Medial Meniscus Tears Made Easy

Assisting the efficient joint relationship in the knee, two cartilaginous menisci rest on the flat surface of the larger lower leg bone (tibia). The inner (medial meniscus) and outer (lateral meniscus) have a flat under surface that sits on the tibia bone and the concave (depressed) overlying surface of the menisci houses the convex (rounded) end of the thigh (femur) bone.

Both of the menisci act as shock absorbers for weight-bearing by providing extra protection to the articular cartilage of the femur and the tibia. It also helps distribute forces throughout the knee while adding stability to the entire knee joint.

An injury to either of the menisci can be both painful and difficult to bear.

The medial meniscus, located in the inner side of the knee, is by far more prone to be injured compared to it lateral (outer) counterpart. This is due to its direct attachment to other structures of the knee such as the medial collateral ligament and the medical capsule of the knee joint.

The “unhappy triad” injury is a common injury in contact sports involving resulting in damage to the medial meniscus, medial collateral ligament and the anterior cruciate ligament.

Meniscus Repair

Only the peripheral zone of the meniscus cartilage is well supplied with blood while the remaining central region of the meniscus lacks a direct blood supply. Therefore, meniscus injuries affecting the central zone do very little healing.  Only if the meniscal tear is on the peripheral edge is a meniscal repair possible.  If a meniscus repair is not an option, a meniscectomy or a meniscus trimming is a surgical option if necessary.

How to Tear a Meniscus

Common causes of medial include direct forces to the outer knee, aggressive knee twisting, overuse trauma, hyper flexion with rotation and excessive birthdays. These factors can result in thinning and tears of either the medial or lateral meniscus.

Injuries to the medial collateral ligament and anterior cruciate ligament will stress the medial meniscus and result in a medial meniscus tear (MMT). Degenerative conditions predispose the medial meniscus to injury. This is a painful injury initially accompanied by swelling and tenderness.

Signs & Symptoms of Medial Meniscus Tear

  • Knee joint line pain which can be increased with twisting and grinding movements.
  • Swelling and tenderness usually accompany the inflammation along the medial joint line.
  • Possible joint locking and “catching” from the tears and loose piece of the meniscus and/or articular cartilage.
  • Range of motion for both bending and straightening of the knee joint may be compromised.
  • Difficulty bearing weight with the involved knee.

Professional Treatment for Medial Meniscus Tear

The severity and type of tear sustained will guide the proper treatment approach to medial meniscal injuries.

  • Seek clinical evaluation of the injury. Improperly diagnosed and managed meniscal injuries can result in problems that you don’t want to experience.
  • RICE – rest, ice, compression & elevation to minimize the inflammation and decrease the symptoms.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Knee braces and sleeves will assist in supporting the knee and reducing the excessive motion that will increase the medical meniscus symptoms.
  • Maintain knee range of movement as early as possible.
  • ·Progressive resistive strengthening exercises for the quadriceps as early as possible maintain dynamic knee stability.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Is this injury related to my biomechanics?
  2. Exactly what structures in my knee are damaged?
  3. Do I need an MRI to assess what exactly my knee hurts so much?
  4. Do I have any articular cartilage damage in any of the three (3) compartments of my knee? If so, do I have arthritis and where?
  5. What kind of exercises do I need to avoid?
  6. Are there any long-term complications with this MMT?
  7. Do I need to visit a physical therapist?

Elite Sports Medicine Tips from Mike Ryan

  • Be Smart Now – Resting early on for 3-5 days can prove to pay off if the MMT quiets down quickly.
  • It’s Not About Medications – Avoid pain medications for pain unless you REALLY need them.
  • Quads Are MCL Guards – If your quad are strong, your MCL will recover fast and with better results. It’s that simple.
  • Avoid Bending With Twisting – That’s a common way to tear a meniscus so avoid this movement combo whenever possible.

Kneecap Pain and Running

Understanding Kneecap Pain for Runners

Patellofemoral pain syndrome (PFPS) typically presents with a dull pain just beneath the kneecap and lower front part of the thigh just above the knee joint.  It is very common injury for runners. Hence, patellofemoral pain syndrome is sometimes referred to as “runner’s knee” or misalignment of the patella.

The patella pain can be elicited during walking, running, going up/down stairs, squatting and even during long periods of rest, without moving the joint. One or both knees can be affected simultaneously and it is more common with women than it is with men.  The reason for the gender issue is based on the fact that women tend to have wider hips, which results in a significantly greater “Q angle” at the patellofemoral joint of the knee.

A number of risk factors for Runners knee have been identified and linked with the onset of patellofemoral pain syndrome in runners. Athletes who log excessive repetitive stress on their knee joint are the most predisposed population to develop patellofemoral pain with an overuse injury.  Other factors include knocked knees, wide hips, flat feet and excessive foot pronation.

The perceived kneecap pain is a result of abnormal forces associated with the patellofemoral joint such as abnormal muscle pulling on the painful patella, weak quadriceps muscles, tight hamstrings, subluxations, dislocations, arthritis, stiff Achilles tendon, tendonitis, and degenerating knee cartilages losing their cushioning effects.

This results in an inflammatory response that unleashes a cascade of protective patella pain.  Interestingly, this area is more often not swollen.

Signs & Symptoms of Patella Pain for Runners

  • Dull aching pain around the kneecap.
  • An increase in symptoms during and/or after lower extremity activities such as walking, running, squatting as well after long periods of rest with the joint in a fixed position.
  • Pain may also be perceived behind the knee.
  • Patella tenderness but not necessarily swelling around the knee.
  • Knee joint catching or locking.
  • Difficulties attaining full range of movement with popping or snapping sensations noted with active movement.

