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Anterior knee pain
The main compartments of the knee are where many of the serious knee injuries occur such as meniscus (cartilage) tear, ligament damage etc. However a high percentage of knee pain comes from the anterior structures of the knee including the patella (kneecap), the patella tendon and various other structures. Anterior knee pain is usually worse on stairs (especially descending) and bad for squatting or kneeling.
Adolescent knee pain
In children and teenagers, especially sporty ones, there are some common problems of the anterior knee. So called patellofemoral pain syndrome is pain associated with abnormal stresses on the knee. Often there is no obvious structural damage seen on MRI. Causes may include misalignment of the patella, flat feet, hypermobility and lack of muscle strength. In cases where there is softening of the cartilage at the back of the patella this is known as chondromalacia patellae. Another common problem in the young is Osgood-Schlatter disease in which the pull of the quadriceps muscle causes multiple small fractures where the tendon attaches to the bone. It is self-limiting but often leaves the patient with life long bony lumps just below the knee caps.
Adult anterior knee pain
A common problem in middle and older age is osteoarthritis at the back of the kneecap. The pain is often hard to localise and may be accompanied by crepitus, clicking and swelling. Bursitis is also common. A bursa is a fluid filled sac which can become inflamed in conditions with antiquated names such as house maid’s knee and parson’s knee. Tendinopathy of the patella tendon is another overuse syndrome which is also known as jumper’s knee. More recently, new pain syndromes have been identified. Fat pad impingement occurs when this highly pain sensitive structure gets pinched between kneecap and thigh bone. Plica syndrome is when an extension of the synovial membrane of the knee becomes pinched in a similar way.
Diagnosis and Treatment
Anterior knee pain is a complex subject and the experienced practitioner will still often require the back up of MRI scanning to support a clinical examination. The majority of the problems described will respond to careful management, hands-on treatment, exercises and correction of misalignment. More severe cases may involve referral to podiatrists, surgeons etc.
The Stiff Neck
The fact that the expression “a pain in the neck” is used to describe anything that’s unpleasant or disagreeable says a lot about problems of the cervical spine. Symptoms can include severe pain, immobility, headache, arm pain and even dizziness and visual disturbance in some cases.
Causes of stiff neck
A stiff neck which comes on suddenly may result from muscle injury, muscle spasm, facet joint dysfunction or disc injury. More long term pain can be due to degenerative changes in the spine associated with aging e.g. spondylosis. Occasionally diseases such as meningitis or chronic conditions like polymyalgia rheumatica and fibromyalgia syndrome may be responsible.
As a general rule if the pain goes on for more than a week, it is sensible to let a qualified practitioner assess it.
A good clinical examination including a neurological work up should help to reach a diagnosis. If there are any so called “red flags” evident then further investigation may be required. I recently saw a patient who had a very painful neck and arm which initially looked treatable. However on neurological testing it became apparent from the findings that he had spinal cord compression. I didn’t treat him but immediately referred him for an MRI scan and subsequently he had spinal surgery to remove a disc which would gradually have taken away the use of his legs. I hasten to add that this was very unusual and I have only seen two such cases in 25 years in practice.
A lot of cases of “wry neck” sort themselves out in a few days. Even in cases where there is a lot of wear and tear hands on treatment is very often helpful. In the modern world there is a move away from overly vigorous neck manipulation towards more gentle techniques. In most of these cases I use soft tissue work and/or acupuncture combined with steady mobilization and specific exercises to produce the desired result.
Cycling and your neck
The sporting success of Chris Hoy, Bradley Wiggins and Victoria Pendleton has given cycling in the UK a massive boost. People of all ages are getting back on bikes and enjoying the sport. This has spawned the amusing acronym “MAMIL” which for the uninitiated stands for “Middle Aged Man in Lycra”.
For many the appeal of the classic road bike far outweighs that johnny-come-lately sport of mountain biking. However the riding position with dropped handlebars is far from ideal from an anatomical point of view, especially in the more mature rider. On a long ride, the lumbar spine is held flexed for hours at a time, leading to increased compression of the lumbar discs. Conversely the neck is held in significant hyperextension which reduces the space available for the nerve roots as they exit the spine. With tyres at 120 psi and no suspension there is the added hazard of shock and vibration being transmitted through to the rider.
The aging neck
Most pro cyclists will retire aged 35 years or younger whereas recreational cyclists are often much older than this when they take it up. Even at 30 years of age the discs between the vertebrae may be beginning to dehydrate (spondylosis) and the facet joints will gradually become arthritic. With the boom in road cycling I have seen many cases of riders suffering neck and shoulder pain, often with pins and needles or numbness in the hands,
What can be done?
