Inner Knee Pain of One Year, Gone in a Month: A Case Study

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You're listening to the restoring human movement podcast where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now your host, Dr. Sebastian Gonzales. Hey everybody. It's your host, Sebastian with the restoring human movement podcast. Thanks for joining the movement movement. This is our first time in the show. Welcome. You missed a lot of episodes in the past and we covered a whole series recently on lower back pain, stenosis, posture, uh, back surgeries, MRIs. So, so many things. It was so many. Now we're going to go a little bit onto a couple of oddball things. I think I'm going to cover today, a case presentation that we had a really successful case of a knee.

Now, when people typically think about ACLs, meniscus, things that are torn need to be repaired and so on. This person had that same experience. There was an acute onset. There was a time where it started to increase in pain after a certain workout, like doing hits training. If you don't know what hits training is, it's a lot of jumping, a lot of boxes, a lot of pushups and squats and so on. And there's usually not a ton of weight involved. There's lots of gyms around that do this style. Nothing's wrong with the style, but sometimes people get knee pain from it. So this person had this for a year and it was on the inner part of the knee. The confusing thing for her was that she didn't really have any positive, um, orthopedic findings.

And what I mean by that is, is some of the testing that people do to stress test the knee, um, to check out the ACL and meniscus and the, uh, the collateral ligaments and the muscles around. There really wasn't too much that was positive. Uh, she did have an MRI though, which showed that there was a quote unquote torn meniscus. Uh, personally, I didn't see the actual image and I didn't see the report, but this is what the interpretation that she was given. And so she felt like it was kind of like, um, she mentioned it never really popped and clicked and it didn't lock, which is more typical of something like a meniscus and, um, or at least a larger one.

Um, but it felt like a, uh, she called it like a contracture, almost like the area on the inner part of the knee just started to contract on its own. Um, some people may think this is something along the lines of a pes anserine bursitis or a pes anserine tendinopathy or tendinitis. Uh, maybe, but in this case it wasn't. And again, going back into usually what a meniscus, uh, is, I guess, I guess I should talk about meniscus here in a second, just cause some people might not know what it is. Um, a meniscus usually is not immediate swelling, but swelling that comes over a couple of days. And it tends to have this like clicking type of, uh, presentation.

It's not like stuck really. And, uh, it does lock and unlock, but it just seems like it's kind of clicky and swollen. Sometimes when people are feeling the sides around the kneecap, they can feel these little swollen areas that happen, especially when they bend it more. Typically knees of this sort also don't like a lot of bend and a lot of twisting, which is a lot of why the examination process, when you go through an orthopedic exam of the knee, a lot of times the meniscus tests are really twisty ones. So she really didn't have a lot of findings of that, at least in the exam. Generally speaking, her knee examination was normal.

Uh, she had more findings in other areas like the back. She also had a, uh, right hip, which, uh, the problem was on the right side. After investigating further and asking her about the hip, uh, I started to realize that this, this, this hip has been, it was a thing that was pretty prevalent and debilitating for a while. I think if I recall, she said she was, uh, I think in a, in a wheelchair or in like unable to really walk on it. I forget what it was. It was big. And, uh, she was unable to fully walk for, I think it was like six, eight months. So it was a while and it was years and years ago.

Uh, this person in particular is about 60 years old and there was also something else that she had on the same side too. There was, uh, there was also an ankle sprain, a torn ligament in the ankle, which is important as well. You might wonder what's this have to do with her, her knee. Well, a lot, uh, typically when looking at knees, when the testing is generally normal and there's a quote unquote, nothing really wrong too much with the knee. We have to look at the possibility of a poor load sharing. It looks like the knee is doing too much because the other joints around it aren't doing enough.

And, um, her examples, which she gave her, the ankle of the foot had been traumatized and disabled and not used. For months and months at a time is actually really important. Usually examining to see if someone is appropriately using these areas, if they have motion, mobility, function, and strength in those surrounding regions should be part of an examination protocol. If it's not, you need to, because it's really important. Now with her knee, since there was really nothing prevalent as an exam, the, the easiest thing to do is go to the surrounding joint that has the biggest, uh, wow factor in the history.

Um, we deemed her as having a spinal referred knee pain, which usually follows something like the femoral nerve track, usually a higher lumbar contribution. She did have stiffness in her upper low back as well, but it's not always the case. Sometimes it's just an issue with, uh, the knee doing too much. As I mentioned, um, she, again, she had a year's worth of pain and was not able to, um, do the things that she wanted to do. She wanted to be active. She couldn't really walk her dogs is hurt every single time too. And, uh, it felt better to sit, but it was painful to walk and run. So I think she had a very legitimate concern, a very legitimate goal, uh, at that age, uh, actually, um, various ages.