Professional Treatment for Runners Knee

  • Rest, elevate and ice the area for 15-30 minutes, up to 4 times a day.
  • Stretching of the quadriceps, hamstrings, hips, ankles and Achilles is a must.
  • Significantly limit or postpone your running for now.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Avoid excessive weight bearing activities.
  • Utilize a self myofascial roller to be used regularly on the quads, lateral thigh, hamstrings and calves.
  • Utilize a knee compression sleeve or patella brace as needed.  They can either decrease or increase the symptoms, depending upon the athlete.
  • Avoid making sharp movements on the knee joint, changing direction with the foot fixed to the ground, bending the knee back and forth.

Asking the Right Questions like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. What type of tissue around my knee is the source of my pain?
  2. Is there any arthritis in my knee and if so, where is it located?
  3. What type of exercise or physical therapy can I do to minimize or eliminate this pain?
  4. Do you recommend I take glucosamine?
  5. Are there any long term complications I should be concerned about?
  6. Do you recommend the use of orthotics for my injury?

Elite Sports Medicine Tips from Mike Ryan

  • Healthy Mind & Body – A healthy body and mind makes for a quicker recovery. Stay positive.
  • AM Stretches – Stretch the muscles around your knee joint before you begin your day.  A proper warm up is always smart if reducing kneecap pain is your goal.
  • Keep Rollin – Lower extremity rolling to increase the blood flow and mobility of the muscles associated with the knee is a must.
  • Gear Up the Right Way – Make sure your equipment from your shoes to your exercise equipment is right for you and not contriputing to the problem.
  • Level Hipped & Level Head – Make sure you don’t have a leg length discrepancy or alignment problem.  When it comes to eliminating kneecap pain, correcting this is priority #1.

Tackling a Lateral Meniscus Tear of the Knee

Understanding a Lateral Meniscus Tear

“I tore my cartilage” is the term most athletes use to describe the possible source of their knee joint line pain.  About 40% of the time, they’re correct.  Now ask them to identify culprit, aka “the cartilage”, in a police lineup and they’ll probably have the look of a cow staring at a fence.

The medial (inner) and lateral (outer) menisci are made up of very resilient cartilage.  Their design and cellular structure allows them to assist in the stability of the distal femur (thigh bone), distribute body weight forces across the joint surfaces and absorb compressive forces as we move.

Injuries to the menisci can significantly impair knee functions. Because of their relationship with other structures in the knee joint, the lateral meniscus is less prone to injury when compared with the medial meniscus. The lateral meniscus has less direct attachments to other structures in the knee. However, the long-term impact of a lateral meniscal injury is more concerning due to the high weight-bearing forces in the lateral compartment of the knee.  In other words, if you have a lateral meniscal injury, your likelihood of needing to have it addressed surgically increases and the presence of accelerated arthritic damage rises with time when compared to the medial meniscus.
The types of injuries to the lateral meniscus vary in location and severity, ranging from splitting into two segments to tearing around its more “C” shaped borders. Over time, meniscal micro trauma can result.

The lateral meniscus has minimal blood supply around its periphery.  With no direct blood supply to its central region, one can typically expect minimal healing with injuries involving this region of the lateral meniscus.

The two most common causes for meniscus tears are direct trauma and degenerative conditions. More often, the traumatic injuries involve twisting of the knee with the knee in a bent position.  This is commonly seen in contact sports. With this mechanism of injury, the foot is fixed to the ground resulting in a stretching of the meniscus. A direct blow to the inner part of the knee joint can also injure the lateral meniscus.

The degenerative damage is more commonly seen in the older population and is often associated with underlying arthritic changes. As the meniscus lose significant blood supply and weakens, it becomes more prone to injury. In this population, simpler twists and forces associated with daily activities may prove to be the cause of a meniscal injury.

Signs & Symptoms of Lateral Meniscus Tear

  • Excruciating pain and swelling immediately or up to 3 days after the activity in question.  Lateral joint line pain increases with rotation of the knee and weight-bearing.
  • Difficulty walking, bending or rotating the knee against resistance due to lateral knee pain.
  • The knee joint may become locked or “catch” if the loose piece of the meniscus is in a position of pain within the joint.  This flipping of the flap or unstable section of the cartilage will typically prevent full extension more often than it will limit full flexion.
  • Joint stiffness and tenderness around the outer edge and back ridge of the lateral joint line.
  • A general sense of insecurity with the knee with increased activity contributing to what older athletes tend to refer to as a “trick knee” due to its unpredictability.

Professional Treatment for Lateral Meniscus Tear

The best treatment is often a treatment of the symptoms and not the injury itself due to the limited healing capability of the meniscal tissue.

  • Ice the knee at least 4 times per day and immediately after all athletic activities.
  • Utilize the latest physical therapy modalities and rehabilitation equipments to control the pain, swelling and tenderness in the in and around the joint.
  • Strengthen the muscles directly influencing the knee joint. Strengthening exercise should be mostly pain-free. Muscles of the thigh, quads in front and the hamstrings in back, should be the main focus along with the hip rotators and the calves.
  • Soft tissue massage and stretching of the surrounding muscles and fascia needs to be included. This encourages the muscles to stay pliable which will accelerate the recovery time.
  • Surgery?  Let the doctor and YOU determine the answer to this question.  Closely monitor your symptoms and your activity level before you decide to “go under the knife”.  If unsure, gradually test your knee with functional activities along with the watchful eye a sports medicine specialist.
  • Eat right and drink right.
  • Be cautious of activities that twist the knee to avoid aggravating the injury.
  • Rest as needed.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Is this injury related to my athletic activities?
  2. What structures in my knee are damaged?
  3. Do I need further diagnostic test like an MRI?
  4. Do I need to have a knee scope and/or a micro fracture surgery?
  5. What kind of exercises do you recommend?
  6. Are there any long-term complications that we should discuss now?

