What better time to write about ‘why knees hurt’ than a day and a half after knee surgery as I sit here jealously watching joggers bounce along the sea wall on a gorgeous Vancouver day. I am hiding out from my three little kids today to give my meniscus a chance to calm down. It was a relatively minor surgery, but my knee is very swollen none the less. I can add this one to my list of injuries and operations that help me experience empathy for my clients instead of sympathy. Unfortunately, over the years, I have been way too good at market research for my work as a physiotherapist! This article will hopefully help prevent you from sitting where I am today, or at very least know when to take the plunge and have surgery on that persistent, nagging knee pain.
A little bit of basic anatomy will give you a better context to understand your knees and this article.
Your knees are simply big hinge joints that are built to flex and extend. They are held together by four major ligaments called your MCL, LCL, ACL & PCL. Sandwiched in the middle of the joints are two C-shaped cartilage cups called your medial and lateral meniscus; these act as both shock absorbers and stabilizers. On the front of the joints your knee caps function to protect your knees and act as levers to help strengthen the pull of your thigh muscles.
knee muscular anatomy
When I assess people complaining of knee pain, my first goal is to determine if one of the above mentioned structures is physically damaged or is something simply disturbing the mechanics of the joint, creating friction and causing pain. I would say that 90 percent of the time it is the latter.
Your shoulder is brilliantly designed to allow your arm to reach, grab, throw, push, pull, etc., etc., etc., but I’m sure if you have experienced shoulder pain in your lifetime you might argue that there are some flaws in the blueprints. I have seen shoulder pain bring some of the toughest guys to their knees and frozen shoulders put women’s lives on hold for 1-2 years. I personally, have dislocated my shoulder multiple times and eventually had surgery on it in 2001. My shoulders and I are not friends, but I have learned how to keep my enemies close and under control.
Knowing what I know about biomechanics and anatomy, I would still have to support the idea that the shoulder is extraordinarily designed, but I would make the case that it should come with a detailed instruction manual of how to actually use it properly. Your shoulder is a complex ball-in-socket joint that’s function is intimately tied to the posture and alignment of your ribcage and thoracic spine. ‘Normal’ movement in your shoulder requires the ball to spin in the socket, the shoulder blade to slide over your ribcage and your torso to remain in a relatively stable position; a problem in any or all of these factors will lead to dysfunction and eventually pain in your shoulder.
It is not hard to determine what structure in your shoulder may be damaged and hurting, but it can be harder to understand why you damaged anything in the first place. Sometimes why is easy. You may have tried tackling a two hundred pound Kiwi rugby player determined to run through you and your shoulder lost the battle like mine did, but most of the time ‘why’ is more complex than you would like. Shoulder pain usually involves a combination of factors that over time lead to the insidious onset of pain.
If you have ever had your back ‘go out’ on you, you will appreciate the following post and may just learn something about how to fix your nagging back issue. Back pain can take many forms and is hands down the most common issue that brings people in to physiotherapy.
“It hurts when I bend over to brush my teeth”
“I can only sit for 10 minutes before I have to move”
“Walking triggers a pain deep in my butt”
“I bent forward and couldn’t get back up”
It happens to the best of us. I have seen lazy, overweight people with back pain; insanely fit personal trainers with back pain, elite athletes, new moms, desk jockeys and I have personally suffered from it on occasion. You can have the strongest core in the world and still be susceptible to hurting yourself or experiencing pain in or around your back. In this article I have outlined the most important factors as to WHY backs hurt because back pain requires an explanation of what is going wrong as opposed to a diagnosis of a condition. You can also watch the video Why Low Backs Hurt.
Step 1 to Understanding:
Things happen for a reason. You don’t just catch back pain like you can catch a cold. It usually is related to something that you have done or are continuing to do poorly, like stand, sit, walk, breathe, bend or lift. An accident or acute injury can set pain into motion, but how you deal with the injury, pain and mobility after the fact is the important part. You are a product of everything you have done or been through up to this point and if that product has left you with chronic back pain then something has to change. You may need someone to loosen something for you, you may need to learn to move more efficiently, you may need to lose weight, or may even need surgery.