A lot of people tend to be concerned about aging and will I be able to live alone? Will I be able to, um, be physically active anymore? Uh, I'm 40. I've had people who have, uh, expressed this concern to me at this age too. Um, I've had people who have, I've worked with who are, um, their, their children are starting to move out of the house and the parents don't want them to, or afraid to, because they need to help. So the independence at various ages is really important. It's scary to think that as you get older, you'll become disabled and unable to fend for yourself, fix your own food, get on and off the toilet, go for walks, take care of your dog, uh, whatever.

I mean, if you live in a two or two, two, two story house, it might be kind of challenging. So I think that is a very legitimate concern, very legitimate goal. And, um, it's very attainable, especially when there's nothing physically wrong with your knee. I know I keep saying that, and I'm not saying her knee didn't hurt because it's perfectly common to have knee or joint or muscle pain, but there's no positive imaging findings, uh, that are really outside the normal for age and activity level. It happens all the time. Uh, and actually, uh, recently people have, I'm catching on to, I think what people are saying sometimes and they say, you know, my image is normal.

Isn't that weird? And, uh, I'll say, not really. And they say, well, yeah, I mean, don't you, you don't think it's weird? No, I don't. It's actually pretty common. And then they keep persisting. And I'm starting to wonder, am I not, am I not reading through what they're asking here? And so now I tend to ask, um, is this a question? And they say, yeah, well, what is it? And then, you know, and then we can go down that route, but no, it's not uncommon. Uh, and so this was no exception to that rule. So let me take you through a process of the, some of the things that we did that really helped her out because, um, a lot of you are going to wonder, uh, also let's cover some of the positive orthopedics test, um, that we did find, by the way, if you guys are clinician, you know, like, wow, I really liked this case already in the paid podcast.

There is, uh, other cases that we do similar to this, but I do them a lot fresher. So I'm more, uh, uh, aware of it. And, um, so in this case, I tested the low back, I tested the hip, I tested the knee. The only thing positive was something called Faber's test on the right hip, which means there's a lack of motion. A single test in itself doesn't mean all of a sudden this hip is not going to work. It just means it's, it's interesting. There's screening processes called, um, the functional movement screen or the, uh, SFMA, which are targeted at identifying things that are not painful, but also not dysfunctional.

Uh, the hip didn't hurt the knee hurt, but the knee was painful and had full function. It just hurt. And so the hip was not painful, but it was dysfunctional. Uh, she also had some positive findings with some neural tension tests that we did on the same side, meaning there was a neural or nerve aspect to her problem, which doesn't mean she needs surgery. It just means that there's a nerve part of the problem. Um, and it's, it's, uh, nerves don't like tension sometimes when they're being provoked. Um, what we ended up doing for her was something called a sideline opener first. We also gave her a little bit of, uh, uh, of knee extension treatment as well.

Uh, as I mentioned, she did have the finding of the meniscus on the MRI. I don't want to discount that, but also I don't think it was really a big part of the puzzle, but sometimes just exposing the knee to a little bit of a pumping action is really helpful to make it. So the knee starts to flush itself because a lot of times when people hurt their knee or their knee hurts, they're afraid of moving it. And so it's really surprising sometimes when people are, they find that actually pumping the knee into a lot of extension, uh, tends to help and it tends to feel good. So we sent her home with those just as a way to kind of milk the joint.

Also, since she did have that nerve, uh, aspect to the problem, we did a little bit of, uh, we call it foraminal opening where you just, uh, uh, release the tourniquet off of the nerve and just let it breathe and de-swell and, uh, return fluid. If you will, it de-swells itself. And so we did a little bit of that. And we also did a few exercises. One's called low bear. One's called diagonal sit. Uh, and we also pattern a single leg pattern, uh, called a single leg deadlift, but we did it on a wall. This was all body weight stuff. Uh, we were targeting to see if she had no pain during the exercise and if she can keep tension.

The cool thing with one of the ones that we picked called low bear is that low bear actually exposes the knee to quite a bit of bend. Uh, it's an exercise that was derived from, uh, DNS dynamic neuromuscular stabilization. And it, it helps out to, uh, create some, uh, support in the spine, but also create some, uh, let's call it happiness of the surrounding hips and knees and various joints to help, uh, create nice muscle co contraction or patterns. And so low bear, they're not moving. They're just kind of in a crouched position on the ground. Like they're a bear hiding from, uh, I guess humans and their knees are bent.

