Articles in Category: General Health

The Knee

Written by Don Williams BSc, MChiro, ICSSD. on Wednesday, 23 September 2015. Posted in General Health, Sporting Injuries, Training and Performance, Chiropractic

The Knee

By Don Williams

B.Sc., M.Chiro., ICSSD., PG Dip. NMS Rehabilitation,

Cert. DNS.   Memb: CAA, FICS, CEA.

 

This month I thought I would write a brief article about the knee.

 

The Knee is such a fascinating joint and unfortunately, is a regularly injured joint, necessitating visits to our clinic for many people.  We regularly receive referrals to assess knee injuries to identify what is actually wrong and how to manage the problem. This often necessitates us referring out for MRI scans and in some cases on referral to some of the excellent orthopaedic surgeons that we deal with.

 

The Knee 1  

 

Types of Knee Injuries:

Knee injuries and pain associated with those injuries generally fall into 3 categories.

 

Firstly, degenerative problems:

This can be osteoarthritic change or general wear and tear due to age or overuse of the knee.

Often age correlated or a result of lots of aggressive sport in the younger years.

 

Secondarily, biomechanical overload injuries:

These are often the result of;  genetic mechanical issues such as pronation of the feet and ankles, “Knock knee”, “bow legged” posture of the knees,  inappropriate footwear, poor technique in running, walking and other fitness activities, poor setup on bike position or sporting equipment or weaknesses and imbalances of the supporting musculature.

 

Thirdly, the pathological or traumatic injuries:

These are things like anterior cruciate ruptures (ACL), Meniscal tears (often referred to as the cartilage), fractures, and collateral ligament tears and issues. Bursitis and tendonitis issues are sometimes grouped into this category but are often more accurately grouped into the second category.

 

But what makes the knee so susceptible to injury:

Several factors really. The knee can be thought of as a force transducer. When we are walking, running, turning and jumping, our knee is subjected to high forces or loads in a multitude of directions.

 

The mechanics of the knee are complex and this article will be far from exhaustive in the description of the knee. But in basic terms the knee is a rolling/gliding hinge joint. Thinking simply, the knee is not a simple hinge (like a door), as the knee straightens, the femur glides across the tibia as it rolls towards the straightened position. This is why the end of the femur has a lengthened cam-like shape, in contrast to the relatively flat shape of the top of tibia. This means that the contact point and force vectors through the joint constantly change as the knee bends and straightens, combine this with the fact that the knee also pivots slightly right at the end of the straightening process make the knee a regularly injured joint.

 

Many health practitioners are taught at university that for the knee to have a pathological or major injury, there must be a large impact or nasty injury mechanism occurs to cause the damage. However, this is very clearly not the case with many of the patients we see at Institute of Sports and Spines.

 

In fact, the 2 worst knee injuries I have seen this year came from very low force activities; one from standing up after sitting on the ground and one from walking along the ground at work and turning to speak to someone. In fact, my own knee injury was not the result of a twist, fall or accident, but purely jogging along a flat footpath, the articular cartilage got caught and tore and it has been a problem ever since.

 

Scans and Imaging for the knee:

Depending on the injury or suspected injury, a range of scanning options are used.

Xrays and pretty good for looking at fractures of and around the knee, gross degenerative change and biomechanical position, they are not good at assessing soft tissue and ligament issues.

Ultrasounds are used to look at tendonitis and bursitis issues and muscle tears around the knee.

MRI scans are generally the image of choice for the knee and are the only means to effectively view meniscal tears, cruciate ligament injuries, collateral ligament injuries and articular cartilage defects.

I have included a couple of images below for interest.

 

Image 1                                                                                             Image 2

The Knee  2  The Knee 3 

The Knee 4

                                                                                              

Image 1 above, the green oval shows reasonable articular cartilage with some thinning. The red circle shows a tear or defect in the cartilage (the white area), the end of the bone has a light area which is bone swelling.

 

Image 2 The blue circle shows good articular cartilage and a healthy meniscus in the correct position (black triangle on the right side).

The red circle shows the lateral meniscus in the wrong place (this is bad ;)) and the green arrow shows us where it should be.

 

 Image 3 to the left shows a vertical tear in the meniscus and a little bit of swelling to the left of the arrow.