This brief YouTube video captures what physical and cognitive therapists wish all of their clients understood. To say that the experience of pain is in your brain is not the same as saying it’s all in your head. The sensitization of your nervous system is a real thing and a significant component of persistent, chronic pain. Watch the video for an illustrated explanation.
For a Canadian resource have a look at these videos below. They are a longer and more in depth presentation of the topic: Overcome Pain and Live Well Again Part 1 Overcome Pain and Live Well Again Part 2 Overcome Pain and Live Well Again Part 3
The best book on this topic is Explain Pain by David Butler and Lorimer Moseley
I treat a lot of the top Seniors level (35+) tennis players in British Columbia, many of whom compete in the national and world championships every year. These are not professional athletes, but very active adults with full time jobs that work hard and play harder. The combination of work + age + sport inevitably results in aches, pains and unfortunately injuries.
The top five things that tend to bring tennis players into the physio for servicing are:
1. Tennis Elbow
2. Rotator Cuff Impingement
3. Knee Pain
4. Torn Calf/Achilles
5. Low Back Pain
Below I will briefly touch on some of the principles you should follow in dealing with these injuries as they relate to tennis, age and work.
Lateral elbow pain does not necessarily follow the “if it hurts, ice it” rule. Nine times out of ten the root cause of lateral elbow pain stems from your neck and the back of your shoulder. It is usually an irritation of your C6 nerve root in your neck and the radial nerve in your arm…that being said, if your elbow is hot, red and swollen, go ahead and ice it, but don’t expect just ice and rest to fix the problem. Hands down the best way to fix tennis elbow is to go for IMS acupuncture to calm down the nerve irritation. Once the arm feels better have a physio teach you how to move more efficiently so your swing doesn’t create too much strain on your neck and shoulder. You may also need a tennis pro to adjust your technique and/or your racquet.
Suggested articles: Elbow Pain: why it can last so long & how to fix it properly Why Elbows Hurt
Rotator Cuff Impingement
Most shoulder pains are some form of an impingement (which implies a pinching of one or more of the tendons of your rotator cuff).
Here is a great TED talk by neuroscientist Lorimer Moseley about how our bodies’ experience pain. He is a funny and engaging speaker as he demonstrates how your brain can create, perceive and amplify pain. Notice the title of his talk!
Lorimer Moseley teamed up with David Butler a number of years ago to create this book called explain pain. It is a great resource for understanding your body as it relates to pain.
I grew up as a long and lanky kid playing every sport that was available to me. I loved team sports and got deeply into soccer and rugby. If I knew then, what I know now about my body, I would have stuck to volleyball and swimming. Don’t get me wrong, I thoroughly enjoyed the sports I played, but I routinely felt like I had been hit by a truck afterwards and still have two wonky shoulders to show for it.
I am what you would call hypermobile. That means that the soft tissues that help hold my skeleton and joints together are relatively looser and more flexible than the average person. It is a genetic trait that a large number of people have, but most have no concept that the way they are put together is not “normal,” or the same way everyone else is put together. It does go both ways, some people would be deemed hypomobile, implying that their spine and joints are relatively stiffer than the average population.
My estimation of the incidence of pain and injury as they correlate to genetic joint mobility:
Being loose jointed may sound like a positive genetic attribute, but let me assure you it can pose a lot of problems for people. Gravity can become particularly annoying when you are hypermobile, especially if you have a job that requires you to sit or stand still for any length of time. We are the only creatures on Earth that are built to stand and walk upright on two feet- that biomechanical feat requires a skeleton that provides both structural stability to vertically stack your body, and functional mobility so that you can move freely. Hypermobile people are built to move and have to work a lot harder than everyone else to stack everything up and stay still. Read More
Tennis elbow and golfer’s elbow are the typical names given to elbow pain; tennis being pain on the outside of the elbow and golf being pain on the inside of the elbow. The more technical term is lateral epicondylitis which simply indicates tendonitis in a specific location. Putting a name to elbow pain doesn’t really help you get rid of it, but understanding why it happens and where it comes from will.