Elite Sports Medicine Tips from Mike Ryan

  • Train With “Training” Specifications: Train smarter.  You can be aggressive and keep your knee pain-free by minimizing the twisting motions during your training.
  • Surgery is Just One Option on the Menu:  Many doctors may tell you otherwise but here is the truth: Just because you have a meniscal tear does not necessarily mean you need to have surgery.  The location of your injury, your pain level, the present knee limitations and your past medical history are the most important factors in determining whether you need to be walking around the surgical center trying to look cool in one of those drafty Johnnies!
  • Grocery Choices: You know when it’s junk or healthy. Help yourself to a healthy diet if you’re serious about getting back to competing like you did 10 years ago.
  • Ride Your Way Up: Don’t play “hero” on day #1 with your agility drills and running.  Bike riding is a great way to get your range of motion back and to start the leg strengthening process the smart way.  It’s time to change your mindset and getting on the bike and in the swimming pool is a great way to start.
  • Employ Proper Techniques: You accidentally did something wrong to incur the meniscal tear so now your focus should be to doing it right. Proper techniques and progression are the keys along with getting in with the right physical therapist.

How to Kick Into High Gear Against Runner’s Knee Pain

Pain associated with running can contribute to some forms of overuse injuries. Constantly subjecting the structures holding the joint to mechanical stress as with running, without allowing adequate time for recovery, is a recipe for developing knee pain. For example, excessive jumping, running, or deep lunges are all potential factors for knee pain. However, knee pain for runners is rarely a “do or die” scenario. In fact, many knee injuries with runners, if detected early, can easily resolved with proper treatment.

Understanding Running Knee Pain

Pain associated with running can contribute to some forms of overuse injuries. Constantly subjecting the structures holding the joint to mechanical stress as with running, without allowing adequate time for recovery, is a recipe for developing knee pain. For example, excessive jumping, running, or deep lunges are all potential factors for knee pain. However, knee pain for runners is rarely a “do or die” scenario. In fact, many knee injuries with runners, if detected early, can easily resolved with proper treatment.

Statistically, runners who consistently run over 30 miles in a week are more prone to developing knee pain. A sign of a potential problem with runners is when a runner starts to feel knee pain after running a shorter distance on subsequent runs.

The kneecap or patella is a small bone that burdens a complex joint function. It is subject to displacement and friction; two common causes of knee pain in runners. A muscle imbalance in the lower extremity is a common factor contributing to knee pain with runners. The meniscal cartilage separating the distal femur (thigh bone) and the proximal tibia (shin bone) is stressed and compressed with running. The hard marble-like articular cartilage that covers the ends of both of these bones and the back of the patella are vulnerable to injury based on activity, age and work volume.  Over time, with insufficient rest or excessive workloads, the articular cartilage and the menisci are susceptible to degenerative changes.

Bad shoes, especially ones that contribute to excessive supination or pronation with running creates a discrepancies with the normal synergistic muscle stress on the patella.  This change in “patella tracking” is a typical factor with knee pain.

Diagnoses such as patellofemoral pain syndrome (PFPS), chondromalacia, Jumpers knee, patellofemoral tendonitis, ITB syndrome, pes anserine tendonitis, distal quadriceps strains and bursitis are common conditions associated with knee pain in runners.

Signs & Symptoms of Knee pain associated with running

  • Perception of pain after running or with prolonged standing.
  • Knee aching and discomfort with rest.
  • Difficulty bending the knee joint past 70 degrees after running.
  • Any point tenderness near the patella or knee joint lines.
  • Perceiving a popping sensation with knee flexion.
  • Any swelling within or around the knee, which increases with running.
  • Clinical evaluation of a Quadriceps angle or “Q Angle” greater than 15 degrees.
  • A lateral displacement of the patella when compared to the other knee joint.
  • A grinding or crepitation behind the kneecap with volitionally bending and straighten of the joint.

Professional Treatment for knee pain

  • Elevate your legs, “rollout” the front & sides of your thighs and then ice your knees immediately after running.
  • Practice and embrace a lower extremity flexibility program, period.
  • Be consistent with a quadriceps and hamstring strengthening routine that is completely painfree for the knees and does not allow the knee to bend past 90.
  • Spend the money to wear running shoes that fit properly with the necessary support.  Your local running store can easily be your MVP when it comes to avoiding running injuries.
  • Avoid running every day.  Mix in other sports such as swimming, elliptical trainer and biking to improve your fitness without injuring your knees.  “Cross train, cross train, cross train!”
  • Minimize your distance on paved roads.  Find golf courses and off-road trails to reduce the compressive forces on your entire body.
  • Ingest more anti-oxidant containing foods such as fruits and vegetables as a natural way to consume anti-inflammatories.
  • Knee straps, shoe insoles and knee sleeves may prove to be helpful at reducing knee pain with running.
  • A thorough evaluation by a physical therapist or runner-friendly physician is a great way to rule-out potential sources of knee pain such as a leg length discrepancy, plantar fasciitis, hip arthritis, low back misalignment, excessive ankle pronation, cartilage tear or tendon abnormalities.

Asking the Right Questions like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Is this injury related to my running?
  2. What type of exercise or therapy can I do to minimize or eliminate this pain and avoid surgery?
  3. Do I need further diagnostic tests to assess this injury?
  4. Are my running shoes a factor to my pain?  If yes, which running shoes would you recommend?
  5. Do I need to be concerned with any long-term issues with this condition?

