Diagnosing meniscus tears: What’s the literature telling us now?

/9 Comments/in , , , , /by

Meniscal tears are commonly observed in an outpatient physical therapy setting. The ability of a PT to evaluate a patient’s knee and diagnose a meniscus tear can help guide the treatment plan for that patient. Having specific tests that can accurately and quickly pick up a meniscal tear are valuable.

Lots of test options but stick with the subjective

There are many theories, tests, and exam techniques that are reported in the literature. I definitely don’t know all of them but have been exposed to a bunch of common ones that I have found to be helpful.

Before I get bogged down with these tests and try to sound intelligent, I’d be remiss to not state the obvious… the subjective portion of the exam is by far the most important aspect and needs to be thoroughly utilized.  In many cases, ok maybe most cases, the client will tell you what’s going on…as long as you ask the questions correctly and listen to their responses.

This will most likely be a blog post at some point in the near future but as a collective profession known as medicine, we suck at listening and utilizing the information correctly. But I digress…

What Tests are out there?

There are many tests reported in the literature, commonly including:

  • McMurray’s
  • Apley’s compression
  • Joint line tenderness
  • Thessaly’s
  • End range flexion/extension overpressure

Unfortunately, the literature does not support using these tests to diagnose and may add to the fear avoidance a patient may exhibit after such a diagnosis. This systematic review and meta-analysis in the British Medical Journal stated:

“The results of this systematic review indicate that the accuracy of McMurray’s, Apley’s, JLT and Thessaly to diagnose meniscal tears remains poor. This conclusion must be taken with caution since frequent methodological design flaws exist within the included studies, most studies suffered from various biases, and between-study heterogeneity makes pooled data unreliable.”

To tell you the truth, I don’t even do the Apley’s compression test. I probably haven’t done the test since PT school sometime in 2001. Never saw a value, kinda like the Thessaly Test. Nice in theory but just not good enough when tried in a clinical setting. Unfortunately, most research and the associated methods are lacking so the results are pretty poor when trying to diagnose a meniscus tear.

Oh boy, now what do we do? Do we even need to diagnose the tear in the 1st place and add more fear to the patient’s hurting knee?

Even need to Diagnose Meniscus Tears?

I say yes… but with a caveat!

We must accurately diagnose and explain to the patient that many people have meniscal tears in their knee. The recent literature builds a strong case for a very good recovery without surgery. That’s right, surgery is often not needed for many people diagnosed with a meniscus tear.

This landmark paper in the New England Journal of Medicine (neighbors of Champion PT and Performance in Waltham, MA) really created waves when it was released in 2013. They stated that “outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.” Now, these people did have a diagnosis of knee arthritis as well, but so do many of the people we see on a daily basis.

Hopefully, many clinicians have changed their treatment algorithms and have opted for conservative treatment first.

Don’t get me wrong, surgery may be needed, especially for the people sustaining an acute meniscus tear.  But that may only be a small portion of the people presenting to us in the clinic.  In these people, I still say give it a bout of conservative treatment to calm the knee down, restore ROM and strength and see how they do. Maybe a 6 week PT course is all they need, you never know. I have definitely seen it work, no doubt!

What meniscus tests do I do?

With all of that being said, I still believe your clinical examination is ultra-important to help guide the treatment plan.

As usual, keep it simple and don’t over-search. It needs to be pretty straightforward and it often is. The exam NEEDS to match the clinical history…let me say that again….the exam NEEDS to match the clinical history.

The client is going to tell me their issue and I just need to make sure my tests and measures solidify my working theory. I promise you that if you ask the right questions the right way, then you will have that much more information to at your disposal.

So, my go-to tests are:

  1. Joint line palpation
  2. End range flexion/extension pain/locking
  3. McMurray’s (but often not very valuable)

…in that order. I’d say joint line palpation and end range of motion are my 2 most valuable tests. I still do the McMurray’s test to see if it can add to the story. It often gives me very little information so I don’t rely on it too much.

Many of you are going to ask why I didn’t even mention the Thessaly test. I see it talked about a lot on social media. I just don’t understand why we’d want to put our client in a weight-bearing position, slightly bend their knee, and have them twist on a painful knee.

Never mind the research telling us that the test is not very valid which goes completely against early research that said it was a valid test.

The more (tests) the Merrier

Maybe we need to combine this test with others to help improve our accuracy as this paper showed in 2009.

Either way, there seems to be a case to cluster tests to help us draw better conclusions, as was stated in this paper in 2006.  “Five positive findings on composite examination yielded a positive predictive value of 92.3%. Positive predictive values remained greater than 75% with composite scores of at least 3 in the absence of ACL and DJD pathologies.”