Tendons are the tough bit of tissue that attaches muscle to bones, and tendonitis literally means inflammation of the tendon. This term can be misleading when it comes to elbow pain because many people have pain that persists for months in the complete absence of swelling and inflammation. That is because elbow pain is not just an overuse injury. It happens when the muscles being used are in an irritable state due to a nerve irritation stemming from your neck and shoulder. Nerves are the electrical wiring of muscles and when they are irritated, it doesn’t take much to overuse the muscles and tendons that they innervate, resulting in inflammation and pain. If you rest the joint, the body will heal the inflammation, but the nerve irritation may persist and thus the inflammation and pain will return as soon as you attempt to use your arm again.
Radial nerve extends from base of neck, through shoulder, down to elbow
Muscles are comprised of a whole bunch of stringy tissue that can stretch and contract. The muscle should have a certain amount of resting tone in it, i.e. at rest it is slightly contracted, not flaccid or extremely tense; this is dictated by the input of the nerve. If the nerve is irritated as it extends from the spine, or anywhere in the periphery it will result in an altered signal getting to the muscle. Read More
– If you have low back pain that means your “core is weak” and a “core strengthening” program would help you.
Sometimes the above statement is true, but just as often it is absolutely not. There is not a direct correlation between low back pain and core strength. In fact, many people that have incredibly strong “core” muscles suffer from regular low back pain, which is because strength is only one element of having good posture, alignment and movement. It is the overall muscle balance in your body and your relative ability at controlling movement that is the true sign of good core stability and a preventative factor to low back pain.
Many, many, many people are stiff as hell, many of these people have low back pain and many of these people think that their planks, crunches and strength program will make them better. Well I am here to tell you that there is a good chance it will make them worse. Granted some will get better, but the most efficient way to improve your strength, flexibility, alignment and pain is to first learn a bit about your body type before pursuing any type of new program.
From a very young age, as you were learning to function in the vertical position, you have been developing strategies for how your body deals with gravity. You picked up some by watching how your parents stand, walk and move. You picked up others from your gymnastics classes and soccer practices when you were six. The hard fall you had on your butt 20 years ago likely altered things and that car accident 5 years ago probably created some compensations. Long story short, your posture, flexibility, movement and breathing patterns are a cumulative product of everything you have done up until today. Read More
Your deep inner unit consists of four muscle groups that should work subconsciously to stabilize your pelvis, spine and ribcage under low load postures and movements like standing, bending and walking. Accidents, injuries and developed muscle imbalances can cause portions of the deep inner unit to not do their job properly; the result can be pain and/or compensation from other muscle groups to try and brace to hold everything together. Some of your other stronger muscles can make up for the deep inner unit, but this usually leads to too much compression on the joints and immobility in the area. You function best when your body can use the little muscles to do light stuff and the bigger muscles to do harder stuff. You can get away with purely building strength in your outer sling muscles, but you will be prone to breaking down more often if the little guys aren’t firing.
The four muscle groups are your pelvic floor, transverse abdominus, multifidus and diaphragm. They form the bottom, front, back and top of your abdominal and pelvic cavity. Recruitment of these muscles is more about thinking than doing. They provide gentle compression to stabilize so your bigger muscles can move you. I don’t like to re-invent the wheel so the best resource to learn about recruitment of these muscles can be found on Diane Lee’s website here: Training the deep muscles of the core
Although becoming aware of these muscles and consciously training them can be very important, they are supposed to act subconsciously and if you align your body in the proper way they will likely fire on their own. I find it is the compensation strategies people choose in their posture that are inhibiting these deep inner unit muscles and that helping a person unlearn bracing strategies helps to fire up the deep inner unit more than trying to focus on them alone. Read More