The hips are bent too. And so she didn't have any pain in this position. So we sent her home with it, which you'd think is not going to be the case if her knee had a meniscus, right? If it was purely a meniscus. So we loaded the knee, we challenged the knee into a bended bent position on day one. We also challenged the hell out of that right hip too. It didn't hurt to do, by the way, I should probably note these exercises we give her any exercise given to you. I'd say 90, 95% of the exercises given to you by somebody who's recommended exercises should not hurt the area of why you're there. Meaning none of these should bother her knee, especially in a pinpoint spot.

A lot of times I do, we do virtuals and in-person sessions with people. And in the past, sometimes when they've been doing, uh, some therapy that hasn't been working or some exercise, they say, yeah, I can, I can fight through it though. I can fight through it. No, I, I, you, we don't need you to. And actually it's, it's ill-advised. We don't need you to at all. Well, how come I was told no pain, no gain? Well, uh, not necessarily. And we need to work with the surrounding musculature and everything. You might in fact, not even feel a single area of your body working dominantly. You'll just feel everything working and that's okay.

And we want that. We don't want to isolate the area of concern in the exercise. I don't want her to feel any problems in the exercise. So we went around it and not to say we're avoiding it, but we're sharing the load. This is actually the best way, in my opinion, to settle the problem the quickest. Okay. So, um, we actually, uh, I'll, I'll fast forward in time because we saw this, uh, this lady, a total of four times as of the point of me, uh, having this podcast. Uh, we did have, um, generally forward progress. Things did improve, but there was a period of time where she said, I didn't have any problems during the week.

Actually, it was the first time in a long time. I haven't had any problems at all during the week, but on the weekend I had a lot of pain. And we figured out that she was sitting a lot. Originally, we kind of figured out that sitting was not painful to her, but it was mainly in short burst. And so the longer she sat there, the more her knee started to hurt and the more it became an issue. And so the easy, easy way to do this was to just change the habit. I know sometimes people think that like doing some big elaborate thing is what's needed. Not necessarily. We had forward progress. We had things were working.

We were loading the hip. We're loading the knee. We're loading the limb. We're loading the foot. We were loading the body and we're getting her back to recovery and function. And her, her pain was dissipating very quickly over the course of, uh, this was over the course of a month. We started weekly at that point in time. And, um, the easiest thing to do is just modify the things that the only thing that really bother, which was prolonged sitting, get up, walk around, squat down on your haunches, sit a different way, do anything, but sit that long in that position, just find something else. And it's not that you can't do it ever, but right now you're, you're picking the scab.

And so the last time I saw her, um, and we will probably see, we'll see her more. And I'll tell you the reasons why in a couple of minutes, but she walked in and she said, I don't have any problems at all. I have no pain. First time in a year that I haven't had any pain. I said, I said, great. That's, that's awesome. You know, and, um, there was some things that we still needed to cover, but generally she responded so well by not doing a surgical approach, not doing a medicative approach and just finding the low hanging fruit. We figured out the hip wasn't working well. The ankle wasn't working well.

Uh, and then this time we moved up into the mid back a little bit too. In this session, what we did is we did a little bit more of what we call the SFMA, uh, examination because she doesn't really have much pain anymore. We want to see what else could be contributing to some of the overload of certain tissues like, the knee. And a lot of times just watching somebody move, just kind of shutting up and watching somebody move and comparing side to side and asking how it feels is really, really informative. I don't think enough people do it. People are searching and watching and looking for pain and just looking at the area of pain.

You need to back up. You need to back up and take a wide view of what's going on here. And you need to see the shoulder and mid back could definitely be part of the knee problem. I know it sounds far-fetched, sounds super far-fetched, but probably the more, the more you've been around the, uh, the rehab conversation or physical therapy or, um, personal training, you'll realize that everything matters. Everything is part of it. Everything is a variable. Now, which ones are more important in the beginning is important. And you got to decide that as a reason why I didn't start with the shoulder to address the knee.

Uh, so normally what we do with these people is we progress them from a first aid exercise, which was the knee pump in the sideline opener to address the nerve, uh, part of it and to address the, uh, the knee pumping part of it, just getting to getting fluid to move away. And then you need to build some baseline supports because the fact of the matter is like, I see this a lot when people, uh, fill out their intake form in our office, they, uh, there's a section that says, how long do you think it'll take you to recover? Uh, some people say 15, 16 weeks. Some people say one week. The funny thing is some of the people who say one week, they've had it for 10 years.