Elite Sports Medicine Tips from Mike Ryan

  • Minimal Miles – Run less while your improve the factors that are contributing to the pain. Common sense is priceless at this point of the injury management plan.
  • Minimize the Meds – It’s easy to pop the pills.  Treat knee pain the smart way by eating healthy and following my advice.  Your stomach will thank you.
  • Drain Your Legs – After every run, elevate your legs while pumping your ankles to drain the waste products and excessive fluids from your your legs for at least 5 minutes.  Start your recovery NOW.
  • Do What Made You Sore – An easy short run on a soft surface the day after a hard run will help reduce muscle soreness.

Going Round and Round with Cycling Knee Pain

Understanding Knee Pain From Cycling

Cycling is a wonderful sport for athletes at any age.  Whether you’re biking the flat roads here in Florida or braving the endless off-road trails in the Rocky Mountains in Colorado, the speed, fitness and fresh air accompanying the world of cycling is a wonderful escape from the “daily grind”.

Bike riding is considered a partial weight-bearing exercise.  Another benefit of bicycle riding is that by adjusting the many moving parts of a bike, you can control some of the lower extremity joint range of motions.  Both of these two points make cycling an activity that sports medicine specialists like me love to see our patients doing.

Like any athletic event, too much cycling and/or poor biomechanics can easily contribute to knee injuries. With that being said, most knee cycling injuries result from overuse.  Overuse injuries involving the knee joint from cycling usually presents with degeneration of the knee patellofemoral joint with a condition referred to as Chondromalacia.  This breakdown of the articular cartilage on the backside of the kneecap can result in pain, knee swelling, quad weakness and decreased knee range of movement.

The onset of biking knee injuries is commonly associated with a sudden change in the intensity, duration and/or frequency of biking. Too sudden a change simply leaves insufficient time for the knee joint and all of the associated soft tissue to adjust to the new demand.

The injuries associated are pretty vast with patellar tendonitis, ITB syndrome and Chondromalacia heading the list.

Competitive cyclists and recreational riders cycling too vigorously at the beginning of the biking season may be predispose to knee pain.  If the bikers ignore this natural urge, they simply don’t progress like they wish and in the long run, will probably become injured or see their performance suffer.

Improper saddle heights, especially being too low, may contribute to developing knee pain.

There is a reason bicycles have gears and smart bikers use those gears to their advantage. “Pushing too big of a gear” is the easiest way to create cycling knee pain.  Poor feet angles on the pedals and improper cleat selection both play their part in developing knee pain.

Signs & Symptoms of Knee Pain from Biking

  • Dull aching pain around the knee joint, especially above or below the kneecap or patella.  Generally the pain follows activity but in advanced cases, the symptoms may be worse in the morning.
  • Crepitation or grinding behind the kneecap with active motion.
  • Difficulty bending the knee joint secondary to pain and possible knee “lock”.
  • Swelling and tenderness from inflammation.
  • Difficulty with climbing up and descending down stairs.

Professional Treatment for Bicycle Knee Pain

  • Pain-free strengthening exercises for both the quadriceps (anterior thigh) and gluteus muscles (back and sides of side of the butt) are a key step.  Did you notice that the first words that I used were “pain-free”?
  • Aggressive soft tissue massage and self-myofascial release techniques to elongate tight muscles and enhance muscle function.
  • Utilizing the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Stretching of the low back, hip flexors, quad muscles, hamstrings and calves should become part of your daily routine.
  • Icing of the knees immediately after cycling and as often as possible throughout the day.
  • Eat healthy to enhance performance and accelerate your recovery.
  • Cross training (swimming, Elliptical Trainer, yoga,..etc.) and easy cycling during the “off days” can help reduce knee and lower extremity stiffness.
  • Check your “Bike Fit” or overall alignment on the bike through the watchful eyes of a certified bike fitter at a local high-end bike shop.
  • Assess your gears, saddle heights, and cleats based on your injury and the advice of your skilled bike fitter.
  • Rest as needed and focus on adjusting your body to be able to cycle pain-free.

Asking the Right Questions like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Is there a biomechanical alignment issue that needs to addressed to improve my injury?
  2. What is my exact knee injury diagnosis?
  3. What type of exercise or therapy can I do to minimize or eliminate this pain and avoid surgery?
  4. Do I need further diagnostic tests to assess this injury?
  5. Should I be concerned with any long-term issues from this injury?

Elite Sports Medicine Tips from Mike Ryan

  • Down With Hills & Distance: Bike Riding Common Sense 101 > Reduce the miles and stay on the flat roads while rehabbing this injury.
  • Eat Right and Pop Fewer Pills: Use healthy foods and not medicine to allow your body to get stronger while decreasing your pain.
  • P R O G R E SS I O N: It’s that simple.  Start slow and never increase your mileage weekly by more than 10%.
  • It’s More Than You Think: Biking is more than just pushing your pedals in circles.  Get back to basics by improving your pedal stroke by learning key pedal drills and exercises from the biking experts.
  • Maintain a higher cadence: Ahigher cadence (revs per minute) reduces the workload on your knees although it makes your heart work harder. Practice pedaling with a higher cadence to reduce the compressive forces on your patellofemoral joint.

Biceps Femoris Tendonitis: The Forgotten Hamstring

The truth is….athletes “pull” muscles. That is something everyone is at risk for with an active lifestyle. Biceps femoris tendonitis is typically an injury resulting from overuse or over stretching of the biceps femoris tendons of the most lateral hamstring on the back of the thigh.

