Meniscal Injuries

The medial and lateral menisci are two important shock-absorbing structures preserving the health, integrity, and functionality of the knee. Their role is to serve as a cushion between femur and tibia and protect the underlying articular cartilage from being damaged by high-intensity vertical forces. Additionally, menisci increase the contact surface between femur and tibia, distribute stress across the knee during weight bearing tasks, stabilize and facilitate joint movement.

Menisci can be torn or completely ruptured, and the severity of the injury will impact on recovery and outcome. Below there are some examples of the most common meniscal tears:

Meniscal injuries can be classified in two main categories: TRAUMATIC and DEGENERATIVE.

Traumatic Meniscal Injury

What is it?

Traumatic meniscal injury often occurs in younger age groups. Most of these individuals are sport athletes below 40 years of age who have sustained a specific trauma in their knee, especially if they play contact sports. The most common traumatic event resulting in meniscal tear is a twisting movement on a semi-flexed, weight bearing knee. Injured people are usually unable to continue to play on after the trauma. Physiotherapists must always screen for the ligaments and, in particular, the anterior cruciate ligament as this can often get damaged by the same trauma. Traumatic meniscal injury is 5 times more common in males than females, because males are more involved in aggressive sporting. Depending on what meniscus is injured, the pain can be located either on the medial or lateral aspect of the knee. Posterior knee pain can often be present, and it is common when the tear is localised on the posterior horn of the meniscus. Common symptoms associated with a traumatic meniscal injury are locking, swelling and giving way of the knee.

What is the management?

Physiotherapy is always recommended as first line of treatment as research comparing 8-week physio programme made of strength, flexibility and proprioception work versus surgery demonstrated that surgery is no superior to physiotherapy. Pain management strategies will consist of rest, ice, compression and elevation in the short term. An exercise-based approach will consist of exercises to strengthen specific knee muscles. Physiotherapy should also address any impairment in mobility and stability if present.

When to request additional investigations or consider alternative solutions?

Once the diagnosis has been made by the physiotherapist, additional investigations are not required because in most cases they will not inform or change the management program. However, a physiotherapist can recommend an MRI scan for those patients experiencing true knee locking or for those who fail conservative management. Generally, if patients fail to respond to physiotherapy, surgical arthroscopy can be considered.

Degenerative Meniscal Injury

What is it?

Degenerative meniscal injury is a non-traumatic injury of the meniscus, and the onset of pain is gradual and insidious. Pain can occur after a minimal trauma (e.g. kneeling while gardening) or increased loading activity (e.g. a walk significantly longer than usual). Degenerative meniscal injury affects older age groups, and it is often associated with osteoarthritis in the knee. Squatting, kneeling and prolonged walking will often aggravate the knee pain. Pain can be localized on the medial, lateral or posterior aspect of knee. There is often knee swelling and giving way. However, differently than for a traumatic injury, the knee will rarely lock.

What is the management?

Physiotherapy management follows the knee osteoarthritis approach, incorporating education and advice, lifestyle modifications, analgesia and self-management strategies, weight loss, manual therapy techniques and exercise. The best exercise regime will include light aerobic training, local knee muscle strength work, active knee mobility and proprioception exercises. Static, low resistance cycling and aquatic therapy are also effective in reducing pain and improving function. Manual therapy techniques are supported by research if combined with exercise. Footwear and orthotic advice can be suggested by the physiotherapist if appropriate for the patient. Walking aids will be recommended for those individuals with significant pain.

When to request additional investigations or consider alternative solutions?

