Am I Crazy To Feel Pain In My Knee When My Scans Are Normal?

My patient came in yesterday saying that his knee started clicking even though he didn't feel any pain with the clicking. There were occasional twinges of pain only occasionally. However, he was worried that his knee will get worse. After assessing his knee (which turned out fine) and reassuring him, I told him my own experiences.

After I had my third knee operation (within the space of a year), my right knee started feeling better. Of course I started training again as soon as the surgeon permitted. For a start, I ran almost exclusively on grass (since it was the softest surface I could find), often going multiple rounds, to ensure that I can get my mileage since I was hoping to compete again after my injuries.  

However, I was much more sensitive about my right knee, to the point of being paranoid about every sensation I felt in the knee. Each time I was on the bus or MRT and if someone came close to my right knee, I'd move away and glare at the person for coming too close to me. Does this sound like you?

Well, it turns out this action of pain sensitization is common across other painful knee disorders as well. In patients with knee osteoarthritis, pressure from placing your hands on the knees alone can trigger pain. The good news is that this sensitization for painful knees can be treated.

The following systematic review investigated 52 studies that studied pain sensitization across four different painful knee disorders. The authors found evidence of pain sensitization in people with knee osteoarthritis, patellofemoral pain and post meniscectomy patients. They however found conflicting evidence in patients with patella tendinopathy.

The researchers found that the extent of structural joint damage in the observed knee disorders does not correlate to the severity of symptoms. Hence, pain is not necessarily a 'signal' from a joint or area that is damaged.  Meaning x-rays or MRI results does not correlate with pain. Some patients have no 'damage' on x-ray/ MRI but have a lot of pain, while others with lots of damage on film may have no pain.

Many factors play a role to determine if a person will perceive a stimulus as painful or not since pain can be a complex experience that is associated with memories, belief and social context. Anxiety, depression, fear of movement, viewing their condition considerably worse than it actually is may also play a part.

It is suggested that repetitive stimulation may lead to subsequent sensitization of the nervous system. This include loading of the knee joint, ongoing inflammation at the knee joint or related tissues and altered biochemical markers. These factors contribute and maintain the pain sensitization in the knees.

In patients with knee osteoarthritis and patellofemoral joint pain, pain sensitization can be treated through exercise therapy, mobilization, pharmacological (yes, painkillers) and surgical intervention. Correct exercise is recommended for treatment of painful knees. There is the incorrect belief that exercise may harm the joint cartilage in patients with osteoarthritis.

If doctors, surgeons and physiotherapists focus less on x-rays/ MRI's and more on factors (including psychosocial factors mentioned above) relating to each patient's pain and disability, there will be more opportunities for collaboration and improved treatment outcomes.

Reference

De Oliveira Silva D, Rathleff MS, Petersen K et al (2019). Manifestations Of Pain Sensitization Across Different Painful Knee Disorders: A Systematic Review Including Meta-analysis And Metaregression. Pain Med. 20(2): 335-358. DOI: 10.1093/pm/pny177.

Scoff Not At Elastic Resistance Bands

Tan Howe Liang (pictured below) is still the strongest man I know. Yes, the same Tan Howe Liang that won Singapore's first ever medal at the 1960 Rome Olympics. He was a senior gym instructor at the gym at the old National Stadium and we often bumped into each other when I was still working there. I was always amazed when he told stories about his training days. Mind you, he could still squat with very heavy weights whenever I saw him train then. 

Silver at the Rome Olympics, SNOC picture

But don't fret if you don't have easy access to a gym or other fancy, expensive gym equipment. Other than your bodyweight, elastic resistance bands can be great for strengthening muscles too.

Not many of you may believe me if I said that training with elastic bands can be just as effective as training with weights for strengthening muscles.

The following systematic review and meta-analysis is possibly the first to compare the effects of strength training for strength gains with elastic tubes and bands versus conventional devices (dumbbells and weight machines).

The search identified 365 articles, of which eight studies were within the inclusion criteria comprising of 224 individuals between 15 to 88 years old. All subjects were performing regular strength training. In these groups were physically active individuals, athletes, individuals with coronary heart disease and moderate chronic obstructive pulmonary diseases.

Results of the meta-analysis showed that there is no superiority for both upper and lower limbs between training performed with elastic bands and training with free weights on strength gains. This was consistent across groups mentioned above and also when compared with a control group in the elderly, individuals with osteoarthritis and even fibromyalgia. 

The authors conclude that training with elastic bands is just as good as conventional resistance for promoting strength gains in different populations using diverse protocols. 

Having elastic bands at home to train with eliminates the need to travel to the gym and this may be more practical and a lot cheaper for certain people who may find it difficult to go to a gym. patients will have greater adherence to strengthening programs too. 

Personally I feel elastic bands are great for strengthening and correcting muscular imbalances. I still use them on a very regular basis. Especially after my accident.

Exercising with bands in my back brace in 2013

Do not let anyone tell you that you are wasting time if you are not using heavy weights and expensive equipment. Effective strength training can be achieved with body weight, free weights and especially elastic bands too.

