Dictionary):
Swelling is defined as “a transient abnormal enlargement or increase in volume of a body part or area not caused by proliferation of cells.” The good thing is that it is transient so, as we have all experienced, swelling subsides over time (see below for hints on treatment). It is due to some form of trauma to the body such as an ankle sprain (the ankle looks bigger) or a muscle tear (larger girth of your thigh with a hamstring tear) or a surgery (which is really a trauma to the tissue). Fluid accumulates – the enlargement is not a consequence of cell division (proliferation) such as may occur with an enlargement due to cancer in a tissue or the enlargement seen in a bone from a healed fracture.
Edema is “the presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body.” Here fluid accumulates between the cells (intercellular). This may be a consequence of tissue trauma, poor circulation resulting in lower leg edema, heart failure, blood clots, lymph node resection as happens with breast cancer, renal failure, pregnancy and cirrhosis to mention a few causes. In outpatient musculoskeletal physical therapy we mostly see patients who have edema due to surgeries (e.g. knee replacements) or an injury causing tissue trauma. We may treat someone who has a comorbidity (co-existing condition) which has resulted in edema but if caused by a particular medical condition your doctor will be treating it, not us.
An effusion is “the escape of fluid into a part or tissue, as an exudation or a transudation.” An exudation is “the escape of fluid, cells, or cellular debris, from the blood vessels and their deposition in or on the tissues, usually due to inflammation.” Inflammation may occur due to trauma or surgery. Blood vessel walls become more permeable or may be compromised. Fluid and cells can thus escape from the artery or vein into the surrounding area. Transudation refers to the passage of fluid across a membrane or tissue surface (e.g. the synovial lining of the knee joint), which may or may not be due to inflammation. In physical therapy, we commonly see a joint effusion where fluid has accumulated in the joint. This may follow a knee or shoulder surgery or an ankle sprain, for example.
Ecchymosis refers to “a small hemorrhagic spot in skin or mucous membrane, forming a nonelevated, rounded or irregular, blue or purplish patch.” This is a medical term for bruising which is defined as “a superficial injury produced by impact without laceration.” Both describe blood leaking into the surrounding tissue. You know this one! Remember biting your cheek when you were chewing gum? Your mucous membrane inside your mouth went blue. Next time you do it tell who you are with that you have just created some ecchymosis in the mucous membrane of your cheek!
In summary, based on the above definitions, you can safely say that swelling refers to the enlargement of the body part involved and the swelling is due to fluid accumulation (edema, effusion) or blood accumulation (ecchymosis, bruising).
How do we treat swelling, edema, effusion, ecchymosis and/or bruising?
In summary, swelling may encompass the terms of edema, effusion, ecchymosis and bruising as long as there is an increase in volume (size) of a body part or tissue due to fluid accumulation. RICE is the treatment of choice immediately after an injury/surgery but heat and controlled movement should not be avoided. If you have lymphedema you should consult with a physical therapist with specialty training in lymphedema management.
YOU CALL TO ACTION!
Sparks location: 775-331-1199
South Reno location: 775-853-9966
Northwest location: 775-746-9222
I thought these two videos from Europe are well done and provide a good description of back pain and how you can control it at a basic level. Watch Part 1 then Part II. Anyone with back pain must make lifestyle changes to control the symptoms. This includes getting in better shape through correcting any imbalances there may be in flexibility, strength, proprioception, balance and core control. A physical therapist can start you in the right direction but then you have to run with it and stay on the program designed for you. What have you found most helpful in addressing your back pain? If you have had physical therapy for back pain and it was not as successful as you would have liked, what do you think was missing?
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I have saved short video of a presentation by an orthopedic surgeon, Dr. Kevin Stone, for your interest. He discusses some interesting cartilage, ligament and meniscus surgical options involving the use of animal tissue. What are your thoughts on the use of animal tissue for yourselves as potential patients?
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