The two most common locations for pain with this injury are at the ischial tuberosity, just below the buttock, or along the palpable tendon near the outside of the knee 2-4 inches above the joint. In other words, at the tendons at the top of the muscle or the longer tendon just below the muscle.

These are the locations of the tendons responsible for connecting the biceps femoris muscle to your pelvis and shin bones. Repeated injuries involving the muscle itself can create a chronic inflammation of the tendons and their enclosed sheath.  This is commonly referred to as a form of tendonopathy.

Tendonopathy is a general term used to describe a combination of ailments. It is often associated with repeated micro tearing and inflammation of a tendon and it’s surrounding sheath. Athletes of all ages and sports are prone to tendonopathies of all three (3) hamstring muscles.

The biceps femoris is one of those hamstring muscles.  It is located at the posterior thigh and moves down the back-outside of the upper leg where it inserts just below the lateral knee. This muscle assists in flexion or bending of the knee, extension of the hip and some rotation of hip movement while the knee is in a bent position.

Avoiding the complicated science behind the reasoning, the biceps femoris is very important for acceleration and deceleration with all running and jumping activities. Injuries involving any of the hamstring tendons or muscle bellies are painful and can easily take up to 4-6 weeks to properly heal.

Signs & Symptoms of Biceps Femoris Tendonitis

  1. Pain or tenderness just under the buttock or at the back-outside corner of the knee with motion.
  2. Palpable swelling and tenderness just under the buttock or at the outside of the knee.
  3. Increased pain with active or resistive flexion (bending) of the knee.
  4. Inability to perform simple exercises without pain anywhere along the length of the lateral hamstring. These activities include running, stair climbing, forward bending with the knees straight while reaching for your toes, pulling the knees towards the chest and backward walking.
  5. It is not unusual to feel a “squeaking” within the distal tendon sheath with slow active knee bending.
  6. Pain with lateral or external rotation of the foot and shin while sitting with the knee bent.

Professional Treatment for Biceps Femoris Tendonitis

  1. Immediately stop activity and apply compression to the area.
  2. Avoid all hamstring stretches for at least 4 days. (Trust me on this one…I’ve learned this valuable tip the hard way!)
  3. Apply ice packs to the lateral knee and/or back of the thigh for 15 minutes every hour.
  4. During and after every ice treatment, apply compression to the involved tendon and the hamstring muscles in that region of the hip/thigh/knee.
  5. When resting, elevate the affected lower limb to minimize swelling.
  6. Avoid prolonged sitting.
  7. Three days after you are able to walk pain free, initiate an easy stretching and non-running exercises plan.
  8. After three days of pain-free stretching and functional athletics, progress as tolerable with strengthening and running activities.  The two key variables at this point to avoiding a setback are Progression & Common Sense

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Are you certain of the diagnosis of biceps femoris tendonitis and do you have any other concerns with my injury?
  2. Are other hamstring muscles, nerves or tendons damaged?
  3. How long can I expect for this injury to properly heal?
  4. Do you suggest that I visit a physical therapist for a comprehensive rehabilitation program?

Elite Sports Medicine Tips from Mike Ryan

  • Check your strength – It would be beneficial to you to consult a physical therapist during your down time. Getting a professional option on your lower extremity strengthen might shed some light on why you got injured in the first place.
  • Stretch it out – Promise yourself that when you recover from this injury, you will spend 5-10 minutes stretching every day.
  • Ice – Regular application of ice on the biceps femoris muscle belly and the involved tendon will help control the inflammation.
  • Take your time – When returning to your sport, take your time. Stretch properly and gradually build up the intensity of your activities.
  • Pay attention – After returning to your workouts, monitor the hamstring signs and symptoms.  If it gets cranky, return to rest, ice aggressively, STOP stretching and try again in two days.

Taming an MCL Sprain

The Medial Collateral Ligament (MCL) is a thickening of the medial or inner knee joint capsule.  The MCL is the stabilizing ligament between the medial distal femur (thigh bone) and the medial upper tibia (shin bone).  The main function of the MCL is to reinforce the medial knee joint against excessive valgus stress or inward bowing of the knee.  Another important function of the medical collateral ligament is to limit the amount of external rotation of the lower leg in relationship with the upper leg or femur.

In summary, the MCL is an important stabilizing structure that impacts most movements of the knee.  The manner in which the knee moves is significantly influenced by the MCL, thus it dictated the function of the entire lower extremity.

The medial collateral ligament is separated into two parts.  The superficial ligament fibers originate along the distal inner femur and insert along the upper inner tibia.  The deep ligament fibers attaches to the medical meniscus cartilage along with the joint edges or margins.

When stress is placed upon a ligament which is in excess of the capabilities of that ligament, the ligament is disrupted.  When a ligament, which connects bone to bone, is damaged, it is referred to as a sprain.

The grade or degree of damage to a ligament is based on the level of disruption of the ligament fibers.  MCL sprains are graded from 1 to 3 with a grade 3 being the worst.

Grade 1 MCL Sprain:

Injury:                           Stretching of the MCL fibers

Symptoms & Findings:         Point tenderness with no instability

Grade 2 MCL Sprain:

Injury:                           Partial tearing of the MCL fibers

Symptoms & Findings:         Point tenderness with mild instability

Grade 3 MCL Sprain:

Injury:                           Complete tearing of the MCL fibers

Symptoms & Findings:         Point tenderness with significant instability

The mechanism of injury is usually related to a blow to the outside of the leg and/or excessive external rotation of the lower leg in relationship to the upper leg.  With grade 3 MCL sprains, a “pop” is noted by the athlete.  When an audible “pop” is noted, the common fear is a complete tear of the anterior cruciate ligament (ACL).

