Mysterious knee pain and/or swelling?

Without any thorough examination, you may have been given the diagnosis of osteoarthritis and be expected to just live with it. However, you may be experiencing Saphenous Nerve Entrapment. Saphenous nerve entrapment is a frequently overlooked cause of persistent medial (inner) knee pain. I chose to write about it because I saw 2 cases of random knee pain and swelling recently. Nerve entrapment is often the cause of pain when you cannot recall a mechanism of injury. This condition can result from low grade irritation over a long period of time from sustained postures or repetitive activities, or perhaps resulting from guarding mechanisms that never fully resolved from a previous injury. Symptoms can be episodic (come and go), may come on randomly, and may resolve randomly as well. The saphenous nerve is the longest branch of the femoral nerve. It travels from the groin, down the front of the inner thigh, past the inner knee, and into the inner lower leg. Because of its long course, it can become entrapped in multiple locations from the thigh to the lower leg. The saphenous nerve is often entrapped by connective tissues where it pierces the muscles of the inner thigh, or where it takes a sharp turn at the inner knee. The nerve can also be injured as a result of an improperly protected knee during surgeries or activity that puts pressure on the nerve (kneeling). It is a pure sensory nerve, meaning it is responsible for sensation and not muscle contraction. As this is a purely sensory nerve, weakness should not be noted with an isolated injury or entrapment of this nerve. Some mild weakness may be present because of guarding from pain, but no significant direct weakness will result from the nerve impingement. Symptoms of entrapment: may include swelling of the knee, a deep aching sensation in the thigh, knee pain, tenderness along the nerve pathway, and altered sensation in the knee and lower leg such as numbness, tingling, pins and needles, reduced sensitivity to heat or cold, reduced vibration sense, and dullness to touch. The main diagnostic features of this condition are altered sensation (vibration sense is usually the first to be affected), and reproduction of symptoms during a femoral/saphenous nerve neurodynamic test. Other diagnoses given for this condition may be arthritis, bursitis, patella femoral pain syndrome, or chondromalacia patella. Treatment to resolve this issue may be as simple as learning to do some gentle nerve gliding exercises. Effective treatment may also involve soft tissue release (via massage or physio); and gentle manual mobilization techniques that reduce mechanical forces on the nerve, improve nerve mobility, reduce muscle guarding, and restore blood flow to the affected nerve. It may not be arthritis, and you may not have to just live with...

Read More »

How to know when I need some help

How to know when I need some help for my pain: We trip, hurt our knee.  Twist a little too far, your back spasms.  That ache in your elbow that used to only be a problem when playing tennis is now bothering you at work and even just reading a book.  Checking my blind spot is nearly impossible now without turning my whole body.     When is it ok to just let things heal in their own time and when do you need to get a professional opinion? The best way to approach this questions is knowing what “acute” versus “chronic” means.  Acute injury symptoms are what the body presents in the first 24-48 hours on the initial onset of pain (ranging from pain that can be dull or sharp, redness, swelling, bruising, difficulty moving the affected area, pain-related weakness, avoidance of activity through protective movement mechanisms).  Chronic pain is when pain continues well after healing should be complete (3-6 weeks) with similar as well as very different symptoms (less swelling, more dull instead of sharp but perhaps increased pain even a rest, better movement range but perhaps still decreased, weakness in affected and perhaps increased locations, and protective movements can increase creating other areas that become sore). Chronic pain is much more complicated to resolve. When we get injured, you should remember the rule of “FIDA”, for Frequency, Intensity, and Duration, Activity.  If you tripped, twisted your ankle, and immediately have pain, or maybe not much pain until the next day (when your body has had some time to begin the inflammatory response).  Pain could be very severe, even at rest, range of motion extremely decreased, and it could hurt just to have your foot on the floor.  The normal healing process should see incremental improvements of frequency (how often it hurts as well as how large of an area affected), intensity (how much it hurts), duration (does it recovery quicker with a movement that normally bothers it) and activity (are you starting to go back more normal activity levels and actions required of daily living).    My general rule is that if all of these FIDA areas are not incrementally improving within a week, I would get a professional to look at them to make sure that you are doing the right things, avoiding the wrong thing, and that things are not more serious that your originally thought. With an injury, there are three stages to recovery. 1. Avoid further injury.. Action: avoid repeating the same thing again, cease current movement, make the “danger” stop. Protect the area.  Action: Move only so as to not continue to hurt yourself, whatever compensations required, take medication if required, heat or ice, rest further. Healed, move on. Action: realize enough time has passed to be out of danger, get back to normal movement and pain free life. Sometimes there was no specific...

Read More »

