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Monday, March 10, 2014
Should Rehab Exercise Hurt?
I went to an orthopedic surgeon last month because my GP said I had a torn meniscus in my right knee. The surgeon took x-rays, which were clean and showed no arthritis, and an MRI of my right knee, which came up clean as well, no torn meniscus. Since I am a mid-distance runner and had been training hard over the past few months, the doctor said I probably overdid it, and he gave me a list of rehab exercises to do. He said I should also immediately start a walking routine and upgrade to a walk-jog program in two weeks. Icing, Naproxen, stretching daily, follow-up with surgeon in 4 weeks.I did the quadriceps strengthening exercises and the stretching exercises he prescribed, and I also started walking, but the pain in my knees - especially the right knee - got worse and worse, and I also developed hip stiffness, pain in my lower back, and now my feet are starting to go numb. The pain is primarily in the inner knee joint and the back of my knee. It gets so bad I am unable to straighten my legs fully when standing, though I am able to straighten them when lying on the floor or seated doing rehab exercises.The teardrop muscle of my quadriceps gets sore from time to time and hurts when I bend my knee and press my fingers into the muscle next to the knee joint. My lower quadriceps muscles are constantly feeling fatigued because of my inability to stand up straight, and this puts a lot of tension on the muscles. I also occasionally get stabs of pain both above and below my right kneecap - a sharp, stabbing pain that makes me cry out and grab my knee. Needless to say, it is scary and has me deeply concerned. Are these pains symptoms of tendonitis?I feel as if the rehab exercises my orthopedic doctor instructed me to do are making me worse, not better. I do not understand the value of strengthening the quadriceps, hamstrings, calf muscles, etc. if it is going to cause substantial pain in the knee joints. Should rehab exercises cause so much pain? Do you feel two cortisone shots (one for each knee) will help and allow me to continue doing the rehab exercises? I am highly motivated and in favor of doing rehab exercises but I simply cannot continue if I am going to be in so much pain and discomfort. I am in favor of getting cortisone shots and continuing rehab.I have a follow-up appointment with my doctor in another week and will discuss my situation with him, but I would love to hear your opinion on rehabilitation exercises and also the value of cortisone shots. Thank you.
Although a high quality MRI scan is very good at detecting meniscal tears, sensitivity is not 100% (that is, you could have a symptomatic meniscus tear despite a "normal" MRI scan - which would then be a "false negative").
However, the fact you have symptoms in both knees makes a meniscus tear less likely as the cause for your pain, since it would be unusual to have bilateral meniscus tears which have become symptomatic at the same time.
Although a diagnosis cannot be made over the Internet, bilateral knee pain symptoms, in the setting of overuse, are often due to patellofemoral pain, which means pain involving or around the kneecap. Patellofemoral pain typically causes pain in the front part of the knee(s), but at times causes pain along the inner (medial) side of the knee (which can be mistakenly attributed to a medial meniscus tear), and less commonly, can even cause pain in the back of the knee. (For further information, a search on this website using the term "patellofemoral" currently yields 48 results).
It is difficult to gain strength by performing strengthening exercises which are painful, since joint pain, for example, will have an inhibitory effect upon muscle activation and muscle tone. For most knee problems, quadriceps strengthening exercises are typically recommended. For patellofemoral pain, in addition to pain-free quadriceps strengthening exercises (and often stretching exercises for the quadriceps and hamstrings), strengthening exercises targeting the hip muscles and sometimes also the ankle muscles may be necessary as well, depending on results from your physical examination.
Cortisone (steroid) knee injections will reduce knee pain when inflammation is present, which may or may not be the case for you. There are many alternative and additional treatment options, depending on what your diagnosis actually is. Hopefully your follow-up appointment with your physician and further reading on your part, will be helpful.
In the meantime, it is important for you to maintain or improve your overall level of aerobic conditioning by a regular program of cross-training, using any form of sustained whole-body exercise (such as stationary cycling/spinning, aquatic exercise, etc.) which doesn't aggravate your knee pain.
Brian L Bowyer, MD
Clinical Associate Professor
Physical Medicine & Rehabilitation
College of Medicine
The Ohio State University