This paper nearly matches my thought process. Obtain a good history, assess the joint line for tenderness, then put the joint at end range flexion/extension. If the symptoms match, then we will OFTEN have a meniscus tear.

Keep in mind that the particular side of the meniscus tear may influence the ability to detect a pathology. Lateral meniscal tears may be easier to distinguish than medial meniscal tears if we’re talking about joint line tenderness alone and was even the case in this 2009 article too.

Final Word on Diagnosing Meniscus Tears

Meniscus tears are pretty prevalent in the outpatient setting. Rehab specialists, including PT’s and athletic trainers need to understand what tests are best to deploy. I’m sticking with my in-depth history, joint line tenderness, and painful end-range as my go-to cluster of tests.

I’m pretty sure it has done me well over the years…and the research seems to match my thoughts too.

Online Knee Seminar Course

We discuss this and much much more in my online knee course that I have with Mike Reinold. If interested, check it out at www.onlinekneeseminar.com and let me know what you think. We cover the anatomy, rehab prescription, ACL, knee replacements and patellofemoral issues both non-operative treatment and post-operative treatment. This is an awesome course if you’re interested in learning more about rehabilitating the knee joint.

 

 

 

The Challenges of ACL Rehab- It’s Never Easy!

/7 Comments/in , , /by

It seems like I always have someone on my schedule that is post-op ACL reconstruction (or anything post-op, for that matter!). Although I thoroughly enjoy progressing ACL rehab because this population is very motivated to get back to their sport or activity.

Knowing that it scares the bejeezus out of me at times!

There are so many variables, almost too numerous to count, that can affect the outcomes. Some are modifiable and some are not. I wanted to take a moment and step back from the boring “just need to get knee hyperextension posts” that I’ve done in the past and take a more holistic approach.

The Little Details

For those that know me, this may be a bit of a stretch. But I honestly think that the little details of the process are just as important as the big picture. It’s like anything else, you need to focus on the little details in order for the final goal to be achieved.  The same is true for ACL rehab but I feel like this is something that is missed by many and can make or break a good outcome (which we know can be hard to find).

There’s a reason why nearly 25% of ACL reconstruction patients have a retear event and need a revision surgery. I’m not saying this is the only reason but I will say the mental aspect of the process can help the athlete during he process, and that begins post-op day 1 when they present to me in the clinic!

So, what’s going through my mind when I’m rehabbing someone after an ACL reconstruction?

via GIPHY

Human Soul, Mind, Spirit

From the get go, I’m trying to figure out the psyche of the person in front of me. Look up the word psyche in the dictionary and it means ‘human soul, mind or spirit’. This exactly sums up what I’m trying to define early on.

The tricky part is connecting with this person (and their family) so they can gain the utmost trust in you. You see, their future is in your hands so there’s a lot of blind trust that is going on early in the rehab process. They’re in pain, clueless to the process and hoping you know what the heck you’re doing.

I know the basic principles of ACL rehabilitation- calm the knee down, get their ROM back and get them walking/running/jumping. There’s a lot more to do but I’m being wicked brief, I know. And it does go way beyond that, trust me! It’s much easier said than done for most.

Some Factors to Consider

Each case involves a gazillion variable to consider when I’m trying to outline a logical rehab program. Often it can consist of:

  • pre-op status
  • graft choice
  • meniscal involvement
  • other joint issues (bone bruise)
  • revision surgery
  • surgeon
  • pain status
  • previous surgery (if so, how did that go?)
  • ultimate goal
  • school status
  • home situation
  • good support
  • insurance (not as much for me due to OON)

It goes on and on, trust me! If you don’t believe me, then read this paper that I found AFTER writing this blog post. Basically sums up my nearly 15 years of experiences very well. Check it out, if you want… Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review.

So my mind races as I’m trying to figure this stuff out. I’m also trying to sound half educated as I progress their program and observe their response to each new exercise, cue and bad joke I make.

Some people freak out with anyone touching their knee cap while others just sit there and chat it up. If I see the freaked out person begin to squirm, I need to anticipate that the next few steps may equally be a challenge for the client. Knowing that (and assuming that), I go into show mode and make every attempt to turn the focus from their knee and each and every painful bend or leg raise, to something very obscure. To me, it’s all about mind games.

Mind Games

Wait, I’m playing mind games with my clients? You better believe it. This is basically how I test my clients’ response to me, my personality, my rehab style and how the next 6-9 months will go. If I see a stoic, scared response, then I need to step up my game and find a common connection, QUICKLY!

The rehab especially at the beginning, is not about their flexion ROM or their swelling control but it’s about them gaining trust in me as their PT. Do they want to come to PT and put their complete future in my hands? Do they trust that I know what I’m doing and can lead them to their eventual goals? I hope so and it starts from that 1st joke I make or that 1st outcome study that I have to quote.

