Muscle Medicine: The Revolutionary Approach to Maintaining, Strengthening, and Repairing Your Muscles and Joints (37 page)

The three major muscles behind the knee, the hamstrings, counter the quads. The hamstrings pull the lower leg back by flexing the knee joint and they extend the hip. They are prone to strain, although chronic hamstring pulls are fairly rare outside the world of high-level sports. A small muscle behind the knee, the popliteus, helps flex and stabilize the joint. Although mainstream medicine doesn’t pay too much attention to the popliteus, many manual therapists find that it is often strained in runners and have had good success treating it manually.

The iliotibial (IT) band (functionally the long tendon of a short hip muscle, the tensor fasciae latae, and the gluteus maximus) runs down the outside of the leg, from the crest of the pelvis to the top of the tibia. It acts largely as a brace, keeping both the femur in place on the tibia and stabilizing the extended knee. Overuse, typically from running, can irritate the IT band and cause nagging pain along the outer side of the leg, especially at the knee and the hip.

The joint is sturdy enough to handle the tremendous forces generated by two of the strongest muscle groups in the body, the quadriceps and the hamstrings. At the same time, it’s vulnerable. It doesn’t have a solid bony covering like the hip or the elbow so the ligaments that hold the joint in place are an easy target in a collision.

The knee is not a simple hinge like the elbow. It bends and straightens, but it also slightly rotates. Its rounded ends roll over the flat top surface of the tibia, which allows for more mobility. You can plant your foot and cut—shift direction— as you run. What makes this extra movement of the bones possible are the menisci,
two crescent-shaped pieces of fibrocartilage in between the femur and the tibia that act as shock absorbers. It’s a wonderful system, until it takes a direct hit or the pieces begin to wear out.

WHAT GOES WRONG, AND HOW TO FIX IT

Mostly Muscular

Front-of-Knee Pain: Patellofemoral Pain Syndrome or “Runner’s Knee”

Chris, then a twenty-year-old triathlete, was confiding to the manager of his local New Jersey bike shop that he was leaving the sport because he couldn’t take the knee pain anymore. His training runs irritated the front of his knee, generating a dull, nonspecific ache that a lot of runners are familiar with—patellofemoral pain syndrome or “runner’s knee.” None of the doctors or therapists he’d seen had been of any help. Dr. DeStefano, a recreational triathlete, overheard him in the store and offered to help. Chris’s kneecap, it turned out, was not tracking properly. The quadriceps muscle that pulls the kneecap to the inside, the vastus medialis, was being overwhelmed by the vastus lateralis, which pulls to the outside. As a consequence, Chris’s kneecap was painfully rubbing against the groove in the femur in which it rides. After three weeks of manual work to lessen tightness in all four of the quad muscles and then physical therapy to strengthen the vastus medialis in particular, the problem was resolved. Chris, now thirty-four, competes as a professional triathlete.

PROTECT YOUR KNEES

Avoid prolonged squatting, for instance, when doing housework or gardening.

Avoid heels that are over one inch as much as possible.

Don’t prop your feet up on a table without some support under your knees.

Don’t sit with one leg tucked underneath you or sit on the floor with your legs to the side.

Jog conservatively. Unless you’re in serious training, try not to run more than every other day (cross-train on the off-days) and try to stick to softer running surfaces.

The quadriceps are almost always at the root of front-of-the-knee
problems. The simplest injury is a quad strain—the muscle fires too hard or too rapidly, and swelling or bruising results. Athletes in high-impact sports such as basketball or high jumping can generate so much muscular force that the tissues around the tendon connecting the quads to the kneecap become inflamed, causing patellar tendonosis or “jumper’s knee.” But the problem that derailed Chris, and derails countless joggers, is patellofemoral pain. Sometimes there’s a mild puffiness around the kneecap, and sometimes not, but the constant ache can make the knee feel like a rusty hinge.

The term
patellofemoral pain
tells us where the problem is located but doesn’t give us any clue as to what’s causing it. There are many different muscle imbalances and joint abnormalities that can add up to a mistracking kneecap.

Women tend to have greater Q angles, which contribute to a running gait that can pull the kneecap to the outside. (Statistics show that females have a greater incidence of front-of-the-knee pain than males.) A kneecap that rides unusually high can also create problems. Fortunately, whatever the cause, the prescription is almost always the same, muscle treatment—and self-treatment—then strength work.

Outside (Lateral) Knee Pain: Iliotibial Band Pain Syndrome

Runners have another familiar enemy, a tight IT band. This dense, fibrous band of tissue runs down the outside of the hip and thigh to the top of the tibia. Under ordinary circumstances, the IT band provides some extra stability for the knee (which can always use it). But when the IT band tightens up from overuse, it can rub against the bony outer edge of the knee, generating anything from a dull ache to a sharp, stabbing pain. The mechanics here appear to be straightforward, but if we work our way back up the “kinetic chain” to find the source of the problem, we may discover other explanations for IT band irritation. For instance, the left side of the patient’s lumbar spine may be tight, causing a decrease in left spinal rotation and forcing an overrotation to the right. This causes the right leg to strike the ground with extra force, irritating the IT band. The manual therapist then works on the lower-back muscles as well as the knee muscles to fix the problem.