An MRI scan is indicated to assess the severity of the meniscal damage once physiotherapy has been unsuccessful. However, degenerative meniscal tears should always be considered on the background of osteoarthritis, hence a X-Ray can be suggested to confirm the diagnosis. It is important to remember that there is a poor link between visible changes on X-Ray and osteoarthritis symptoms. Corticosteroid injections are beneficial to reduce pain in case of early-moderate osteoarthritis but not effective for meniscal injuries. Injections will promote pain relief only for few months, their effect tends to reduce the more you use them, and you cannot abuse of injections because, over time, they are shown to increase the amount of joint cartilage degeneration. Therefore, it is always important to use injection as a complementary strategy to manage your pain and always continue with physiotherapy and exercises after you have had the injection. Degenerative meniscal tears can be treated with surgical arthroscopy but, especially for elderly patients with significant degeneration of the knee, there is the concern that more damage can be caused to the joint cartilage during the process. Therefore, often the surgeon will have to evaluate whether knee replacement is better. Knee replacement is generally appropriate for cases of severe pain with functional limitations, when the pain is not controlled with analgesics and the patient has failed physiotherapy.

Understanding low back pain

What is low back pain?

Among MSK injuries, low back pain (LBP) causes the highest burden with a prevalence of 568 million people in the world suffering from it. LBP is also the main reason for a premature exit out of the workforce. According to The British Pain Society, it costs an astonishing £10 billion on the UK economy. LBP is defined as pain arising from the lumbar spine, which can be divided into two big categories: “specific” and “non-specific”.

• Specific LBP accounts for 5% of the total cases.

Of this percentage, 4% is due to RADICULOPATHY (see the next section below for more information) and 1% is due to RED FLAGS, serious conditions that can present as musculoskeletal pain but require urgent medical attention. These Red Flags are: Tumor/Cancer, Infection, Fracture, Compression Pathology (e.g. Causa Equina Syndrome or Myelopathy), Inflammation (e.g. Spondyloarthropathy) and Metabolic disease (e.g. Osteoporosis). Physiotherapists must always screen for serious pathology at the beginning of the consultation and, if there is suspicion, onward referral to doctors and/or Accident and Emergency will be made.

• Non-Specific LBP accounts for the remaining 95% of the total cases.

The term “non-specific” means that it not possible to identify the exact cause of the pain. Surprisingly for many patients, a definite diagnosis cannot be achieved even with radiological investigations (such as X-Rays or MRI scans). Having said that, transitory changes in specific structures of the spine (discs and joints) can underpin the onset of pain in most individuals (see below).

LBP is usually categorized in 3 subtypes based on the duration of the pain: ACUTE (less than 6 weeks), SUB-ACUTE (between 6 and 12 weeks) and CHRONIC (longer than 12 weeks).

What can cause acute low back pain?

In most cases, people suffering from LBP who attend physiotherapy clinics will have a pain either discogenic or arthrogenic in nature.

Discogenic LBP originates from the discs of the spine when they have sustained specific changes overtime, such as dehydration or degeneration. These changes will initiate a cascade of peripheral and central events ultimately resulting in the perception of pain. However, you must not be fooled: disc dehydration/degeneration occur in every individual in response to aging and load exposure overtime and having some minor alterations in your spine does not mean that you will feel pain. In fact, discs are designed to modify their shape in response to sudden or repetitive load, acting as “shock-absorbing elements” of the spine. Minor protrusions or herniations are present in most individuals, and they will neither create pain nor impact on people’s ability to function. However, even if disc changes do not compromise spinal health in most cases, specific types of alterations can underpin the onset of LBP. For instance, when the disc bulges significantly out, it can sometimes result in one of the following:

• a narrowing of the spinal canal with potential compression of the spinal cord (SPINAL STENOSIS);
• an inflammation that irritates the exiting nerve root (RADICULAR PAIN);
• a compression of the exiting nerve root leading to alterations of the neural function, such as pins and needles, tingling, numbness, loss of power and reduced sensitivity (RADICULOPATHY).

Arthrogenic LBP originates from the joints in the spine called facet joints. This is more common in the aging population as joint pain is often the result of age-related arthritis, which can affect not only the joint itself but also its innervation, producing both local and radiating pain.

What can cause chronic low back pain?