Now we need to clarify what this means and what the goal is, is the goal to reduce pain. You can do that just by sitting there, don't move, don't move at all. Your pain will dissipate. And this is no way to live, but it is very adequate for is a very adequate form of pain management. Now, one week will not do anything, anything at all for getting you back into what your real goal might be. I've been trying to do a better job of asking people, uh, you know, why are you here? And they say, well, my knee hurts. Um, well, yes, but what is your pain holding you back from? Um, doing dishes. Come on.

Like no one wants to do dishes. Like, what do you really want to do? What would you do if you woke up tomorrow and your knee didn't hurt whatsoever? Well, I'd probably go hiking. Where'd you hike? I do Mount Whitney. Great. That's a very valid goal. Now let's, let's scale this back a little bit again. You've had pain for 10 years. You've been restricting movements of your knee for 10 years. Uh, realistically, let's, let's just have an adult conversation here. What makes you believe that your knee is strong enough to go up Mount Whitney in a week? Why don't I, I'm going to have to train. Yeah, you will.

And so the easiest way to get back into training in hiking is going to be to do rehabilitation, challenging exercises or challenging rehabilitative exercises, and then get into a strength condition protocol that doesn't hurt you. You need to have a push, pull, carry, squat, and hinge exercise, and you need to spend some time on it. With that being said, although pain can be reduced very quickly, the timeline of a week, two weeks, three weeks is really not bad. Reducing pain, if you're picking the right thing, and I do really mean this, I, from the bottom of my heart, if you are going somewhere and it's been 13 months and you still have no pain, you still have pain, there's a possibility you're doing the wrong thing.

Usually three, four weeks generally is a very long timeline. We've had people who have reduced their pain in a week, two weeks, three gives us a little bit more wiggle room, but, but generally within the first month, you got to know you're getting better. It has to improve. It has to improve dramatically or else you're probably doing the wrong thing. And by the way, there's many things you can try that you probably haven't yet. There's a lot, probably the two things that I mentioned here, the knee pumping and the sideline laying on your side to deswell the nerve, probably are a lot of things that people haven't done yet.

They just started doing tissue work and scraping tools and stuff like that, which is not wrong if it's right. If it's right, it works. If it's wrong, it doesn't work. Now, back onto the timeline, you need to consider that pain can reduce, but it doesn't restore function, strength, resiliency. That takes time. It takes hard work. And quite honestly, a lot of people don't want to do it. They're looking for an easy fix, a quick fix, a surgery or an injection or so on. Now, again, that's not, they're taking the, they're not taking the easy way out. You're not taking the easy way out. If you do that, you're just, just manage the pain and reload the limb.

I do mean the limb, I mean the foot, the ankle, the calf, the thigh, the hip, the glute, the hip flexor, all of it, all of it, even the core, even the upper body, all of it matters. If you're looking to return back into what you want to do, like hiking Mount Whitney, which is the highest mountain in the continental United States, if you don't know, you need to spend some time. And so think about what you really want. If you guys think out in the future, what would you do if you woke up tomorrow and there's no pain and you wish you could hike Mount Whitney or, you know, go for a run or train for, or do a marathon?

Remember how long it's going to take you to get to that point. So I'd plant that tree now. Start your progress of reducing pain and restoring function now. And then you're going to have adequate time to get to your goal. I hope that makes sense to everybody. Now, if you're looking to work with us, we'd love to work with you. We do have in-person and virtual sessions. Believe it or not, a lot of the movement screens that I mentioned on this podcast can be performed virtually. I remember in the beginning of everybody, the stay-at-home order, people didn't understand what virtuals were. They're like, how would a chiropractor help me virtually?

They can't put their hands on me. The typical things that somebody would do to you, if you went to a chiropractor who's doing hands-on stuff, no, it can't be done. I would agree with you. But coaching exercises, coaching mobility exercises, flexibility ones, strengthening ones, watching movements, it really, really, really can change the game. And the fact of the matter is, knees typically respond best to a rehabilitative approach. Hands down. Most of them don't need surgery anyways, unless your knee is physically locked in one position and cannot move. That's kind of it. So if you guys are looking to work with us, please reach out to us.

There's a link in the bottom of the podcast. Or you can email us, info at p2sportscare.com. And we are very conservative of everyone's time and budget. And I hope you see that we are trustworthy and we only want the best for you. So we recommend what we think it will take to get you back to your goal, not what you want to hear. So it's a little bit of tough love. So I hope you guys are ready for that. All right, we'll see you next time. Subscribe to the show. Thanks for being part of the movement movement.