Ask A Physio: If My Knee Hurts, Why Are You Looking At My Hip?

As physios, we see bodies differently than most people. This is a good thing - you want your body specialist to see beyond the obvious! But what is often obvious to us is a mystery to others.

You may have heard one of us talking about the “kinetic chain”, a concept borrowed from the engineering world and repackaged for health care. The basic idea is the movement in one joint will create and affect the movement of the next joint, and so on. If your pain is in your elbow, we would be doing you a disservice if we didn’t also look at your wrist, shoulder, neck and upper back as well.

The kinetic chain is a big reason why one-size-fits-all approaches don’t work.

We don’t tell you to simply Google your symptoms and treat yourself. One person’s treatment approach for sciatica will be completely different than the next. My grandma’s elbow pain often has a completely different cause than my daughter’s elbow pain, even if they are in the same spot. Looking at the body as a whole is imperative to proper treatment.

A Case Study in Kinetic Chains: Runner’s Knee

A great example of this is someone with runner’s knee, also known as patellofemoral syndrome (PFPS). To understand how PFPS develops, an understanding of knee biomechanics is crucial.

The patella (aka the kneecap) rides in a groove on the femur at the front of the knee and is critical for proper knee movement. The patella acts as the attachment point for ALL your quads - think of how much muscle that is! To stretch out your leg, your quads first contract and pull on the patella. The force is transmitted through the patellar tendon (or ligament, depending on who you read) and pulls on the tibia, the main bone of your lower leg. Without the patella, the amount of force required for the quads to unbend the knee is simply too great. The patella acts as a fulcrum, giving the quads a mechanical advantage.

Need a visual? Check out this fantastic video:

Muscle imbalance is one of the main causes of PFPS. The patella is held in its position by a fine balance of muscle and connective tissue. Muscles that attach to the patella directly - we’re talking about the quads here - are obviously a main focus. But there’s many more muscles to consider. Consider these two examples:

1. One cause of PFPS is tight calf muscles. The gastrocnemius, one of the calf muscles, attaches at the back of the leg above the knee and can have a great effect on knee function. When these muscles are too tight, people tend to walk more in a pronated foot position (see photo on the right), increasing the forces at the back of the knee and adding to the compression and irritation of tissues around the patella.

2. The IT band runs the length of the thigh on the outside of the leg and attaches to the outside of the patella. The gluteus maximus, the large muscle in your buttock that controls hip extension, attaches into the top of the IT band. If the glutes aren’t doing their job, you can experience knee pain even if it isn’t the source of the problem.

We don’t expect you to know the ins and outs of this - that’s our job! When you come in for a little rehab, don’t be surprised when we start checking out your other joints - you may be surprised by what we find.

If you need to see a physiotherapist, give us a call at (778) 630-8800, email us or book online. We would love to work with you!

Ask A Physio - Why Is My Joint Making That Noise?

Joints can make peculiar noises. They can snap, pop, crack, grind, grate, click and clunk. The proper name for these noises is crepitus. Many people become understandably nervous about this, especially if it is a “new noise.” Although crepitus is generally unwelcome, it is not as scary as you think.

When people come to physiotherapy for joint noises they generally have similar concerns. They want to know what is causing the noise and how to stop it.

The general perception people have is their joint must now be degenerated and “bone on bone.” People take this as a sign of aging and extreme arthritis and become scared for their joints. They do not want to unnecessarily wear the joints down.

So what do they do? They avoid the noise! They stop climbing stairs and getting down on the ground to play with their kids and grandkids. They tell me they have stopped doing the movement that initiates the noise in order to “preserve” the joint or avoid “making it worse.”

It seems logical right? If I rotate my neck to the right and it snaps or clicks I may feel unsettled by that and want to avoid that feeling. I hear constantly from my clients that they don’t swim anymore because their shoulder clicks when they bring their arm over their head, or they no longer squat because their knees click on the way down.