 

Management of Knee Pain:

When you have knee pain, correct assessment and diagnosis of the problem is critical. We have unfortunately seen many patients who have had a lot of treatment for the wrong diagnosis, resulting in poor outcomes.  A comprehensive physical and orthopaedic examination should give a working diagnosis which may then indicate treatment direction or relevant investigations to confirm the suspected diagnosis.

 

At IOSAS, we generally start our assessment with gait analysis, looking at joggers, work shoes etc, analysis of movement patterns and muscle strength to look for weakness and imbalances, followed by an orthopaedic joint assessment. This then directs how we will manage the presentation to move you towards the outcome you desire.

 

Most biomechanical issues of the knee and overload syndromes can be managed conservatively and don’t progress to surgery.  Advanced degenerative change of the knee will often require joint replacements and ruptures of ligaments and meniscal tears which catch or lock will usually require surgery with a degree of urgency.

 

Treatment options:

For many overload / degenerative and biomechanical issues, addressing mechanical issues and contributing factors can be a big part of the solution. Acupuncture, Massage and Chiropractic and other physical therapy interventions can be useful to address the current pain presentation. Progression towards rehabilitation and retraining may be indicated to prevent recurrence.

 

Due to the nature of the cases that we see, some patients require surgical intervention to help resolve their issues. It is vital in the post-operative phase to focus on rehabilitation and strengthening to make sure there is relatively good balance or symmetry in the strength and control of the knees to hopefully prevent future recurrences.

 

Generally, effective assessment and management of knees gives a greater probability of a good outcome.

 

If you have a new or ongoing issue with your knee, come in and see us, we might be able to help you get a better outcome.

The Knee

Written by Don Williams BSc, MChiro, ICSSD. on Thursday, 15 October 2015. Posted in General Health, Sporting Injuries, Training and Performance, Chiropractic

The Knee

By Don Williams

B.Sc., M.Chiro., ICSSD., PG Dip. NMS Rehabilitation Cert DNS. Memb: FICS, CEA

 

Knee pain and dysfunction is a common presenting complaint to our team here at the clinic.

On a daily basis we see a wide range of knee injuries ranging from overload injuries to developmental disorders and from trauma to serious pathology. Generally, knee conditions can be grouped into a these categories. This article aims to clarify and describe some of these issues and strategies to deal with them.

 

The Knee is an important link in our biomechanical chain for all of our standing activities. Injuries to the knee will affect our ability to stand, walk, run, ride and even sit and work. When you have suffered a severe knee injury you start to realise just how vital they are for our sport, recreation and normal daily activities.

 

Knee 

 

Traumatic Injuries

Any time there has been an impact, fall, major twist or other traumatic event. Pathology including ruptures, tears and fractures should be eliminated.

 

Ligament Ruptures (ACL, PCL, Collaterals)

ACL or Anterior cruciate ligament ruptures are probably the most well-known and are particularly prevalent in ball sports, although they can occur in a range of circumstances. The ACL prevents the lower leg (tibia) from sliding forward in regards to the upper leg (femur). Complete ruptures require graft stabilisation, partial tears can be conservatively managed with rest and rehabilitation exercises. Some theories suggest that if the person is not young, then a complete rupture does not need to be repaired, however, it appears to us that there is a higher prevalence of knee replacements and marked degenerative changes in the ruptured side compared to the normal side. We are fans of having a graft and effective rehab.

The PCL (posterior cruciate) prevents backwards movement of tibia and is less frequently injured, and usually in combination with the ACL and/or Collaterals.

Collateral ligaments prevent side to side movement of the knee. They will sometimes be repaired and once again, full ruptures are more often in combination with ACL and or PCL ruptures.

 

Meniscal Injuries

Often called cartilage injuries. The meniscii are little “C” and “J” shaped rings of cartilage, wedge shaped that help locate the knee for effective movement. The inner 1/3 is poorly vascularised and tears can cause a “flap”, which gets caught. These may require debridement (arthroscopic clean up) to remove the flap and stop the catching and jamming. The outer 1-3 to 2/3 does have blood supply and sometimes tears in this area will heal. Conservative management is certainly worth trialling and if not successful progression on to surgery to “stitch up” the tear can be indicated.

Bursitis

 

Articular Cartilage injuries

The articular cartilage is the smooth hyaline cartilage that covers the ends of the bones and allows the knee to glide smoothly through its movements. Injuries to the articular cartilage are less common and are usually traumatic. They are very difficult problems to manage and often don’t recover well. Optimising joint mechanics can be helpful. Different surgical interventions are aimed at trying to grow new cartilage, transplant cartilage and remove jagged edges with varying success.