Signs & Symptoms of a Sprained MCL

  • Pain along the medical or inner knee joint.
  • A sensation of “looseness” or instability when bearing weight on the involved leg.
  • A “wobble” of the inner knee is noted when the leg is lifted and swung in a side to side manner.
  • Generalized swelling of the inner knee which tends to increase with prolonged walking.
  • The quadriceps leg strength is quickly diminished secondary to pain and swelling.
  • The athlete’s confidence in the leg and the ability to be functional is typically directly related to the degree of instability.
  • When a meniscus tear accompanies a sprain of the MCL, internal knee joint catching or locking is reported.

Professional Treatment for a MCL Sprain

  • Immediate icing and immobilization of the knee.
  • Compression to the knee joint to control swelling.
  • A knee brace is utilized for all weight bearing activities for all MCL sprains and while sleeping for all grade 2 & 3 MCL sprains.
  • Painfree active and passive range of motion (ROM) while avoiding the last 20 degrees of ROM for all grade 2 & 3 MCL sprains.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Conservative quad strengthening exercises are implemented starting on Day #2 with initial ROM limited to 90 to 20 degrees.
  • Bike riding can be started on Day #2 as tolerable while avoiding the last 20 degree of extension until the swelling and pain are reduced to 50% of maximum levels.
  • Conservative measures are taken to avoid all activities that allow the knee to “drop inward” or gap medially along with all functional movements that externally rotate the foot and lower leg.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Are my two cruciate ligaments stable?
  2. What grade is my MCL sprain?
  3. Do you have any concern that I have any secondary damage to my knee such as a bone bruise, meniscal tear, chondromalacia, an inflamed plica or damage to my articular cartilage?
  4. What do you recommend that I do for my rehab, on my own or within a rehab clinical setting?
  5. Do I need a rehab brace now and will I need a functional brace when I return to my sport?
  6. What are my guidelines to return to running, limited activities and full-go activities?

Elite Sports Medicine Tips from Mike Ryan

  • Tighten Up – Careless treatment with a sprained MCL will result in a loose MCL.  Is that a problem?  Question: Have you ever tried to run fast or play tennis with a shoe with no laces?  Exactly…
  • Quads Rule – Strong quads or thigh muscles are directly related to your ability to return to your sport after the MCL has completely healed.
  • Build up the Sides – Progress slowly with the side-to-side movements.  Agility-type movements are important for most sports so the MCL needs to be properly prepared for that type of stress.
  • Look Down – Can you see your sneakers?  Make sure they are the proper footwear for your sport.
  • “Mirror Mirror on the Wall” – Check your legs look in the mirror.  If the involved leg looks smaller, you still have some high intensity strength work to do.

Playing it Smart with Pes Anserine Bursitis of the Knee

What is pes anserine bursitis? This ailment, while not extremely common, can be quite painful. It is the result of inflammation of the pes anserine bursa, which is located just below and to the inner side of the knee. A bursa is a fluid filled sac that acts as a cushion and is located close to most major joints of the human body.

This is a location vulnerable to repeated injury in athletes due to the fact that several ligaments, tendons, and muscles all meet in this same general knee area. This area of ‘high traffic’ can become aggravated with overuse. A typical mechanism of injury is a direct blow to the per anserine area at the upper inner tibia just below the knee. As you know, there is very little protection in this area with no muscle bellies or large fat stories to buffer the trauma.

The MCL, semitendinosus, sartorius muscle, and gracilis muscle all meet at the proximal tibia where this important bursa is located. They each provide support and alignment during body movement. The pes anserine bursa acts as a lubrication device, which minimizes the stress to the underlying tissue during interaction of the knee and all the surrounding tissue. This allows for proper body mechanics and weight distribution with all activities involving the lower extremity.

Sign and Symptoms of Pes Anserine Bursitis

Pes anserine bursitis is most common in long distance runners. Failing to properly stretch is a main cause but this condition also occurs in athletes who tend to contact the ground with their foot rotated outward. Even the slightest outward rotation of the lower limb during contact with the ground causes poor weight distribution and strains the inner thigh muscles and knee ligaments.

The following are symptoms of pes anserine bursitis:

  • Pain at the inside of the knee with repetitive knee movement (usually while extending the knee or climbing stairs).
  • Palpable swelling, warmth and tenderness on the inside of the knee 2-3 inches below the jointline. Often the pain associated with a bursitis can be minimal and the athlete reports that it “looks a lot worse than it feels”.
  • Redness over and around the area of the per anserine.
  • Pain located just below the inside joint line of the knee, which increases with resisted knee flexion and/or adduction (pulling the legs together).
  • Knee weakness associated with activities.

Professional Treatment for Pes Anserine Bursitis

Do not underestimate this injury. Take the necessary time off to allow for a full recovery prior to returning to your activities. One of the most common mistakes athletes make with this injury is not allowing for ample time to allow for sufficient healing before subjecting the tissue to high level stress. When this happens, the symptoms return much worse than previously experienced as you enter into the world of “chronic bursitis” and let’s just say that is not a fun place to be!

The following are my treatment recommendations for this condition:

  • Rest affected area by minimizing the activity associated with the cause the ailment.
  • Apply ice packs for 10-15 minutes 3-4 times daily.
  • Utilizing the necessary therapy modalities to decrease pain and reduce swelling.
  • Regularly stretch the knee, thigh muscles, and hips to promote relaxation of the area. Remember to breathe!
  • Proper diagnosis from your primary physician may require a referral for an x-ray an/or special test. Pain caused by pes anserine bursitis can mimic that of a stress fracture of the proximal tibia with endurance athletes.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Are you certain of your diagnosis of pes anserine bursitis or are there other injuries the source of these symptoms?
  2. Are all of the surrounding knee structures stable and intact?
  3. What activity do you believe is causing this pain and what can I do to prevent it in the future?
  4. Would you evaluate my lower extremity biomechanics to see if I have a leg length discrepancy, alignment problem or foot pathology that is a contributing factor to my injury?