My response to these clients is always the same - I ask:

“Does it hurt when it clicks?” 

Because here is the thing. There are many causes for crepitus. And yes, some of them require treatment, but many do not! Before anything else, we need to figure out what is causing the clicking and decide if we have to be concerned about it or not.

Most snaps, crackles and pops are pain free and totally harmless.

If you do not experience pain when your joint makes a noise you don’t have to worry about it and can continue with business as usual. 

Common Causes of Crepitus

• The most common culprit is gas bubbles popping within the joint (think cracking knuckles). When the joint is stretched and released a gas bubble is formed and then pops, causing the noise.

• The crepitus could also be a tendon or ligament snapping over a bony structure. In this case there might be pain, but it has nothing to do with the joint and a whole lot more with the muscle. This would require an assessment, range of motion and strength exercises from a physiotherapist.  

• Arthritis. Yes, sometimes crepitus is because of arthritis.  But please know that the clicking or grinding does not mean you are doing “extra damage” to the joint. If you have arthritis a primary goal is to maintain range of motion. Working through your available range should be a priority rather than being avoided. If your knees are a little extra talkative but you have no pain and no decrease in function I would encourage you to continue with your activities. There are so many benefits to exercise (cardiovascular, mental, general strength, etc.) and it would be a shame to throw all of those away because of a misconception that you had about your click-y knee. 

Speaking of Knees…

Most noisy joints I see people for happen to be knees. If you’re wondering what that noise is and what’s causing it, here’s our top three noises people complain of and what they could mean (please be aware that this is a gross generalization but is meant to give you a decent idea):

1. Snapping, cracking or clicking “outside” of your knee: This is often due to the patellofemoral joint. The patella (aka kneecap) lives in a little groove that it is supposed to glide up and down in when your knee bends and straightens. If the patella is not properly aligned (maybe from an injury or muscle imbalance) it can make noise as you crouch, use the stairs, or just with bending and straightening your knee. If these noises are inconsistent, occasional, and pain-free I would not worry. If they are constant and painful then seeing a physiotherapist can be very helpful.

2. Snapping, cracking, or clicking “inside of your knee”: This is often your meniscus, which is the cartilage shock absorber within the joint. With injury or degeneration over time this structure can tear, rip or peel back. In some cases a flap of cartilage can get caught out of place and this will often cause the joint to “lock.” If you have a click within your knee that causes a sharp pain and sometimes causes the joint to lock it is likely a meniscus problem and you should visit a physiotherapist. 

3. Creaking or grinding: This is most often associated with arthritis. If it is early stages and you are noticing some pain it is definitely worth a trip to your neighbourhood physiotherapist as an arthritis management plan can significantly impact the maintenance of range of motion, strength and function in the joint. (Side note - since exercise is one of the best ways to manage osteoarthritis, we offer the GLA:D Program!)

Again, if you experience these noises and there is no pain then I would not be too worried about it. But if you have these noises and they are painful it is probably worth coming in to see a physiotherapist. We will assess your joint range of motion, muscle strength and balance, and see if we can identify the cause for the click so we can come up with a treatment plan that will work for you. 

If the noise bothers you enough that you cannot stop worrying about, come on in. If nothing else we can confirm to you that it is harmless and you can have peace of mind moving forward with your activities. We are always happy to help! 

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If you have any questions or would like to schedule an assessment please call Ladner Village Physiotherapy at 778-630-8800, email us or book online at ladnervillagephysio.com 

Knee Arthritis 101: The Basics

Arthritis is a big topic and there is no way I could cover it all so today I am just going to cover some of the basics to help you understand what is going on with your body.

First of all, it’s important to note that there are many types of arthritis. The two most common types are:

1. Degenerative arthritis, also known as osteoarthritis (OA for short)

2. Inflammatory arthritis such as rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis

Today we will be discussing osteoarthritis of the knee.