In general, 90% of LBP cases resolve within 6 to 8 weeks with appropriate physiotherapy. However, in some cases symptoms can continue for longer and, sadly, some individuals will have long-standing pain. Chronic LBP occurs when the impairment is more localized in the central nervous system than in the musculoskeletal system. This happens because our nervous system is “plastic”, where neural plasticity refers to the ability of the nervous system to change its activity in response to internal or external stimuli by reorganizing its structure, functions, or connections. Stimuli that can trigger this include bad prolonged postures, wrong repetitive movements, traumas, strains and surgery. In chronic pain states, these stimuli will produce a cascade of events in the body that will ultimately affect the nervous system. Examples of these events are:

• Tonic and persistent stimulation of nociceptors (nociceptors are sensory receptors that detect signals from damaged tissue);
• Altered excitability of nerve fibers (nerves start firing electric impulses randomly and spontaneously rather than in responds to a specific stimulus);
• Modifications of ion channels with consequent altered signal transmission (transmission of a signal within a neuron is carried out by the opening and closing of ion channels; alterations of these channels will cause abnormal transmission of signals from the periphery to the central nervous system and vice versa);
• Up-regulation of specific genes (neurons will increase the expression of specific genes which in turn will amplify the number of receptors in their surfaces: with more receptors, neurons will become more sensitive to specific signals, thus responding more frequently than what they should to peripheral stimuli).

The result of the cascade of events will be the perception of pain despite the absence of an ongoing injury.

Can physiotherapy help with acute and chronic low back pain?

Yes, it can. Physiotherapy uses a series of interventions to help people reducing or eliminating pain from their back. For chronic pain conditions, it cannot always be possible to get rid of the pain completely, but improvements in functionality, mobility and quality of life will be achieved with the right therapeutic approach. Management strategies used in physiotherapy include:

• Provide people with education, advice and information about their problem, tailored to their needs and capabilities to help with self-management strategies
• Prescribe bespoke exercises
• Use manual therapy techniques (spinal manipulation, mobilization, soft tissue techniques and massage)

What are musculoskeletal injuries and why is physiotherapy important?

What are musculoskeletal injuries?

The WHO estimates that approximately 1.71 billion people suffer from musculoskeletal (MSK) injuries worldwide. These injuries range from those that arise suddenly and are short-lived to lifelong conditions associated with ongoing functioning limitations and disability. MSK conditions comprise more than 150 injuries affecting the bodies of young, adults and elderly people. These injuries are typically characterized by pain, limitations in mobility, dexterity and overall level of functioning, reducing people’s ability to socialise, work and enjoy life. MSK injuries include problems affecting:

• Joints (e.g. osteoarthritis, dislocation, instability, hypermobility and stiffness)
• Bones (e.g. osteoporosis, osteopenia, fracture and bone stress response)
• Muscles and Tendons (e.g. contracture, spasm, tear, rupture, inflammation and tendinopathy)
• Ligaments (e.g. laxity, sprain, tear and rupture)
• Spine (e.g. acute and chronic neck, upper back and lower back pain)
• Peripheral nerves (e.g. carpal tunnel syndrome, radiculopathy and radicular pain, sciatic nerve injury and entrapment neuropathy)
• Multiple body areas or systems (e.g. rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, ehlers-danlos syndrome, fibromyalgia and complex regional pain syndrome).

Why is physiotherapy important?

MSK injuries are the highest contributors to the global need for rehabilitation services. Physiotherapy is at the forefront of rehabilitation services as it is an evidence-based practise and takes a ‘whole person – holistic’ approach to injuries, aiming to promote health and wellbeing in every individual suffering from pain. Physiotherapists help people affected by MSK injury, illness or disability through a series of interventions, such as movement and exercise, manual therapy, acupuncture, education and advice. Physiotherapists maintain and optimize health and fitness for people of all ages, helping patients to manage pain, prevent disease and achieve the highest level of quality of life. Physiotherapists are degree-based health-care professionals who deliver much more than a simple massage. Some physiotherapists have gone through extensive post-graduate training and are able to, among other things, independently prescribe medications and perform soft tissue and joint injections. Many others are involved in education, research and service management.