 

Degenerative changes

Frequent presenting complaints. In severe cases knee replacement surgery will have a profound impact on the mobility and ability to enjoy life. In less severe cases, addressing footwear, improving mechanics around the knee and hip can be very helpful.

Research does not support the theory that running specifically speeds up degeneration of the knee. We are big fans of optimising gait mechanics in runners and wearing appropriate footwear. Really, the more active we keep people, generally the better they do.

 

degenerative change knee

 

Fractures

Knee fractures, whilst not being very common, do occur and there are a range of different types of fractures. Mostly they require a period of immobilisation and the use of crutches. Some cases will require surgery. We do see these at times but regularly refer on for orthopaedic assessment and management in the early stages, then reconnect again after the fracture has healed for rehabilitation.

 

Overload injuries

There are a range of overload injuries which occur around the knee. These can be simple injuries of the calf, hamstring and quad muscles which in turn effect the mechanics of the knee, causing pain and dysfunction. Additionally, we will see issues develop as a result of dysfunction in the ankles or hips. Poor footwear choices and foot mechanical issues will overload the knee leading to problems. Weakness in the gluteal muscles and poor hip mechanics will also cause problems. Differentiating what the deficiency is and how to address this is the important point.

 

Patellofemoral/patella tracking syndromes

These issues present usually with pain behind the knee cap or near the new cap. Usually the issues are with the patella tracking laterally or too far to the outside of the knee. This causes increase pressure on the “groove” that the knee cap runs in causing pain in the back of the knee cap or in the groove itself.  More often worse with flat footed people or people who drive their knees together in squat and lunge exercises. These are usually simply managed and if addressed relatively early will normally settle relatively quickly with homework.

 

Bursitis

There are little fat pad with sit on top of the patella, above and below the patella and on the medial (inside of the knee) a couple of centimetres down from the joint.  Direct impact or trauma can cause these to become inflamed or irritated, although they more frequently become sore from overload from poor mechanics or movement patterns of the lower limbs. Early management may include ice and anti-inflammatory regimes, although a long term outcome is usually best achieved by addressing the weaknesses and dysfunction which cause the problem.

 

Developmental disorders

These conditions may be regards as histological disorders. The usual onset for these conditions is in the early teenage years and often coincide with growth spurts. Essentially the insertion point of the tendon on the bone starts to pull away and becomes inflamed and painful. In rare cases they can completely snap off. They are more commonly associated with explosive sports (sprinting, jumping, and kicking) and are usually conservatively managed. They can recur over a number of years, although good compliance with homework makes them quite manageable.

 Osgood Schlatters occurs where the patella tendon inserts on the tibial tuberosity (on the upper shin bone) whereas Sinding Larsen Johansson disease occurs at the bottom of the patella (knee cap).

We usually incorporate activity modification in a flare up with management of the inflammatory process. Then incorporating stretching and strengthening exercises to improve the mechanics and flexibility to manage the presentation and prevent future flare ups.

 

Pathology

There are a number of pathologies of the knee ranging from low force fractures through to malignancies (tumours) and other weird and wacky complaints. Developing complaints for no apparent reason may be a serious problem but it may be an overload issue, so certainly don’t panic until it has been assessed and identified.

 

When we assess new knee injuries are first point is to eliminate major pathology then address the issue if it falls within our scope of practice

 

Management of Knee Injuries

The management of all of these injuries can vary but the principles remain the same; effectively assess the injury and the causative factors, identify the problem, protect the knee from further injury, treat the problem, progress the knee back to normal function.

 

Inappropriate footwear is certainly a common contributing factor. Generally speaking, flat/ low arch feet need stability and control in footwear, high arch/rigid feet need cushioning. Less commonly we see feet that require complex combinations of cushioning and support. These unusual foot types are not normally well managed by the shoe chain stores.

 

Poor mechanics in running gait and exercises (squats, deadlifts, leg press etc) can also be a big factor. It is not easy to simply describe how to do these activities appropriately. However, if you have issues and want them assessed, book an appointment with Don Williams or Martin Cooper and they will be happy to assess your movement patterns and show you how to improve any deficits.

 

At Institute of Sports and Spines we pride ourselves on doing comprehensive assessment of presenting complaints, using advanced imaging, such as MRI to confirm and identify the problem and then develop effective strategies to address the issue. At times this requires referral to orthopaedic surgeons for complex cases. If surgery is required we are well equipped you help you work through the problem and progress back to normal.