Here are the top five things you absolutely need to know about arthritis:

1. Arthritis is not a catastrophic diagnosis. You can continue to thrive and lead an active lifestyle with an arthritic knee and it’s not the end of the world. 

2. Exercise is your best friend. Say this with me, three more times!

3. X-Ray findings are not proportionate to functionality or pain levels. Someone who describes “occasional stiffness” in their knee might have a “severe” x-ray, while a “mild” x-ray might belong to someone who describes unbearable pain that keeps them awake at night. X-rays do not give the whole picture!

4. Most knee pain from arthritis is from structures around the joint, and that pain can settle. It’s not the cartilage nor is it the outer compact bone causing the pain in your knee. 

5. There are things you can do to slow the progression and maximize your function.

Let me say this loud and clear:

Maintaining an active lifestyle is one of the best things you can do if you have arthritis!

Let’s look at a classic scenario.

Meet Stacy. She’s 62 and tweaks her knee while out for a run. That weekend she goes away for a vacation with her family. They play golf, tennis, and even go kayaking! Now her knee is quite sore and even swollen. Stacy decides to rest for a few weeks figuring she just over-did it while away. But it’s still swollen two weeks later.

She goes to her doctor, who orders an x-ray. The x-ray uses technical terms like “osteophytes” and “joint space narrowing”. She is told she has arthritis in her knee. That night Stacy has company for dinner and a friend, let’s call him Gary, said he has the same thing! Gary says his knee is “bone on bone” (and demonstrates grinding with his knuckles together while making an awful scraping noise) because all his cartilage has “worn away” and that his friend Steve had to have a knee replacement and limped for months.

Now Stacy is devastated. She doesn’t want arthritis and she certainly doesn’t want a knee replacement. She feels doomed. 

What happens next? 

Option A: Stacy is scared and wants to protect her knee. So Stacy stops playing tennis and stops golfing, she hires someone to do her gardening and doesn’t even really walk the dog anymore because if running hurts than walking probably isn’t great either right? (I want you to know it hurts me deep down inside to type that). But when Stacy suddenly stops exercise and spends many hours per day sitting her knee gets stiffer and her muscles get weaker.

In her mind this has confirmed her worst fears that her knee is in awful shape (look how quickly it’s deteriorating!) and tries to protect it further by resting even more. This cycle of inactivity can is bad news bears. 

It also doesn’t have to be this way. 

Option B: Stacy doesn’t worry about Gary or his friend Steve because she knows nothing about their situations and her doctor didn’t mention surgery at all. Stacy’s knee is still a bit stiff and sore so she modifies her activities for a few weeks. Runs on the dyke become walks with the dog and she tries pickleball with a few friends instead of tennis. To her delight the knee pain improves! Her muscles have stayed strong from her modified activities and she still enjoyed her time out and about. Now Stacy is in a position to gradually rebuild and reintroduce activities she enjoys as she is able. (This scenario is a lot better if you ask me). 

I will say it again: exercise is your best friend.

You are not wearing out the joint further by exercising. It is the most effective treatment for early and moderate knee OA (not to mention other health benefits). Exercise helps you maintain range of motion and strength. It is a lot easier to maintain strength and range than build it back up again after it has been lost.

Also, do not underestimate the benefits of exercise for the rest of your body. Many people who get an arthritis diagnosis self-impose activity restrictions and become more sedentary. This can have detrimental health benefits including increased risk of high cholesterol, heart disease and diabetes. Further, muscle weakness and joint stiffness can be contributing risk factors to falls. People with osteoarthritis experience 30% more falls than those without.

There is no use going too hard all day every day and being in extreme pain just for the sake of it but don’t stop all activity completely. You have to find a middle ground between activities that are challenging vs. aggravating (which is easier said than done). A physiotherapist can give you recommendations on which activities can be modified and help you figure out strength and range of motion exercises that are appropriate for you specifically. 

