Treating Highly Irritable Patients with Knee Pain

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses the current literature around best practices for degenerative meniscal issues, including graded manual therapy, self-relief at home, and loading. Mark also discusses how to begin with the highly irritable patient & progress through the full plan of care as symptoms reduce & tolerance to load increases.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

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MARK GALLANT All right, what is up PT on ICE Daily Crew? Dr. Mark Gallant here, lead faculty of the Extremity Management Division alongside Lindsey Huey. Happy to be here today, coming at you on Clinical Tuesday. What I'd like to talk about today is degenerative meniscus tears and what is the best path going forward to treat them. So what we'll get into today is a few things of overall arching research and philosophy about degenerative meniscus tears. So those are those tears that person's around the age of 40. There's usually no relevant recent trauma. So we'll get into again, general research philosophy. And then what we're going to talk about is what do you do when that tissue is really irritated? How do you move them forward clinically? And then what do you do when it's, when it's less irritable and we're really trying to get them back to all the things that they love the most. GENERAL RESEARCH PHILOSOPHY So what we see with these degenerative meniscus tears in the research, a few interesting points. So first is, that when Horga et al in 2020 took 230 asymptomatic knees, ran them all through the MRI tube, what they found in their research is about 30% of those folks had a meniscus tear or some sort of meniscus degeneration. So even in asymptomatic folks, having some tissue changes to the meniscus tissue is quite normal. Then Thorland et al in 2018, they had a surgeon who went in and did a scope of arthroscopic surgery to over 600 knees and while the surgeon went in there determined is there damage to the meniscus or is there no damage to the meniscus. What they found was an equal number of folks with no damage to the meniscus reported signs of mechanical knee pain that we typically associate with meniscus injury. So things like catching, locking, and lack of extension of the knee, we have historically associated those with a damaged or torn meniscus. And what Thorland et al found is, no, this really is more of a sign of that the knee is not doing well, that the health of the knee is not at its max capacity. and that's likely why they're getting those catching, locking, lack of extension, not that one specific tissue or a couple of specific tissues are to blame. And then finally, over the last decade, we have study after study, systematic reviews, randomized control trials showing that if you compare someone who had conservative care like physical therapy versus having surgery to their meniscus, that after a year, the outcomes are the same, if not better, favoring the physical therapy side with far less medical cost. Last year, what came out is we now have Cochrane-level review evidence, a Cochrane study showing that scoping these meniscus knees, or knees that supposedly have meniscus damage, is no better than placebo. So again, many asymptomatic knees are gonna have changes to the meniscus, whether that's degeneration or tears, Most knees, whether they have a meniscus tear or not, if they are unhealthy and not doing well, they're going to show signs of mechanical knee pain such as catching, locking, and lack of knee extension. And when we take it even further and we look at who gets better if we treat them out for a year, again, Cochran level review evidence saying that we should not be scoping those knees, which has led my partner, Lindsey Huey, to often using the phrase, stop the scope. There's a couple podcasts here a ways back if you want to check them out where Lindsey went into more depth of the all the research showing why we should not be scoping degenerative meniscus tears or at least not scoping them as a first line of treatment. She also has a episode on our virtual ice where she goes in depth to the scoping the knees. STOP THE SCOPE: THEN WHAT? So what I want to talk about today is stop the scope, then what? Then what do we do after that? So how are we going to effectively treat these people to get them back doing the things they love? So Let's start with the highly irritable patients, someone who comes in, their symptoms are at that 7, 8, 9 out of 10 symptoms. How are we going to treat them? Well, modulating their pain is always a good place to start. So can you use your manual therapy, your joint mobilizations, your dry needling, your myofascial decompression, or your soft tissue techniques to take their symptoms from that 8 and get their symptoms down to a four, a three, a two, something that's a little more manageable. When we're doing our joint mobilizations for these folks early on, what we're going to do is we want to do them in more of a open pact or positions that are not challenging the end range as much. So both flexion mobilizations or knee extension mobilizations. Again, at this point, we are not trying to get after knee stiffness or range of motion limitations. We're trying to create fluid exchange. We're also trying to pump any chemical irritants out of the area. And really the biggest thing is we are trying to get a positive stimulus into those tissues so that the central nervous system will calm down a bit and allow us to load the knee, which will effectively improve its long-term health. So again, very mid-range, open-pack joint mobilizations. With your dry needling, what we typically see is it works well to go distal from the knee. So putting your needles in hamstrings, quads, glutes, tissues that relate to the knee, but are not going to create fear for that patient by putting the needle directly into the area or tissue that is sensitized. Same with your soft tissue mobilization or your cupping. When you, after you do your joint mobs, your dry needling, they're feeling a little better. Then we're going to give them a self-mobilization to follow it up when that person is more irritated. Again, we want that to be more of that open packed, less challenging end range. If they have a flexion deficit, we like to go on the floor doing a heel slide, but having a thick band provide an anterior tibial glide, which will further modulate their symptoms and allow them to get through a nice comfortable range of flexion. If their deficit is more knee extension and the pain and symptoms are high, we're going to have them do a quad set but put a towel behind their knee so that they know there's an end range and they're not going to bottom all the way out into their symptoms. You can also add a band to distract the tibia and that sometimes can be an added benefit for those folks. So you're going to do your pain modulation technique in the clinic You're going to give them some sort of self-mobilizLation to help further modulate pain at a fairly high volume, 15 to 20 reps to really pump that tissue. LOAD AROUND THE KNEE And then as early as we can, we want to load the tissues surrounding the knee. So