 

With almost all knee injuries Rehabilitation exercises are usually an important factor in achieving a good outcome, whether an overload or mechanical issue caused the issue or whether a traumatic injury caused weakness in the controlling muscles, addressing these deficiencies will improve your long term result.

 

We also offer a range of treatment modalities from Acupuncture and Massage to Chiropractic to help you through the symptomatic phase.

The Obesity Epidemic

on Wednesday, 15 June 2016. Posted in General Health, Training and Performance

The Obesity Epidemic

Daniel McDonald

B.ExSSci and M.ClinExPhys. Memb: ESSA, ASCA Level 1 Strength and Conditioning Coach

Level 2 Representative Coach (Cricket Australia)

 

The obesity epidemic has been a hotly debated topic in Australia over the last few decades. The statistics don’t lie and indicate that 65% of Australians of all ages are overweight, and 35% of these are obese. This is an alarming figure compared with just 20 years ago. The defence chief of the Australian army reveals that a study shows that one in seven Australian soldiers are too overweight for service in the field. Morbid obesity has recently been classed as a disability by the International Classification of Functioning, Disability and Health. This is due to the extreme movement limitations and orthopaedic concerns it places on people.

 

The greatest risk factors for obesity are physical inactivity and increased intake of energy dense foods (i.e. those high in fat and simple sugars). We live in a world that is based on convenience, making it difficult to be as active as we once were. One only has to look at the introduction of home delivery services and the ease of which we can access the world via technology to realise that reasons to get up and leave the couch are becoming less.

 

Obesity refers to an abnormal accumulation of body fat in proportion to size. In other words, an increased weight compared with height is indicative of a more obese individual. This relationship is known as the Body Mass Index or BMI. As a very general measure, BMI can categorise a person as either underweight, normal weight, overweight or obese. However, the BMI scale is not the most reliable indicator of obesity as it fails to distinguish between the amounts of lean muscle mass and fat mass. For example, a very muscular athlete who isn’t very tall may be in the overweight or obese categories which suggest he’s at an increased risk of obesity related disease, which is inaccurate.

 

A more reliable indicator of being overweight or obese is measuring waist circumference. Research indicates that excess central fat mass around the stomach places us at an increased risk of obesity related diseases such as diabetes, high blood pressure, coronary heart disease or heart failure, musculoskeletal aches and pains, breathlessness and some cancers. There are also psychological effects such as reduced self-esteem and self-efficacy, anxiety and depression.

 

A lot of people are driven to reducing their mass and looking better on the outside which raises the question of fatness versus fitness. Is it better to be overweight/obese and fit, or thin and unfit? Having good cardiovascular fitness lowers disease risk and has been shown to reduce all-cause mortality. Therefore, when undertaking a weight loss exercise program, the focus should be on increasing the body’s level of conditioning to reduce this disease risk.

 

Initially when undertaking a weight loss exercise program, our first goal is changing behaviour and engaging in regular exercise. When looking at the amount of weight loss over time, it is a reasonable expectation to lose 0.5-1kg per week over the first 6 months for obese individuals. It is important to aim for steady weight loss and be patient to prevent relapse. The overall aim is for adherence to physical activity long term to live a healthier and happier life both physically and mentally. Those who aim for rapid weight loss may have success in the short term; however these routines are not sustainable long term and are often accompanied by relapses. These routines are often accompanied with overtraining and restricted caloric intake which are often detrimental to health.

 

There are so many myths surrounding how much exercise is good for you, which type of exercise to do and the volume of exercise. An exercise physiologist can help assess you and get a good picture of your physical activity history, interests and goals and then prescribe an individualised exercise program for you. No individual is the same, we all have different capabilities, movement limitations and gym experience. Exercise physiologists have specialised knowledge in tailoring exercise to suit individuals with musculoskeletal limitations and any other medical conditions which you may have. Their knowledge of exercise is vast and they are aware of many different variations of exercises that will suit your gym experience. At Institute of Sports and Spines, all programs are conducted in a fully supported and motivational environment. We have a range of facilities and services to help you measure and understand your BMI, waist measurement, waist hip ration and body composition testing to give you an accurate measure of percentage body fat, lean muscle mass and give you a more accurate understanding of how much weight/fat you can safely lose. For more information on Exercise Physiology, or to book a consult for assessment or exercise programs please contact our clinic.