Ok, so I hope you get it by now. If you have arthritis you should exercise. But let’s keep going, shall we? Let’s discuss why this diagnosis doesn’t have to be all doom and gloom.

What causes the pain in knee arthritis?

The cartilage that degenerates has no nerve endings nor does the hard compact bone beneath it. So they cannot be the source of the pain. So which structure is actually responsible? 

The three main causes of knee pain associated with arthritis are:

1. Periosteum - the thin lining of tissue around the bone, it has nerve endings and supplies blood to the bone. If it tears it will hurt. 

2. Synovitis - Synovium is the connective tissue lining of the joint itself. It can become inflamed and very painful. Synovitis can feel like joint tenderness or pain, swelling, and nodules (hard lumps). 

3. Bone edema - This is more common in women who have underlying osteopenia or osteoporosis since the bones are already weaker. When stress on the bone increases, as is the case with arthritis, the deeper central layer of the bone can become swollen, which feels like a deep and intense ache. 

Remember:

• Not everyone with OA has these issues.

• If you do experience pain from these structures it will likely settle down over a few weeks or months and your knee pain and function will return back to baseline. It’s not forever.

• Like I mentioned above, the severity of an x-ray does not correlate with pain or disability.

• Treatment should not be based off of the x-ray.

• Do not let a bad x-ray be the reason you stop your favourite activity.

• Do not let a bad x-ray make you afraid of feel doomed.

• Please please please do not get surgery just because the x-ray is bad especially if everything else is great! (Disclaimer: obviously I am a physiotherapist and not your surgeon, so I’m not the one making calls on surgery. But if a surgeon is pushing for you to get surgery and you feel completely fine I would be asking why they feel it is necessary. They might have an excellent reason - that’s cool, making calls in grey areas is what they do all day every day so their opinion should be considered - I just don’t want you getting surgery because a friend of a friend had their knee done so you figure you might as well join the club). 

The Arthritis Foundation provides a very general list of things you can do to slow down the arthritis progression and keep you are healthy and active as possible. These include:

• Maintain a Healthy Weight: Excess weight worsens OA. Combine healthy eating with regular exercise to maintain a healthy weight.

• Control Blood Sugar: Many people have diabetes and OA. Having high glucose levels can make cartilage stiffer and more likely to break down. Having diabetes causes inflammation, which also weakens cartilage.

• Maintain Range of Motion: Movement is medicine for joints. Make a habit of putting your joints through their full range of motion, but only up to the point where it doesn’t cause more pain. Gentle stretching, raising and lowering legs from a standing or seated position, daily walks and hobbies such as gardening can help.  Listen to your body and never push too hard.

• Protect Joints: Make sure to warm up and cool down when doing exercise. If you play sports, protects joints with the right gear. Use your largest, strongest joints for lifting, pushing, pulling and carrying. Watch your step to prevent falls. Balance rest and activity throughout the day.  

• Relax: Find ways to reduce or avoid stress through meditation, listening to music, connecting with friends and family, doing fun activities, and finding ways to relax and recharge.

• Choose a healthy lifestyle: Eating healthy food, not smoking, drinking in moderation and getting good sleep will help you to feel your best.

I really hope you feel slightly better about an arthritis diagnosis. This is something that can be managed.

If you have any questions about your arthritis or are looking for some specific suggestions to help your daily life please contact the clinic via email or phone us at ( 778) 630-8800. We look forward to meeting you!

Runner's Knee

Patellofemoral Syndrome is a classic injury that causes pain around your kneecap. It is also something that I myself am dealing with right now. Also known as “Runner’s Knee,” it’s usually a dull achy pain that is worse with going up and down stairs, running, jumping and squatting. It can also get cranky when you sit with your knees bent for a prolonged period of time such as watching a movie. It is very common and the cause can be multifactorial, so I am hoping that this post will give you a basic understanding of what may be going on with your knee.