I don’t know which one will win them over but I have to be ready to offer either (or both). The last thing I need to happen is to have them show up for the next session and completely lose faith. If for some reason their swelling is up or their pain is worse (which happens in nearly 100% of the cases that I see) then I need to be able to talk them off the ledge and let them understand that it’s completely normal.

N=1 mindset

They have no comparisons to make. They also think their experience is worse than all others and that no one else has had swelling 2 weeks out of surgery. Or that all people can walk without crutches 7 days out of surgery, but they still have their crutches 14 days out. They have an n=1 mind and have no other experiences to compare it to but I have a database of cases to rummage through in my head.

Hope my mind can come up with a similar situation, make it real for them and get them back to reality…and get their faith back!

Trust me, no surgery is a guaranteed success and we know ACL surgery is a long ways a way from being perfect but we can truly make a difference by our confidence and personality.

I’ve made a career of this and can’t stress it enough!

Like the post? We have more to offer…

I hit upon all of this a little bit more in my online knee course that I have with Mike Reinold. If you’re interested in learning more about how we treat the knee, then go to our all online knee course that covers all topics including post-op ACL, TKA, PF surgeries. Also non-op treatment of the knee and a great overview of treatment progressions. The discussion boards are a great way to interact with other professionals and chat about the course and your own personal cases/experiences. Check it out soon!

Welcome to LennyMacrina.com!

/0 Comments/in , , , , /by

Welcome to my new website, LennyMacrina.com

I hope to share some of my insight into the field of physical therapy, rehabilitation, and performance.

My goal is very simple: Take a huge step back from the complexities of all of the information on the web and make it more intelligible and applicable to your daily practice.

I plan on periodically reviewing the newest orthopaedic and sports medicine research that is cutting edge. But at the same instance, I want to convey some of the classics that still remain pertinent in my physical therapy practice today. I truly believe that rehabilitation can take a very simplistic approach and still get tremendous outcomes for your patients.

The logo was created to combine my initials with the depiction of someone performing an overhead movement. You see, I treat many overhead athletes, particularly baseball players, and this has helped shape my career into what it is today. But this is a small piece of what I do on a daily basis.

My passion lies in returning people to their highest function after most orthopaedic injuries. My goal is to build upon my daily experiences and report what I believe is the most succinct PT out there.

I have been practicing therapy physical since 2003 and have made it a point to keep things simple, for both mine and my patient’s well being.

Let’s be candid…they’re not looking for complicated solutions that are confusing. They want a simplistic approach that is understandable and easily adapted into their lives.

I will help to navigate the PT intricacies that are currently out there and make rehab a lot more straightforward and fun too!

Again, welcome to my website…I hope you enjoy the new journey I’m about to undertake.

If you want to learn more and stay up to date with my posts, you can join my team and get my tips to regaining knee extension after surgery AND a promo code to save money off of a Medbridge Education subscription:

Thanks!!

2 Tips to Improve Your Post-op Rehabilitation Outcomes

/2 Comments/in , , , , /by

I’ve treated hundreds, if not thousands of postoperative patients in my career. I’m always surprised to hear from others how they progress their patients. When I first got into physical therapy, I was all about protocols. I didn’t have much experience.

I would literally follow it word for word and do my best to match the person to that little piece of paper. Little did I know that I was gravely mistaking! This post will hopefully improve your post-op rehabilitation outcomes.

As I became more comfortable, let’s say 1-2 years in, I got cocky and progressed people based off of their presentation. I almost wanted to show off to THEM that they were doing better than the protocol. This made them want to go faster through the process and all was good…kinda.

Wake up call

Then I began to see people get sore, stiff and regress. So much for being the guru of post-op rehabilitation. I had to reassess my approach.

Fortunately, we had a steady flow of post-op patients at our disposal in Birmingham, AL.  Each day, week and month I would get 1, 2 3, 4 new post-op patients a day. I would look for the protocol and fight the temptation to progress too quickly.

Trial and Error

Through experience and chatting with Kevin Wilk (and Mike until he left for the Red Sox in 2005), I began to take a more conservative approach, especially during the 1st 6 weeks after surgery. I realized the protocols were intentionally broken down into phases of rehab for a reason.

Those initial weeks after surgery are all about calming the joint down. Whether it is a knee replacement, an ACL or a rotator cuff repair, they all cause pain and swelling. We truly need to address each circumstance on a case-by-case basis.

There are always the outliers, and you know who they are. The guy that walks in with no crutches 1 day out of surgery and says “I’m here for PT, let’s do this”.

