Most of us enjoy the freedom to be able to do the things we like, when we like, and how we like. These freedoms can sometimes be crippled for various reasons making life a hardship and drag. One of those cripping effects is pain. Pain can quickly change the mood, desires and decisions of anyone at the drop of a hat from happy, enthusiastic to negative and depressive. One particular pain that can be very frustrating to deal with his knee pain. Have you ever been walking and all of the sudden just started feeling knee pain? Or have you ever gone up and down stairs and feel or have your knee give out because of pain? These can be very frustrating situations especially when just the other day it was feeling just fine! By better understanding the hierarchy seriousness of knee pain and the origins of them, those frustrations can be appeased and solutions can be found..
First, let’s look into the question that most people with knee pain have. How do I know if my knee pain is serious? This question in general, most of the time is pretty easy to answer.. The following criteria of knee pain usually require an MRI that leads to some form of surgery. When there is an acute injury to the knee causing pain along the joint line that is sharp and stabbing with some clicking causing the knee to “lock-up” usually requires advanced imaging and oftentimes surgical intervention. There are usually some visual signs of swelling that accompany this presentation.
Some examples of these types of injury could be a sport related injury as a “cut and run” type maneuver. This is where the athlete plants their feet and rotates their body and knee to quickly change direction. An over rotation in the knee during the planting-of-the-feet can cause collateral ligament and or meniscus (cartilage of the knee that acts like padding) to get injured or torn. Another more common one can be simply a step down where the distance traveled or the location of the landing spot is underestimated by the person and they lose balance causing the knee to buckle increasing strain on the tissues due to the miss step. This can also cause collateral or meniscus injury. Anything outside of this knee pain is a little bit more challenging to deduce and usually is not as severe or there are several options of treatment available that doesn’t have to deal with surgery. This is the knee pain that comes on unexpected–the phantom knee pain! Where and what situations typically predispose someone into developing this type of knee pain?
To answer these questions, a better understanding of what makes up the knee joint is needed. The knee is a pretty simple joint as it has basically two motions–flexion and extension. There is some rotation in the joint itself but it is not a significant amount. Knowing which tissue causes the motions, and which one supports the motion can better help us identify possible origins of knee pain that is brought on by motion.
To begin with knee flexion. Its range of motion is produced via the following muscles: the hamstrings, gastrocnemius, sartorius, gracilis, plantaris, and popliteus. The muscles that make up knee extension are: the quadriceps (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius, and tensor fascia latae. One of the many interesting things about this joint and virtually all other joints is that many of the acting muscles have to rely upon their antagonist muscles in order for them to work properly. An antagonist muscle would be one performing the opposite motion such as extension is opposite of flexion. The muscles that would be doing flexion needs the muscles that do extension to relax in order for that ROM to happen smoothly and with the least degree of strain or stress. So we can say that all the muscles that move the knee need to be working together. Any imbalance in the structure or overcompensation can lead to symptoms of discomfort and pain in the knee and knowing those pain patterns for all of the muscles and structure is vital in determining which structure/tissue is having problems manifesting to the body with a sign of help in the form of pain.
When discovering the source of the tissue responsible for the knee pain, it is good to look at your recent history. Recent trauma such as a direct blow to the knee during a sport event, slip and fall, motor vehicle collisions or other similar events make it easier to deduce the irritated/damaged tissue causing the pain. When a recent trauma/accident doesn’t happen, it can be a little more difficult to discover the tissue source of the knee pain. The good news is scientists and doctors have studied and mapped out pain patterns for irritated/damaged tissues that make it easier to narrow down tissue sources of pain. For muscles a big part of pain maps come from their trigger points.
Trigger point origins came from John Kellgren, a physician and professor of rheumatology at Manchester University in the early 19, who observed that the pain in myalgia or what is known today as myofascial pain syndrome; originates in small circumscribed, tender points in muscles. He noted that depending on the depth and intensity of pressure, pain could be felt at the pressure point or radiate or be felt at different locations in the body. He also observed that these pain patterns with/without pain referral could be alleviated with injections of pain killer (novacaine) medication at these points.
Kellgren’s work inspired another doctor Janet Travell to study it further. She discovered that these “tender” points were triggered by hyperactivity at these points in the muscles which can cause the muscle to change at those points into a more fibrous or more “hardened” area. She gave them the name trigger points (TrPs). Her work along with others, led to mapping a majority of the body’s muscles trigger point areas and their pain referral patterns. Their findings are well documented and discussed in their extensive book Travell, Simmons & Simons’ Myofascial Pain and Dysfunction where the process of TrPs formation can be studied more in depth. For the intent of this article it can be summed up as an over increased amount of effort/strain/prolonged contraction or over contraction in a muscle fiber which results in the formation or activation of a trigger point(s). Basically it can be streamlined into an “overworked” muscle and when it is overworked it complains via pain. A similar comparison could be made to overworked individuals as well–they are prone to complain.