Hurt Versus Harm

Most people that book an initial physiotherapy assessment are in pain. Quite often they do not have mechanism of injury that is apparent to them. It is common to hear, “I’m so sore but I didn’t do anything that I can think of to feel this way”. Not knowing what made them sore in the first place adds fear into the equation. When I ask them what their goals are by seeking help from physiotherapy, they often reply, “I don’t want to do anymore damage or permanent damage so I want to know what is going on”. When people are afraid of doing damage they decrease many of their favourite activities. Therefore, it is our goal to get you back to doing what you like to do as soon as possible. The first step to doing this is educating people about pain mechanisms. To simplify things, I like to divide pain into one of two categories.  The first is INJURY where there is tissue damage. This includes sprains, strains and fractures. Injuries have an apparent mechanism, and while the tissues heal you may do HARM if you load the tissues too much. This is why these injuries may require splinting or bracing as they heal. The second category is PERSISTENT PAIN where the main mechanism is a guarded nervous system rather than a tissue problem. If we do something our nervous system is uncomfortable with, it will start to guard and then it will begin to let us know we are exceeding the tolerance limit by HURTING. We are programmed to avoid pain, so by causing hurt our nervous system is trying to control or change our actions. If we are sore after doing an activity in this instance, we have not done damage to something. Rather we have upset our nervous system that is monitoring and processing all forms of sensory input that is coming at it. Why is your nervous system upset? The main reason….OXYGEN. More specifically, a lack of oxygen. The metabolism of cells is dependent on oxygen which is carried via blood flow. If blood flow to a tissue is restricted, metabolism in that area is compromised and the nervous system registers this as a possible threat. When this scenario happens often enough or it builds to a significant level, then your body hurts. This usually causes us to change our actions in one of two ways: move or fidget to return blood flow to the area, or restrict activity to minimize loading the tissues. When your nervous system gets irritated and starts to protect, it keeps some muscles turned on continuously to splint movement to try to minimize strain on structures. However, this continuous muscle tone can later become problematic by partially compressing blood supply thus registering as a threat to the nervous system and causing hurt. Treatment of persistent pain I boil down to...

Read More »

Walking: An Exercise or Activity?

I’m often asked “Is walking good for you?” In short, the answer is YES but the rewards and drawbacks of ‘walking for exercise’ depends heavily on the individual. For example, are you are free of injuries or impairments that would cause you to walk with a correction? Do you have a sore heel causing you to put more weight on one leg? Do you experience pain while walking or after? Do you have poor balance and at times worried you might fall? If you’ve answered yes to any of these questions, it’s important that you minimize risk. Injury will take the benefit out of any workout. What are the primary benefits of walking? For me, walking is an activity that can be fun (who doesn’t love a social walk with a friend on the waterfront.) Walking gets the body moving. Increases blood flow which contributes to a healthy heart and brings greater fluidity to lower body joints. Walking challenges your weight bearing bones to help fight osteoporosis. In general walking is a low-impact activity that has minimal “wear and tear” on your joints. Walking is free, can be done most anywhere and is one of the best things for your mind & body. The downside to walking: it won’t on its own build muscle. Walking gives you a great cardiovascular boost but offers little improvement in muscle strength. As we age (after the age of 25) we start to lose muscle mass, this is called “sarcopenia”. It becomes fairly critical that we continue to build muscle mass as we age. Walking alone will not give you everything you need to be fit for the long run. I like to think of walking as an “activity” rather than “exercise”. I think any type of sport or recreational movements are in the same column. Activity in my opinion still has many benefits (physical, as well as psychological and social) but if you really want to play or engage in an activity with less chances for injury or “wear and tear” on your joints, then you need to do the fundamental work called “exercise”. I highly suggest weight training using machines or free weights, yoga, pilates, and body-weight training movements (squats, push ups, planks). Exercise is the hard work, and activity is the fun! In summary, walking is great. It’s just not the “be all and end all” of a complete fitness program. If walking is the one thing you do, good for you. You are moving! That’s better than a lot of people! If you are keen to experience the benefits of true fitness try adding exercises that build muscle. You will soon discover an ability to enjoy all types of physical activity safely and with greater...

Read More »

Should I stop running?

By David Lee, Physiotherapist It is a common fallacy that running is bad for your joints and accelerates wear and tear. There is, however, no real scientific evidence of this. For the most part, this line of thinking is not true. If done excessively,  running can violate your health, though not really your joint health. It actually has greater impact on muscle health and it can accelerate muscle wasting if dosed incorrectly. Done in the right amount, it can be a great way to maintain your running skill and running fitness. Rarely anymore do people need to completely stop running. Most often, adjustments in volume or intensity enable people to continue running productively. The information on this site can help you understand what to ask and look for when evaluating your running...

Read More »

Break the Ice

Old habits die hard. Ice is used almost universally for treating injuries and pain. I remember in physio school how our go-to response for anyone looking for help was often “just put ice on it.” This weekend, while watching a basketball tournament, I witnessed people rushing for ice packs at the first sign of any inflammation. When will we learn to trust the wisdom of our bodies? Acute inflammation is the body’s way of repairing damaged tissue. Swelling is a normal response and, when thwarted, the healing process can actually be delayed. Science is finally catching up and more and more trainers and therapists are questioning the use of icing protocols. METH (movement, elevation, traction, and heat) is often preferable to the traditional RICE (rest, ice, compression, elevation). While ice can sometimes be helpful for numbing pain, early mobilization is the better rehab approach. In our clinic, we tend to see more people dealing either with persistent pain due to chronic inflammatory conditions or acute pain that occurs without any known injury. Again, most often these conditions respond best to mobilization that restores blood flow to the nerves, relaxes muscle tension, and lubricates joints. Touch and movement are the primary modalities we use to reduce pain and restore function. We’ve been swimming against the tide of our profession for long enough to know that new evidence does not change tradition very quickly, even among educated professionals. It’s an even bigger challenge to overcome accumulated “wisdom” from the way things have always been done among youth athletes or weekend warriors. So, the next time you twist an ankle or tweak your shoulder, spare the ice pack. If you want to get active again, start moving gently in a way that will return you to normal more quickly. We’d be happy to guide you if you need some...

Read More »