Mark: Hi, it’s Mark from TLR. I’m here with Dana Ranahan. She’s the owner of Body Works Physiotherapy in North Vancouver. One of Vancouver’s and certainly North Vancouver’s favourite physiotherapy office. And one of the most famous frankly, one of the most popular in Vancouver and Dana has been voted best physio in North Van multiple times. We’re gonna talk about knee pain today. How are you doing Dana?
Dana: Good Mark. Thanks so much for that grand invitation.
Mark: So knee pain, like the weather’s getting nice. People are starting to get active again. Maybe they’ve been in a little bit of their couch potato phase from the pandemic, and now they realize, Hey, I can get outside. What do they need to be careful of? If they start getting a little bit of pain in their knee.
Dana: Well, I think that’s a really important thing to be thinking about now for everyone, because especially with the restrictions in BC here, just being lifted now, and people are starting to want to get active again.
I think now there’s a strive to return to sports, soccer, whatever it may be. Sometimes, you know, you’re going to get back with your running group or your cycling group or whatever it is. And I think the automatic as to want to go back to what we were before, let’s say before the pandemic, if we’d been less active during that time. Or if there’s any time you have a period of less activity. Maybe work takes over, or life, kids take over and then you want to return to sport or activity is easy to overdo it.
And so the knees are often a joint that takes a lot of the brunt of activity. Sometimes they’re often the victim, even if there’s problems up or down the chain. And so it’s easy to get overuse injuries or knee pain, or sort of ligament injuries can even happen in the knee if you jumped back to activity too quickly.
Mark: So a lot of people talk about, or I’ve heard of people having issues with ACL injuries, what’s an ACL injury. And what is it? Well, how would I know if I’ve torn my ACL?
Dana: Well, the ACL is called the anterior cruciate ligament. And as a ligament deep inside the knee, that was really important for stability in the knee. So it helps prevent translatory type forces or rotational forces in the knee. So basically a structural stabilizer inside the knee. And it’s a common ligament that can be injured.
So I mentioned return to soccer, let’s say, and I had an incident last year with a youth soccer team that I helped coach and I’m physiotherapist for the team, where these are 15 year old girls that are returning to training and they’d had about, you know, six months off with COVID and then returned to training.
So it was not even a game situation, but they’re cutting and changing direction. And so it can be a ligament this girl ended up injuring her ligament where she cut just the wrong way and the ligament was torn. And it’s probably because she hadn’t been kept up her fitness and her strength and then tried to return to some of those same activities, exercise where she’s more vulnerable then to injure that ligament.
Mark: And how would she know that, like how would that present? What actually happened when she had the injury?
Dana: Well, classically the way that the ligament is torn, so there can be various ways. Sometimes it can be a hyperextension injury of the knee, where if let’s say you’re running and you step into a pothole and your knee sort of overextends. Or more commonly, what I would see is where the knee pivots. So it’s like if you’re slightly bent in a standing position and you kind of pivot on the knee. It’s like a pivoting action where the knee would spin in, let’s say on the foot and the classic presentation for knowing that the ACL is torn is that you would hear a pop sound.
So often and in this girl’s case, she was training. There was no contact with another player. They were doing like a one V one drill and the other player was challenging her. And she went to cut and turn, heard a big pop, and the knee gave out. So that’s the classic presentation where the pop. So if anyone hears a pop, as they’re doing any kind of pivoting action, for sure needs to have their knee investigated to be sure that they haven’t actually torn this ligament. Because the ligament just basically pulls off the bone or can be torn in two which if that’s happened, then usually we need to consider a surgical reconstructive procedure, which would require a referral to see a surgeon or specialist.
Mark: And the aftermath of that can be that there’s a lot of swelling or not or like a lot of pain?
Dana: Well that’s the interesting thing about the anterior cruciate ligament is when we have an ACL tear, it doesn’t always present with swelling in the joint. So in this girl’s situation, she had a little bit of swelling, but pretty minor. And I think the family thought, oh, she just sprained your knee a little bit and it’ll be fine.