We have managed to rehabilitate many national athletes back from injury and even avoid surgery in many cases using elastic bands to strengthen the injured areas. Especially in cases when a weight plate/ bar is initially too heavy and risk further injury and load to the person's joints.

Reference

Lopes JSS, Machado AF, Micheletti JK et al (2019). Effects Of Training With Elastic Resistance Versus Conventional Resistance On Muscular Strength: A Systematic Review and Meta-analysis. Sage Open Med. DOI: 10.1177/2050312119831116.

Don't neglect the legs

How To Increase Range Of Motion

All the kids posed for this picture

A typical comment from many of our patients is that they have been stretching all the time but their muscles still feel tight. 

Range of motion (ROM) is necessary as part of our health and important during sports performance. And static stretching is often prescribed to get better ROM gains. We know from previous research that static stretching is effective in improving our range of motion. 

However, the latest systematic review/ meta-analysis shows that strength training (ST) is just as effective as static stretching in getting improvements in ROM.

The researchers pooled data together and found eleven good quality studies comprising 452 participants to derive the following results.

Interventions lasted between 5 and 16 weeks while training frequency ranged from two to five times a week. Subjects included healthy sedentary subjects, subjects who already participate in ST subjects with fibromyalgia and subjects with chronic neck pain. There were also elderly adults who had difficulties in one of four tasks, transferring, bathing, walking and going to the toilet.

Both ST and static stretching groups showed significant improvement in ROM in seven of the studies. Differences between the groups were non significant. They did not find any significant differences in active and passive ROM for both ST and stretching. Dynamic stretching did not improve ROM in any of the groups.

You must be wondering how ST helps to improve ROM that is not statistically distinguishable from static stretching. The authors wrote that ST with an eccentric focus requires the muscles to produce forces in a lengthened position. This is what helps improve ROM. They also found that concentric strength training improves ROM when full range is required.

One study demonstrated significant reductions in pain associated with increases with strength, suggesting that decreased pain sensitivity may be another mechanism in which ST help increase ROM. Another mechanism may be an improved agonist-antagonist co-activation helping ROM gains.

The authors concluded that both ST and static stretching can improve ROM both in the short and long term suggesting that there are both neural and mechanical factors at work. Both ST and stretching can be prescribed to help improve ROM. If one does not respond or adhere well to a stretching program, they can switch to strength training instead.

What does that all mean you (if you did not understand the discussion above)? If you're looking to get an increase in your range of motion say in your knee joint, you can do eccentric strengthening exercises with some stairs at home. This previous article explains everything in a simple manner.

Just remember that static stretches are best done after exercise as just one bout of static stretching can slow you down as well as reduce your maximum strength.

Reference

Afonso J, Ramirez-Campillo R, Moscao J et al (2021). Strength Training Is As Effective As Stretching For Improving Range Of Motion: A Systematic Review And Meta-analysis. DOI: 10.31222.osf.io/2tdfm

Still Using Kinesio Tapes Even If Research Paper Says They Aren't Useful?

I saw two patients with badly sprained ankles this past week. The first patient was hobbling while shuffling on one foot. I definitely made both of them better. And I used Kinesio tape as part of my treatment to help with the swelling. So I was very surprised when a systematic review and meta-analysis found that Kinesio taping did not improve ankle function or performance in people with ankle injuries.

A systematic review meta analysis is a search aided by computer looking for all randomized and clinically controlled studies while meta analysis means using statistics to combine the data derived from a systematic review. So the published review is not an article to scoff at.

However, I looked through the supplementary material, and the tapes used were of course of different brands, different taping techniques were used, and it included different types of ankle injuries. Some of the taping were done on the calf muscles, some around the ankle joint, while others taped the Achilles tendon. In my opinion, that would not be fair as different brands of tape would have been compared, there were different conditions, and different techniques were implemented. Not to mention that not everyone would have learnt how to tape appropriately since there are different brands of tape. It would be similar to comparing apples to oranges.

Some of the studies

Note to self. Even if it's a systematic review or meta analysis, make sure you read everything and not just the title and the conclusion. 

As clinicians, we would never just use Kinesio tape or any tape alone just to treat a patient. For the two patients mentioned above, we would never get optimal results just using tape on them. We use our hands to assess, mobilize and/ or manipulate their ankles, while others may use needles, ice, tape or even modalities to treat their patients. Others might teach exercises to get their patients better.

Should we stop using Kinesio tapes? Definitely not. If we use them correctly, they definitely work. Have a look at another of my patient after I use the original Kinesio tapes for just five hours. Scroll down to see more evidence.

Surely you can see the outline of the Kinesio tape

Reference

Nunes GS, Feldkircher JM, Tessarin BM et al (2020). Kinesio Taping Does Not Improve Ankle Functional Or Performance In People With Or Without Ankle Injuries: Systematic Review And Meta-analysis. Clinc Rehabil. DOI: 10.1177/0269215520963846

In the picture below is a patient with a hamstring tear.

Here's how his hamstring looked like 3 days later in the picture below. I have lots more photos like these in my phone of my patients. Contact me if you're still skeptical, I'll show you all the photos from my phone if you like to see them. 

3 days later