The following image represents the TrPs pain pattern of all the muscles that have a direct relationship with the knee as mentioned earlier in the article.
As seen in the image, all of the muscles mentioned above do refer pain to some aspect of the knee when they get to an overworked state. The next question that you might be asking is how do these muscles get “overworked” and is there anything that can be done about it? Is there anything that can be done to prevent it? The answer to this question is yes!
Since we don’t have a direct event causing the tissue to be irritated, getting to an overworked status requires the muscle to overcompensate over a period of time. There are many overcompensating patterns, but the basis for most of them fall in the category of stability issues with the involved structures, particularly the bones. They are the backbone for movement in the body. For stability issues with the knee we are looking at the femur, tibia and a little bit of the fibula. These bones themselves primarily get stabilized by the structures they connect with which includes the knee joint, the hip joint and the ankle joint. If there is instability in these joints, then muscles have to overcompensate to create stability enough to generate force to perform their range of motion. This added extra effort overtime wears down the muscle and these trigger point areas form. It is tempting to think, when dealing with stability in the knee, that the instability that matters most is the knee joint. That may be true for a majority of direct trauma to the joint itself injuries, but when that is not the case, the hip and the ankle are often overlooked which are vital to stabilizing the femur and tibia from above and below.
You may be asking yourself now, “How can I tell if my hips or ankles are stabilizing correctly?” This part requires more specialization and I recommend that you seek the help from a provider that specializes in functional stabilization. Some of the best techniques out there for stability work are administered by practitioners who study and practice dynamic neuromuscular stabilization (DNS) and or use the Functional Movement system (FMA/SFMA).
SFMA is a screening tool that competent practitioners use to determine if a muscle joint system in the body is functioning optimally. Optimally meaning the motor control (how the brain consciously and subconsciously activates and deactivates muscles) of the muscles that move and stabilize a joint are optimized for maximum force, and stamina with the least stress or strain on all of the involved tissues. With these screen results, the practitioner will be able to know what area and type of help that is needed to improve stability. DNS is a great technique for showing that as well, but goes more in depth of the fixing or applying the help that is needed in those joints. It is based on universal developmental patterns in infants. For an infant to go from a floppy cute baby to able to be a cute standing and walking mobile wrecking machine, certain core muscle groups have to be engaged at certain milestones in order to make that happen. Most would agree that walking toddlers are pretty flexible and suffer from little to no neuromuscular skeletal pain as compared to adults who could have a wide variety of aches and pain. DNS developed a technique that teaches our older body to move and stabilize like it did when it was an infant. Thus waking up those dormant patterns that are more stable and provide more support to the body and its activities of daily living.
Once the muscle structures that are causing the symptoms in the knee and the stabilization strategies that need to be improved are identified, an effective treatment plan can be administered. A plan that helps to bring relief to the overworked muscles as well as trains the body how to optimize a better less stressful movement pattern is what you are looking for in getting the quickest and longest lasting relief for our knee pain with stability issues.
There are some professionals out there who will attribute a majority of knee instability and pain issues to having a large Q. A Q angle has to deal with the angle that is made from the femur to the tibia. In women it is larger due to wider hips and it is reported that women in general have higher accounts of knee pain/issues in life then compared to men. However, studies conflict on establishing a Q angle as a significant contributor to knee pain. The same thing comes up when professionals are talking about knee anteversion.
This is how the femoral neck of the femur comes out of the acetabular or hip joint.
Either way, the first round of defense for knee pain with these indicators is usually not to surgically change the Q angle or anter/retroversion of the hip. As previously stated by addressing the overworked nature of the structures and improving the stability of the system, many knee pain conditions can be helped regardless of angles. This is possible because this method applies solutions that incorporate these anatomical variants. There is optimal stability for the knee in individuals with an anteverted or retroverted hip and or with an increased Q angle. A person can be trained to use what they have better. Most would agree that putting forth the effort of improving the function of the existing structures is a far better route then the route of surgically altering them which includes in and of itself extensive functional rehabilitation.
Not to mention the risk of surgery itself. If retraining of the hip, knee and or ankle functional stabilizing system has no effect, then maybe a surgical route could be considered.
This is the reason why we here at Integrated Health Solutions make it our job to not only identify and treat the tissues that are causing the pain, but utilizing both SFMA and DNS techniques along with other specialized protocols to identify the instability causing the overworked muscles and solutions for treating them. We spend 30-50 minutes per treatment with our patients making sure that origins pain, the cause of the origins of pain and lifestyle changes need to lessen the chance of relapse are addressed and incorporated. Don’t let that knee pain keep you handicap any longer by letting us help you by giving us a call 317-449-2020 and find out how you can get your knee and lifestyle back.
Content provided by Dr. Andrew Sanders
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