So minor swelling doesn’t seem that bad, but that big pop click on the pivoting action. Knee gave out not able to keep training. Those were like red flags to warn you that something else has gone on. Sometimes the ACL ligament will get torn in conjunction with other ligaments in the knee, and they can call that, you know, if the ACL and the medial collateral ligament, or the MCL, as well as the meniscus, which is like the shock absorbing cartilage in the knee can get torn together and they call that the unhappy triad. So sometimes when you get this click sound or pop sound, you can get a combination of factors happening.
Of course, when you get those multiple structures involved, it’s a bit more complex procedure. But those people might have a bigger swelling effect. Maybe not able to weight around the joint and so on. So there could be a myriad of things happening. However, the ACL is kind of the clear one where you get this click. Doesn’t always have to have swelling. If you get a big pop sound and the knee gives out, it needs to be investigated to be sure that someone gets on the right path right away, at least understanding what’s happened to their injury and how they should be addressing the recovery.
Mark: And so what’s the protocol. How do you treat that?
Dana: So if we’re think that someone has torn or ruptured their anterior cruciate ligament, it’s a referral to see a surgeon. As physiotherapists, we need to refer them back to see their family doctor. So to get a referral to see a surgeon, which usually as you know, there’s a bit of a wait list, takes some time.
So we would treat that injury like a knee sprain, trying to settle the swelling, trying to improve their mobility, get their strength kicking back in. All the while they’re waiting to see the surgeon, depending on how quickly they get in, you know, some people will pay privately or waiting in the public system can be a bit slower. It might be a couple months before you could see someone.
And in the meantime, we can try to help settle down the knee. But the knee needs to be evaluated because if there’s been a full tear of that ACL, especially in a young athletic person, they’ll look seriously at doing a surgical reconstruction of the ligament.
Where they take either a piece of the hamstring tendon or the quadriceps tendon to effectively replace that ACL ligament inside of the knee. And then after that surgery, there’s quite a lengthy rehab process. So I can talk you through that, but that might be the next step. So it, depending on what it is, if it’s a minor, maybe it’s a partial tear, maybe they haven’t ruptured it. Then our treatment would include what I described, you know, a bit at manual work to help the knee move better, settle down the swelling, some exercise progression, starting slowly and building up to more function. And, you know, if it’s a milder tear to the ligament not torn in two, then you know, it can be a couple of months of like physio rehab exercises, and then return to sport. If it’s more serious than the surgical referral would be, you know what we need to look at it.
Mark: And if for the tough ones out there who would just ignore this and go, you know what, it didn’t swell. I can keep going. What’s going to happen. What’s the long-term. What’s the result of that going to be?
Dana: Well, we know that without the anterior cruciate ligament, that the knee is structurally less stable, and some people can be more stable with secondary ligament restraints. So some people might be able to function better without an anterior cruciate ligament or an ACL. And some people can’t. So in some situations, people would have that injury and they could maybe return to some activity.
And I know in the past I’ve treated people that have, yeah, I thought it was better and they try to return to sport and the knee just gives out on them. So they try to cut and turn the knee gives out. So effectively the knee would be less stable and less able to perform the function or sport that you’re looking at, without giving out repeatedly and swelling and painful and whatnot.
So it could be that. Some people might get away with a little bit easier, but most people have some kind of limitation that they’re going to have their knee give out, or they’re going to have a problem with it. And not everyone who has a tear in their ACL, like torn in two, has it surgically reconstructed.
A lot of times as we’re older, you know, depending on what you’re doing and let’s say you’re going to continue cycling. Well, maybe the ACL, isn’t something that needs to be fixed to allow you to ride a road bike, for example. If you want to return to skiing or soccer or something where there’s more cutting motions, there might be different considerations. You know, age, sport where the physical demand you need and so on. So it might depend on the whole picture.
Mark: Any other long-term like, I can imagine it without that it’s going to put a lot more pressure on the other ligaments et cetera, the whole joint. So arthritis issues, et cetera, might be more pronounced.
Dana: Definitely. And I think that would be what would show up down the line. You know, if someone had had an injury and then tried to return activity would have the issues we discussed. But if it’s someone that could get by, maybe you had a tear in their ligament, didn’t realize, to get back to doing most activities they wanted to do. Maybe they’re a runner and they don’t need to pivot on the knee and they can manage that. However the impact of running, if you have sheer forces happening on the joint, that is not controlled well by that ligament, it just wears the joint surface.