the quads, the hamstrings, the gastroc soleus complex early on when things are irritated, it's going to be challenging to get a lot of tensile load through these, through these tissues. It's also going to be challenging to get them at an end range. So, we're going to do mid-range knee extensions and we're going to do Knee flexion, so either banded, monkey feet, whatever you can do to challenge those hamstrings with a light load and a mid-range at a high volume. And then whatever way you want to load the gastrocs and soleus, but again, going low tensile load, high volume. And then what sort of functional thing can you get that person into? A lot of times those folks have challenge with loaded knee movements. We want to get them back to that as early as possible. without stirring up their symptoms. Early on, what we find best is to go double leg activities that don't have a lot of shear involved with them. So not a lot of twisting and rotation. So we love a body weight squat and even a body weight squat to limited depth to keep that person comfortable early on. So again, symptoms are high. You're gonna go manual therapy, more for challenging symptoms, not challenging their end range. You're going to go self-mobes that have the same type of style where they're more mid-range, really creating a pump to that tissue, giving some positive input. You're going to start to challenge the knee extensors, the knee flexors, and the gastroc soleus complex with lighter tensile load. higher volume again thinking pump and getting positive positive stimulus in the system and we want to get them used to doing their functional activities double leg body weight squat with a depth that they feel comfortable with is a really nice way to do this now then that person is going to come back and their symptoms are going to be lower so they're going to tell you know what i was at an 8 out of 10 but over the last couple weeks, I've been hitting all the stuff we talked about. The manual therapy felt good. Now my symptoms are more in that two out of 10 range. I feel like I can get after it a little bit more. So now when we're doing our joint mobilizations, we are gonna go straight down to the end range and really challenge the end ranges of these tissues and make sure we facilitate that they can restore full flexion, full knee extension. For our dry needling, now we are gonna get much more direct at the tissues of the knee. So we really like to needle the popliteus, the hamstrings, the gastroc soleus, tissues that are right there interacting with the intra-articular knee tissues. For your follow-ups, now again, we want to get them right into those end ranges of tissues and really start to challenge them. CHALLENGE END-RANGE We love the classic terminal knee extension with a really thick band. Spanish squats can be another way to get after this. We also, for the knee flexion after the mobilization, we're gonna get into a child's pose position with a towel behind the knee. I'll come on tomorrow on our Instagram feed and demonstrate what this looks like. So they're gonna have a towel behind the knee with a band keeping it placed, and they're gonna rock all the way back into deep end range knee flexion to really challenge the end range of that motion. Now, loading up the local quad, loading up the local hamstrings and gastroc soleus at that point where they can tolerate more tensile load, we're going to go long arc quads, really loading that up, whether that's a classic knee extension machine, your monkey feet, banded long arc quads. you can hit spanish squats in this position to really load the quads up for our hamstrings we're really going to start to challenge the length tension relationship of those by doing things like nordic curls You can also do Nordic curls or bridge walkouts to really challenge those hamstrings can be another nice one. And then in this phase, we are really getting into the concentric eccentric in functional activities. We really like transitioning to single leg activities in this phase. your split squats, your kickstand RDLs, your single leg RDLs are very nice for this phase, really challenging that knee overall from both a proprioceptive balance and load perspective. When you're doing your squats and your deadlifts in this phase, really starting to load them up, how heavy and how much stress can that tissue take during this phase. Step ups are another really nice one to add in. So again, during that low irritability phase, now we are challenging end ranges of tissue. We're really trying to put positive stress into the quads, hamstrings, calves, Our functional activities, doing single leg, whether that's split squats, RDLs, heavier on the double leg squats, deadlifts, step ups, all work really well. Once they can tolerate that phase, with 2 or 3 out of 10 or less symptoms, then we've got to really get them back to their more dynamic activities if that's what they choose to do. Here's where we're going to do things like box jumps, rebounding jumps where they jump from one box height to the floor up to another box height. We're going to hit things like jumping ropes so they get their plyometric endurance up. single leg hops for distance, running for distance, cutting. This phase we really want to focus them on getting back to the activities that are challenging them and some pivot rotation movements that are going to challenge that sheer force to the knee. SUMMARY So overarching themes. For these degenerative meniscus tears or degenerative meniscus damage, surgery is never the first line of defense for these folks. When they're more irritable, our manual therapy is gonna be much more mid-range, calming things down, giving a positive stimulus to the nervous system. Our follow-ups are also gonna challenge more in this mid-range, again giving positive stimulus, mid-range knee extension, banded or monkey feet hamstring curls, low to the gastroc soleus, and typically double leg functional activities. Once they can handle those things where symptoms drop below that five, now our manual therapy gets much more into the end range of those tissues. Our follow-up MOBS are also gonna get into the end range of those tissues. I'll show that, Child's Pose Rock Back tomorrow on our Instagram feed. Our knee extension, our hamstring activities are gonna be much more higher tensile load. Our functional activities will switch into single leg or much heavier and stressful double leg activities. Once they can tolerate that at a two or three out of 10, then we're really gonna start getting into their running, jumping, cutting, dynamic motions overall. Hope this helps as far as treating out those alleged meniscus tears and avoiding them from going into an unnecessary surgery. If you'd like to catch us on the road, I'm gonna be in Highland, Michigan, just outside of Detroit this weekend. Lindsey will be in Scottsdale, Arizona this weekend. And then the next opportunity to catch us will be Lindsey will be in Carson City, Nevada, February 17th and 18th. Hope to see you all soon. Hit us up in the comments if you have any questions or things to add to this conversation. Have a great rest of your Tuesday.

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