Elite Sports Medicine Tips from Mike Ryan

  • Take a Timeout – In order to prevent any further aggravation to the knee take time off NOW so you can enjoy your sport next week.
  • Stretch It Out – Stretching works wonders for the body and proper healing of an injury such as this where muscles and tendons are involved.
  • Refill The Ice Tray – By now you may want to purchase additional ice trays after all of the icing that you will be doing! Ice is a great vasoconstrictor and it quickly reduces swelling. Apply the ice to the inside of the knee.
  • Baby Steps – After you feel you are healthy once again do not go out and run a half marathon! Start small and avoid obstacles such as hills and high intensity workouts while your leg strength and flexibility improves.

Why Fat Pad Impingement Hurts so Damn Much

Understanding Fat Pad Impingement

The infrapatellar fat pad is a sensitive mass of tissue that lies behind the patella tendon and on the front side of the knee joint.  With it being located below and behind the distal end of the patella or kneecap, it’s quite vulnerable to trauma and is an obvious source of pain.

It is not the most common of knee injuries but it may be one of the most difficult ailments to eliminate.  The main function of the fat pad, or Hoffa’s pad, is to provide a protective padding to the knee’s condyles located at the distal end of the femur or thighbone.  Many knee injuries involve a blow to the front of the knee and the fat pad is an effective structure to buffer the forces on the vulnerable articular surfaces of the distal femur.

The two most common mechanisms of injury for fat pad impingement is a direct blow to the patella and front of the knee and hyperextension of the knee joint itself.  Both mechanisms create a pinching of the fat pad resulting in swelling of the pad and surrounding tissue.

With this type of a knee injury, the fat pad becomes very painful and slow to heal. Due to the location of the fat pad behind the patella tendon and the high forces associated with the patella itself, an enlargement of the fat pad can significantly impair the overall function of the knee and quickly limit the athlete’s leg strength.

Signs & Symptoms of an Impingement of a Fat Pad

  • Palpable swelling below and to both sides of the patella tendon.
  • Pain below and to the sides of the patella tendon with squatting.
  • Pain below and to the sides of the patella tendon with leg extension along with noticeable bulges to the sides of the patella tendon when the knee reaches full extension.
  • Increased warmth and a sense of fullness in front of the knee below the patella.
  • The inability to actively extend the knee to full extension due to pain when pressure is applied to both sides of the patella tendon.  This is referred to as a Hoffa’s Test.

Professional Treatment for Fat Pad Impingement

  • Resting the knee while avoiding all activities that apply pressure to the anterior knee and/or increase symptoms.
  • Ice, ice and more ice.
  • The necessary modalities and therapy devices to reduce swelling, decrease pain and restore normal knee mechanics.
  • The use of a roller and massage therapy for the hip flexors, quadriceps, ITB, hamstrings and calves to increase tissue mobility and reduce patella compressive forces.
  • Painfree flexibility activities for the hip flexors, quadriceps, ITB, hamstrings and calves to improve lower extremity range of motion.
  • Implement a quad-strengthening program that is painfree while being performed in a range of motion between 90 degrees of flexion and 20 degrees from full extension.
  • Patellofemoral taping can be an effective treatment for sub-acute and chronic knee injuries that involve the patella and the patella tendon.
  • Knee sleeves that provide stability and motion control to the patella may be helpful if additional pressure is not applied to the infrapatella area.

Asking the Questions a Pro Athlete Would Ask

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Are you certain of the diagnosis (Dx) of fat pad impingement and does this Dx match my mechanism of injury (MOI)?
  2. Are there any additional complications to this injury that I need to be made aware of?
  3. I’m concerned about losing my quad strength so what can I do to help me maintain my lower extremity strength?
  4. Do I show any signs of a mechanical abnormality such as a leg length discrepancy or chondromalacia that needs to be addressed in addition to my fat pad injury?
  5. What type of progression do I need to follow when I return to my sport?

Elite Sports Medicine Tips from Mike Ryan

  • Start Treatment ASAP – You don’t want a chronically inflamed fat pad.  Treat it the right way now and be done with it.  If you wait expecting it to “just go away”, you may be sorry that you did.
  • No Go 2 Stop & Go – Stop & go sports such as tennis and basketball are no friend to a painful fat pad.  Don’t be in a rush to return to such sports until the swelling is minimal, the quad strength is at least 90% and the pain is mild.
  • Pray for Help – Kneeling on the knee, as in the praying position, will increase the symptoms of an inflamed fat pad.  I’m not suggesting that you stop praying but a simple pillow under your knee will help make your religious duties much more comfortable.
  • Looking Elsewhere – If your fat pad is painful yet the mechanism of injury just does match up, the problem may be from somewhere else.  Chronic foot pain, tight hips, a symptomatic plica and Jumpers Knee are just a few examples of injuries that can indirectly inflame a fat pad.
  • Avoid the Knife – I have seen very few fat pads that required surgery.  I strongly suggest that you avoid getting surgery on this issue until you have exhausted all of your conservative options and been diligent with your rehabilitation.

The Inside Scoop on ACL Tears

The evolution of sports has proved to be a fascinating and often amusing combination of creativity, science and hype.  From the lightest of high-tech equipment to the craziest of celebrations, the world of athletics is changing every year.