Inside The Knee

First, let’s go over the anatomy of your knee shall we? Your knee is actually more than one joint! There is the big joint between your femur (thigh bone) and your tibia (shin bone), but there is also a joint between your femur and your patella (kneecap). In fact, your patella sits in a little groove at the base of the femur and when you bend or straighten your knee the patella glides up and down it’s little groove.

This is all fun and games until it starts to hurt. There are generally a few contributing factors for patellofemoral pain, I have listed a few of the more common culprits below:

• Overuse: Activities that require high levels of repetitive stress on your joints are more likely to cause Patellofemoral Syndrome. All of that running and jumping can cause irritation underneath the kneecap as it rubs up and down over the femur.

• Alignment Issues between your hips, knees and ankles: If your hip muscles are weak then your form can suffer. Have you ever done a squat and noticed that your knee kind of collapsed into the midline rather than staying aligned and straight? That is hard on your knee. People with that technique error have a higher incidence of Patellofemoral Syndrome. If you can’t control your knee when you are standing still you are most likely not in control when you are running or jumping or stepping off of a curb either. If you do something incorrectly for about 30-60 minutes straight & 3-5 times per week, that can result in a LOT of misdirected force.

• Women are more prone than men to patellofemoral injury: It is speculated that this is because of wider hips (so the knees more naturally bias inwards). Strengthening your outer hip muscles (such as the gluteus medius) can help prevent or correct the inward collapse of your knee.

• Muscle imbalances: There are four separate parts to your quadriceps (the big muscles on the front of your thigh). If the outer muscle is stronger than the inner muscle (which is often is) then the patella gets tugged toward the strong side. This also can cause it to track improperly in its little groove.

• Inappropriate footwear:  If you overpronate or have flat feet you could likely benefit from a shoe that has cushion and support rather than a minimalist shoe.

• Being overweight: When you are going down stairs your knee experiences three times your body weight in forces and pressure. If you weigh 200lbs then each knee is taking 600lbs. The forces are even higher (4-5 times your body weight) when you squat to tie a shoelace or pick something up off of the floor.

• An injury: Falling on your knee or dislocating a kneecap can increase chances of patellofemoral pain.

What Can I Do About It?

Because patellofemoral pain is multifactorial, there is generally not one simple answer that will give you a quick fix (bummer, I know). For this reason, I strongly suggest making an appointment with a physiotherapist so they can properly assess your personal situation. Treatment will involve the following:

• Addressing your risk factors and will likely include strengthening your quads and your hips

• Suggestions for altering your current training program will also be made

• Tape may also be helpful to alleviate painful symptoms temporarily

FAQ: Is biking instead of running a good option?

The is by far the most common question I get from runners with knee pain who are looking to maintain their cardio and activity levels while they rehab their knees.

My answer? Maybe, but not necessarily.

I know that is an extremely vague answer but here is why. Although biking has less overall force going through your knees compared to running, it is still a repetitive activity that involves a lot of knee bending and straightening. If your seat is too low or too far forward this can make your knee bend too much with each revolution, putting unnecessary excess force through the knee. Also, having the gear of your bike too high can cause increased force through the knee. For some people it is a viable alternative to running while others find that biking is still too aggravating. It really needs to be assessed on a case-by-case basis.

For those who are curious this is how I ended up with my sore knees…

I popped both of my children (40lbs each) into a bike trailer and proceeded to ride for 20+km while hauling them behind me. It was my first time riding my bike in several months, my seat was too low, the load was too high, and the volume was too much. Should I have known better? Probably. Was it a fun day? Absolutely. Will I rehab my knees back up to running the distances I want and get back to squats with resistance? Of course! Will it take some time and patience……. Also yes.

Good luck running out there everybody!

As always, if you find yourself battling a running injury of any kind please call us at 778-630-8800 to make an appointment with one of our skilled physiotherapists so we can get you back on track as soon as possible.