If you love cycling but have associated symptoms the good news is that you may not necessarily have to give up. Most manufacturers produce comfort orientated versions of their road bikes. The geometry of the frame is different to give a more upright riding position. Additionally components can be changed to further enhance the effect. Stem risers are available and a shorter handlebar stem will bring the rider more upright too. The saddle is also on a slider which can be brought forward. Additionally some hands on treatment and/or acupuncture may be enough to free the troublesome joints. As a cyclist who has suffered with this problem myself, I am very sympathetic to fellow sufferers.
The Problem Hip
The first recorded attempt at hip replacement occurred in Germany in 1891 using ivory to replace bone. However the first clinically successful replacements were performed in the 1950s and 60s by Professor John Charnley in Manchester. Technology has come on enormously since then and now 160,000 replacements are done every year in England and Wales with success rates running at around 96%.
This is a very common problem usually affecting older people. In my experience some cases are long term (chronic) in which the hip will gradually stiffen up but then grumbles on for years with only minimal deterioration and often manifests as episodes of pain. Others come on more acutely and deteriorate rapidly with a downhill path that leads to the surgeon’s door within months. As an Osteopath it often surprises people that I am very much in favour of hip replacement surgery. I think there is a strong case to have the surgery early as this avoids prolonged periods of limping which damages the spine and other joints which cannot be replaced.
Greater trochanteric pain syndrome
Of course many pains around the hip area are not caused by osteoarthritis and do not require surgery. I see huge numbers of cases of greater trochanteric pain syndrome which used to be called trochanteric bursitis. Most of the pain is in the buttock and down the outer side of the thigh (osteoarthritis of the hip is commonly felt in the groin and front of the thigh). Currently this is thought to relate to a dysfunction of the tendon of one of the buttock muscles.
Acetabular labrum tear
Since the advent of MRI scanning this has become a much more common diagnosis. The condition is caused by a tear in the lining of the socket of the hip and shows up as a “catching hip”. Specialist MRI is used for diagnosis and surgical repair usually fixes the problem.
Leg pain, numbness, tingling and weakness
Sciatica is a hugely common problem. It often starts as low back pain which then radiates through the buttock, back of the thigh and into the calf. The foot may become numb or tingle. Severe cases can lead to foot drop due to weakness in the muscles of the leg. Famous sufferers are as diverse as footballer Thierry Henry and playwright William Shakespeare
The vast majority of cases are mechanical in origin. In other words there is no disease process as such, but the nerve roots have become compressed by the surrounding tissues. Commonly a prolapsed (“slipped”) disc will do this, although the facet joints can also produce a similar effect if inflamed and spinal instability (spondylolisthesis) is another cause. Occasionally the same sort of symptoms can be caused by a muscle in the buttock (piriformis) tightening around the sciatic nerve itself-the so called “piriformis syndrome”. Men sometimes get sciatica if they habitually drive cars with firm seats with a thick wallet in their back pocket which squashes the nerve.
In many cases a clinical diagnosis is all that is necessary i.e. no special tests are required. The tell tale signs are the history, a reduction of ability to lift the leg up straight and maybe a loss of muscle power or ankle reflex. Plain X-rays are relatively unhelpful but the MRI scan will often reveal the cause of the pressure on the nerve roots.
As ever it is best to start with simple treatments first. Hands on massage, manipulation and acupuncture will be helpful in many cases. Where possible, mobility should be maintained and as pain subsides core stability exercises should be encouraged to reduce the risk of recurrence. Cases that don’t respond to this may go for spinal injection (nerve root block or epidural) and a very small percentage may require surgery to remove the offending disc or stabilize the spine.
“Pins and Needles”
What is it?
Medically “pins and needles” is known as paraesthesia and we’ve all experienced the prickling, tingling, numbing or burning feelings that occur after accidentally sleeping on an arm or sitting on a hard toilet seat for too long. The nerve is temporarily squashed but normality returns within a minute or two of moving. Some pins and needles are however longer lasting and this phenomenon often merits further investigation.
What causes long term pins and needles?
Many cases of long term pins and needles that I see are also caused by mechanical nerve compression but the cause of the compression may not disappear so easily. For example pins and needles in the hand may be coming from the wrist (carpal tunnel syndrome), forearm (pronator teres syndrome), elbow (ulnar nerve injury), or neck (spondylosis/osteoarthritis). The particular fingers affected often give a good clue as to the precise whereabouts of the nerve compression. However it is important to be aware of the many other potential causes of paraesthesia.
Sometimes the nerve itself may become diseased (neuropathy), often as a consequence of other medical problems. For example, diabetes can commonly lead to pins and needles especially if it isn’t controlled properly, as can Vitamin B12 deficiency, malnutrition, chronic alcohol abuse, chemotherapy, hyperventilation, toxin exposure and neurological disease. Occasionally arterial disease may show up as pins and needles too.
What can be done?
As ever accurate diagnosis is the key. The vast majority of cases that I see in practice have a simple mechanical explanation and can be treated using the time honoured hands on techniques to “free up” the nerve. However in severe cases or when a medical problem is suspected I liaise with the GP to achieve the best result for the patient.