Often what gets labeled as IT band pain syndrome is just the muscles on that side of the leg causing pain and dysfunction. True IT band pain syndrome causes locking of the knee and severe pain on the outside of the knee.

Muscle or Joint?

Meniscus Tear

In her late fifties, Sister Carol Zinn serves as a high-powered liaison between the Catholic Church and the United Nations. One day, she missed a step walking down some stairs and landed hard on her right foot. Without time to contract her leg muscles, the impact shock traveled straight to her knee joint. The jolt was only mildly painful, but over the next few hours the joint became swollen. She was left with a constant dull ache and a sharp pain when she flexed her knee. Dr. DeStefano saw her a few days later and began manually working on all the major muscles that support the knee, but progress was slow. He sent Sister Carol to Dr. Kelly, who found a torn meniscus on an MRI, but nevertheless decided the damage didn’t warrant surgery. He gave her a corticosteroid injection, which calmed the area down and allowed her to make an important overseas trip. For the two years since then, Dr. DeStefano has successfully kept her pain at bay with regular manual treatment, and Sister Carol continues to travel constantly.

In Sister Carol’s case, her damaged meniscus was without a doubt the source of the problem. The question was whether the meniscus needed to be surgically removed or whether her condition could be managed by concentrating on the traumatized muscles.

We like to say that the MRI has its pros and cons. Having such an accurate picture of what’s going on inside the joint can help us make more accurate diagnoses, but it can also reveal incidental findings that are not the cause of the pain. The meniscus is a case in point. Unlike an X-ray, an MRI will reveal a tear in the meniscus, but it can’t always tell us whether the tear happened last week or last decade. In Sister Carol’s case, she may have torn the cartilage by landing hard on that step, or an old tear might have left the knee more susceptible to the force of the impact.

In any event, the injury shut down the surrounding muscles. Inflammation triggered muscle pain and a buildup of fluid around the joint. The most conservative step was to work on those muscles, first with manual therapy to speed up healing, then with physical therapy to make them strong enough to compensate for the lack of a healthy, stabilizing meniscus. The goal isn’t a perfect knee, just one that functions as well as it possibly can. In Sister Carol’s case, a single injection of an anti-inflammatory
corticosteroid worked wonders. But lacking the support of a healthy meniscus, her knee is still prone to irritation and tightness; she sees Dr. DeStefano for treatment every couple of weeks.

Sometimes it is a fresh meniscus tear that is the source of difficulty. Typically, a piece of the torn cartilage gets trapped between the femur and the tibia, causing pain or the joint to “catch” or “lock.” Here, surgery is the likely option, but only to remove the troublemaking piece of tissue. Again, if older people, with the help of therapy and anti-inflammatories, can comfortably get by without meniscus surgery, they probably should. There’s a particular reason for this. All too often, the meniscus tear is the consequence of wear-and-tear deterioration affecting all the cartilage in the knee. The missed step or the awkward twist is just the proverbial straw that broke the camel’s back. If the articular cartilage that allows the femur and the tibia to move smoothly against each other is in similarly bad shape, then knee replacement surgery looms on the horizon. There’s little point to subjecting the patient to a meniscus surgery if the whole knee will shortly be replaced.

KNEE STATS

According to the latest statistics, between the ages of twenty-five and seventy-five, your chance of having disabling knee pain or injury is about 50 percent. About one in five Americans over age sixty has chronic knee pain, compared to one in seven for chronic hip pain.

Young people are looking at a different scenario. If they tear a meniscus, it’s most likely the result of trauma. If the tear is small enough, the pain and swelling may subside so quickly the damage never gets diagnosed (perhaps to show up on an MRI twenty years later). For a more serious injury, the location of the tear may determine the treatment. When discussing surgery, there really isn’t such a thing as an “unnecessary surgery.” Orthopedics repair damaged structures because they are damaged. The question is whether that structural damage is causing the patient’s symptoms. As with a lot of orthopedic procedures, the question isn’t whether meniscus surgery is good or bad, but good or bad for whom, and under what conditions: Sister Carol or a twenty-year-old point guard?

Joint/Orthopedic

ACL (and Other Ligament) Tears

In skiing, all it takes to tear your ACL is landing off-balance after going over a mogul. Dr. DeStefano treated a well-known U.S. skier who had suffered a total body blow after flying off a downhill course at full speed. Luckily, her most serious injury was a torn ACL. Well into the 1980s, the standard treatment would have been to rush her into surgery, then put her knee in a hard cast, inadvertently ensuring that the traumatized muscles would completely atrophy and the knee joint would freeze shut with scar tissue that would have to be painfully broken up in physical therapy. Now, we wait several weeks before surgery. We let the inflammation subside and we build up the muscle strength and the joint’s range of motion. Dr. DeStefano had such good results manually working on the skier’s supporting knee muscles (mostly the quads and the hamstrings), she felt like she didn’t need the ACL surgery after all. When her ACL was tested, the tibia still slid out from under the femur; strong muscles might hold her knee together for everyday life, but not for barreling down a ski run at seventy miles per hour. But all the muscle work had set her up beautifully for the surgery, the flexible cast, and the rehab that followed. She returned to competition, where she added several medals to her collection before she retired.