Then you have the guy who gets rolled into PT with a wheelchair and can’t do anything because he’s puking, constipated and cranky. Completely different approaches to rehab for these 2 folks.

The cocky guys need to be held back a bit because you know he’s going to keep pushing it and make his knee swollen. The guy in a ton of pain needs reassurance that you will take good care of him. You just need him to be a big part of the process and get over his fear.  You’re almost playing mind games on a daily basis and need to adjust to each individual’s personalities.

Regression to the Mean

The majority of people present somewhere in the middle- can function but in some pain. They know they need to do the PT and you know they need more pain meds, quickly!!

They’ll unwillingly participate in the early process because the doc said so but often not like you for it. Then they’ll thank you later on when they’re moving well and feeling great!

So with that, what 2 things do I think people need to consider when rehabbing a post-op patient?

via GIPHY

The 2 most important factors to progress a post-op patient

  1. Don’t overdo it- less is more
  2. End feel assessment

Don’t Over Do It- Less is More

As tempting as it is to progress someone quickly through the rehab process, fight the temptation in the early phase of PT. That 1st 4-6 weeks after surgery are critical to regaining homeostasis in the joint.

Dr. Scott Dye talks about this perspective in regards to patients that have patellofemoral pain or anterior knee pain: The pathophysiology of patellofemoral pain: a tissue homeostasis perspective. His research has really shaped how I treat and progress people.

The quicker you can get the joint to ‘calm down’, the better they’ll be able to progress. I utilize range of motion and some modalities such as ice. I can’t overstate it enough that we can make or break an outcome in the first 4-6 weeks.

There’s no need to crank on someone’s knee because the protocol says you must have a certain ROM by a certain time. I’ve found great success with simple passive range of motion seated at the edge of the table at least 2x each visit.

It’s a lot more of a comfortable position for the patient than the dreaded prone ROM. Keep in mind, this puts a stretch through the quadriceps. It becomes an extra barrier that you must get through in order to achieve your motion goals. Plus, the patient feels like a WWE wrestler and may reflexively tighten up in anticipation of pain.

Each patient would get 5-10 minutes of PROM at the beginning and end of each session. No matter how busy I was or how many people were staring at me ‘waiting for their ‘next exercise, they all got 2 ROM sessions.

They looked forward to the range of motion and patiently watched me go from table to table (this was back a couple years ago) knowing they were next up.

This hands-on interaction is very important to develop the PT-patient relationship. This will hopefully blossom in the coming weeks and months as the patient progresses through the process.

I wrote about this previously for our Champion PT blog and I’m sticking to it Power of Touch. I truly believe that this is often missing and a huge complaint from people who end up coming to Champion PT in pursuit of reclaiming their functional goals.

End-feel Assessment

In my opinion, end feel is the single most important aspect of rehab progression a therapist needs to consider.  Being able to assess end-feel may be one of those skills that come with experience.

If a post-op rotator cuff is having painful guarding, then the therapist must adjust the process. Maybe it’s the frequency of the HEP, or the actual HEP content, or the patient’s pain control. There are so many factors to consider but the fun part is adjusting and reassessing. It’s a constant game of give and take!!

Commonly, the PT has to dive deeper into the patient’s life to figure out why this end-feel has changed. Often times a past medical history of diabetes can cause increased stiffness.

Also, you’ll find that they stop taking their pain meds because ‘they make me feel funny’ or ‘I have to drive to PT, don’t I?’ Everyone’s response to a surgery is different and it is very important to understand what could affect a patient’s presentation, as complicated as it may seem.

Ultimately, the goal is to get a nice capsular-like end-feel that has the potential to slowly stretch out as you progress the intensity of the ROM.

Assess and adjust each visit

I usually have them increase the frequency of their home exercises or adjust the daily frequency to easy bouts of motion 3-4 times per day. Most people think doing it 1x per day (if you’re lucky) is all they need so they can get credit for doing their ‘homework.’

I’m not afraid to lay the guilt-trip on them and remind them that their outcomes will only be as good as the effort they put into their rehab.  This usually gets the point across and we can progress on with the rehab process. This will allow us to quickly gain back the ROM and usually make that end-point not so hard or painful.

Conversely, a Bankart repair in a young athlete should be progressed at a slow speed so the tissue is not ‘stretched’ out. This often results in a nice, capsular endpoint. Should they begin to feel tight, don’t panic! Young adults, say up to 25-30 years old, very rarely get too tight.

Let the process happen, progress appropriately. The excessive ROM gains may cause the patient to have further issues down the road if their instability returns.

Take Home Point…

As much as we think we know about rehab progression after surgery, the only true feedback is from the patient.  Listen to them, monitor their response to the rehab and you will be well on your way to getting superb outcomes.