In the minds of those involved in sports, some aspects remain the same.  One of those constants is the impact of the three most feared letters in sports.  Those letters linger in the minds of the athletes, coaches, team owners and the fans themselves.  They all brace for the injury reports hoping not to hear those three dreadful letters.  They all know the significant downtime needed to recover from these alphabet season assassins.  No one talks about it but we all know that when these three letters “come to town”, this athlete’s season is over.


There they are.  Although not everyone knows what the three letters stand for, we all hope that our anterior cruciate ligaments remain strong and healthy for our entire lifetime.  An ACL or anterior cruciate ligament tear requires 6 to 9 months of intense rehab with no guarantee that the athlete will fully recover.  Those two simple facts justify the reason why we all fear a torn ACL.

ACL Tear Success Story

During the 2009 season Tom Brady, All-Pro quarterback for the New England Patriots, returned from an ACL tear that took place during the 2008 season.  The media and the fans spent most of the off-season pondering the questions:  “Can Tom fully recover from this surgery and will he be the same superstar player that he was before the injury?”

The wait is over and Tom has returned to his winning ways with two outstanding seasons since he was helped from the field in pain with an anterior cruciate ligament tear.  To put an exclamation point to his successful recovery, Tom was recently awarded the 2010-11 NFL Most Valuable Player Award.  It’s a true credit to Tom’s dedication to his profession and the Pat’s Head Athletic Trainer Jim Whalen and his staff’s efforts.

ACL and Its Role in Stabilizing Your Knee

The anterior cruciate ligament (ACL) is the key stabilizing ligament in the knee.  The ACL starts at the distal posterior lateral (back and outside) femur (thigh bone) and crosses the knee joint and attaches to the proximal anterior medial (upper front and inside) tibia (shin bone).  The ACL is one of the two internal knee cruciate ligaments that serve to stabilize the forward/backward shifting of the knee along with a considerable rotational controlling function to the most common injured joint in sports.

The ACL’s most important role is to keep the skin bone properly positioned under the thigh bone by applying a backwards force to the shin bone when the athlete is decelerating and changing directions.  With an ACL tear, this shifting and rotational instability are the most common complaints of someone who has a torn ACL.

Knowing the Truth about an ACL Tear

Now that the formal medical stuff is covered, let’s talk about the reality of the ACL and how it impacts you as an athlete.

Personally, I’ve been involved with the rehabilitation of close to eighty high-level athletes with ACL injuries.  Over 90% of the outcomes of these athletes who required ACL reconstruction surgery has been outstanding.  The average length of time for a full recovery and return to full and unlimited activity has been approximately 8 months.  Depending upon the time of year and the NFL schedule, a quicker recovery is easily possible.  I’ve worked with professional athletes who have returned to full speed in almost half that time. Sometimes that is not always a good thing and I’ll address that in upcoming articles.

With a more aggressive return to full activity, the risks of tendonitis, chronic swelling and articular cartilage complications are often increased as well.

To Brace or Not to Brace

Preventative bracing before you get hurt for high-risk players is a smart decision.  Knee braces may appear bulky but when a brace is fitted properly and the athlete becomes comfortable wearing the brace, few athletes will notice that they are wearing a brace.  Research clearly shows that a properly fitted knee brace will not limited agility movement or negatively affect a football player’s ability to perform.  Especially when the sport includes contact such as football and hockey, preventative knee bracing is the practice of the wise athlete who wants to stay active for a long, long time!

The various types of ACL tear surgeries and the rehabilitation of an ACL tear are topics for future MRF articles.  The objective for this article is to help you shed light on the sports medicine facts related to anterior cruciate ligament tears.

Telling the Athlete the Bad News

No athlete wants to hear a certified athletic trainer or doctor tell him/her “…your ACL is torn and your season is over.” I’ve personally been that person dozens of times who has looked into the eyes of elite professional athletes to give them that very same message.   Their tears say it all.

I was involved in the HBO show called Hard Knocks with the Jaguars in 2004.  During one of the episodes they aired a gripping live scene of me telling an emotional player on the practice field that he had a torn ACL and his season was over.  I love my players and moments like that never get any easier for me.

Questions to Ask About an ACL Tear

A smart professional athlete with a torn ACL who wants to safely return to his/her sport will ask his sports medicine specialist the following questions:

  1. How much of my ACL is torn?
  2. What medical grade, from 1 to 3, would you grade my instability for the following tests for both knees?
    1. Lachman Test
    2. Valgus Stress Test at 30 degrees.
    3. Anterior Drawer Tests
    4. Posterior Drawer Test
  3. If you are recommending an ACL reconstructive (ACLR) surgery, which type of surgery and why?
  4. Who do you recommend to coordinate my treatment?
  5. Do you recommend that I wear a brace for future athletic events?

Tips to Have a Successful Recovery from an ACL Tear

  1. No Special Pill – A torn ACL is what it is.  No one has invented any special ACL vitamins or specific exercise to make the ligament stronger.  Training properly and protective knee braces may prove to be your best medicine.
  2. Coaching Tip – The best prevention principle for ACL tears is to slowly progress with the fundamental basics of your sport to ensure that your lower extremity strength and flexibility are optimal.
  3. Where the Rubber Meets the Road – Proper shoe wear is crucial to avoid too little or too much traction.  Both of which would negatively impact the knee stability.
  4. Surgery? – If you suffer a torn ACL and your future plans include being active at a moderate to high level, reconstructive surgery is highly recommended.
  5. “Pop’s” Are Not Good – According to research, 60% of athletes who hear a “pop” in their knee have an ACL tear.