So typically people get arthritic changes much sooner, and even people that have the ACL ligament reconstructed, will have degenerative changes at an earlier stage because they can only put the ligament back so perfectly. You know, if it’s too tight, the knee wouldn’t be able to move. So they need to make it enough that it restricts motion, but it probably has a bit more slide or sheer force on the joint even once the ligament has been reconstructed.
So some of the research shows us that within five years after an ACL construction, that people are starting to have a bit of wear and tear changes on their knee. And that’s even after having it reconstructed. So if they don’t have a reconstructed and keep a fairly high level of activity, there’s higher chances of arthritis at an earlier age.
And, you know, if you look at this young 15 year old soccer player, we want to prevent these injuries if we can, because now she’s sustained an injury, we can only do what we can to help her move better and feel better as she ages. And we want to keep her in a healthy, active person through her lifetime. But she’s going to need to manage that knee injury, right, going forward in the future to know what her limits are. And if she doesn’t, she will end up with you know, some degenerative change at an earlier age, which at the age of 15 is hard to relate to, but that’s something that you need to consider. You know, a lot of these youth are having this type of injury and how can we prevent it? And if they do get it, how can we get right on top of it? So they’re starting the right rehab process from the get-go.
Mark: So let’s maybe just touch on prevention. What’s the way to not have this happen when you’re racing to get out there because the sun’s out and my God, we can go outside. What’s the way to prevent that?
Dana: Well, I think when we’re looking at say return to sport would be a gradual return to activity. So soccer is the example we’ve been talking about, maybe they get out to start working on some simple little lateral movements, drills. Easy work that the coaches would have to help them ease into and then doing some work on their own. So maybe some strength work in the hips, working on alignment, balance exercises, a few key things. And the team that I’m working with right now, we’re still been doing some fitness training, you know, socially distanced outside at a grassy area, with just a few kids at a time. And that’s really been helpful for them doing a bit of core strength, a bit of hip strength, a bit of balance work to try to keep all this sorts of stuff happening while they haven’t been able to play their sport.
So definitely before someone returns activity, I think they need to gradually build up the activity as well as amp up a little bit of strength work that they’re doing to help support the activity that they’re doing. And that’s the preventative thing, you know, with soccer. Again, they have like some prevention programs for youth that get them working through certain drills. The FIFA 11 Plus Program is a great program, is ACL prevention, to try to help you control movement patterns so that you don’t turn your knee in and don’t pivot on it like we talked about.
So anyone out there in the soccer world can use that as a reference. And I think we’ve seen the incidence of these injuries dropped down. In the past, you know, it used to be that girls because of our female anatomy with our pelvic alignment and our knee alignment are more vulnerable to the ACL injury compared to young male athletes.
It used to be like an eight to one ratio, which I think is dropped down now. I think it’s closer to four or five to one, but I could be wrong on those numbers right now. But with all the prevention and different strategies that we now know we can do to help avoid injury, those are really key things, I think as well, to have everyone out there be aware of.
Mark: So strengthening yourself in preparation. Don’t just go out there and go hard again, basically because your tendons will be, and ligaments will have weakened because of inactivity. Muscles will get stronger a lot faster than tendons and ligaments.
Dana: Yes, definitely. And I think that’s the key. Like if we’ve had, you know, let’s say if you’re a soccer player and you haven’t played since December or hockey or whatever it is when they sort of had the restrictions cut down, we’ve been now six months without sport.
So it’s going to take you at least a couple of months to kind of build back towards the strength that you need to be able to play at the level that you were at before things shut down let’s say. So I think that needs to be something you consider, even in the youth athletes. They can probably develop their strength a little quicker because of their whole physiology of their age and so on.
However, it still requires some time to get muscle strength and to slowly put load on the tendons and ligamentous structures. So they start to develop more integrity to resist the loads that we want to put on them. So it’s gotta be a gradual thing.
Mark: Listen, if you’ve got some knee pain and you want to find out what’s going on, the place to call is Body Works. You can reach them at (604) 983-6616 in North Vancouver, North Burnaby, even Vancouver got people coming from all over to see Dana. Or you can book online at body-works.ca. Thanks, Dana.
Dana: Great. Thanks so much, Mark. Have a great day.