FAQ Category: Knee

It sounds like he had a medial patellofemoral ligament (MPFL) reconstructive surgery. The surgeon uses graft tissue (usually a tendon from a donor bank or from some other area of the patient’s own body) to reattach the ligament. The goal is to reduce pain, stabilize the patellofemoral joint (where the knee cap rides up and down over the thigh bone), and prevent patellar dislocation.

There are many different ways to accomplish this and no one way known to have the best results for everyone. Researchers are currently looking at results reported for different graft choices, graft tension, and fixation methods (ways to attach the graft in place). This type of information will help surgeons find better ways to stabilize the knee and prevent a disabling condition for these young athletes.

Complications are reportedly fairly high following this particular procedure. In a recent review of studies, researchers found a complication rate of 26.1 per cent. This figure represents an overall complication rate from all the studies combined. The procedure was a success but the complication rate was considered significant. Rates actually ranged from zero (no complications) up to 85 per cent.

Taking a closer look at the specific complications, there were patellar fractures, patellar instability, loss of knee motion, pain, infection, and other wound complications. The most common revision surgeries were to remove bothersome hardware or manipulate (move) stiff knees to restore motion. It is believed that tensioning the graft too tightly may be the cause of the stiff knees. With more study to identify the best ways to reconstruct damaged MPFLs, this complication may be prevented in the future.

Finding ways to measure change in patients’ level of satisfaction, function, stiffness, disability, or other symptoms like pain and swelling is a challenge. Each diagnosis has specific differences. Even within one single diagnostic category (like knee osteoarthritis), there can be a range from acute to chronic, mild-to-severe, and symptomatic or asymptomatic (X-ray findings of arthritis but no symptoms).

Current standard of practice is to use the Western Ontario and McMaster Universities Osteoarthritis Index, commonly referred to as WOMAC. This is a reliable and valid measure of self-reported change for patients with hip or knee osteoarthritis. As you have seen from using it, the survey has 24 questions that are broken into three categories.

The first category measures pain during activities, the second evaluates change in stiffness, and the third looks at physical function. Activities such as standing up from a sitting position, walking, climbing up and down stairs, or putting socks on are included.

Studies consistently show that the WOMAC is responsive to change in patients with hip or osteoarthritis and that’s why it is used most often.

There are two other tests that have also been shown to be responsive (i.e., measures change before and after treatment). These include the Knee Outcome Survey (KOS) and the Lower Extremity Functional Scale (LEFS). The KOS assesses limitations caused by pain, swelling, and joint instability. The LEFS looks more at the degree-of-difficulty someone has performing specific tasks during activities of daily living.

The best way to get a handle on which one to use in your practice might be to use all three with specific groups of patients. See which one is easiest and least time consuming, while still giving you the information you are looking for.

In today’s evidence-based medicine, patient satisfaction is important, but so are other measurable outcomes based on change in symptoms or physical function. In a recent study by physical therapists, three tools were used to measure change in knee function. Results were compared by looking at the reliability and responsiveness of these three tools. All patients (168 total) in the study had a diagnosis of knee osteoarthritis.

The three tools compared included the most widely used scale that you mentioned: the Western Ontario and McMaster Universities Osteoarthritis Index or WOMAC. The other two patient surveys were the Knee Outcome Survey (KOS) and the Lower Extremity Functional Scale (LEFS).

Each one of these self-report instruments measures function in slightly different ways. For example, the WOMAC looks at pain during activities, stiffness after prolonged positions, and ability to perform movements like standing up from a sitting position, dressing self, going up and down stairs, and walking. The KOS assesses limitations caused by pain, swelling, and joint instability. The LEFS looks more at the degree-of-difficulty someone has performing specific tasks during activities of daily living.

Everyone in the study completed all three surveys before and after treatment. Treatment consisted of a physical therapy program of leg strengthening, stretching, balance, and agility exercises. The exercise program took place twice a week for six to eight weeks. Patients were followed for up to one-year at regular intervals (two months, six months, 12 months).

The results showed that to measure change in knee function, all three tools are reliable and responsive. Therapists using these self-reported instruments may get slightly different information but all three surveys will reflect change and can therefore be used to obtain outcome measures. There was a trend observed with all three tools: the longer the follow-up, the less reliable the tools were to measure patients’ responsiveness to treatment.

There may be some specific reasons for this trend. For example, as people improve there may be less change occurring making it more difficult to measure change with these particular questions. There may also be differences in patient osteoarthritis that contribute to reduced observations of change. For example, someone with acute arthritis versus someone with a chronic condition may not respond to treatment in the same way. More studies are needed to examine these factors more closely but for now you can be assured that using any of these three tools for patients with knee osteoarthritis may help you measure results.

These was a recent article published by a group of physical therapists who took the time to review all the studies published on exercise and knee osteoarthritis (OA) up through the year 2011. Exercise recommendations from that study for people with knee osteoarthritis include the following:

Lifestyle, including diet and exercise is still and always the best bet for working with degenerative joint changes that produce this condition we call osteoarthritis. These are things you have some control over — we call them modifiable risk factors.

Being inactive and/or overweight are often the first modifiable risk factors patients are directed to pay attention to and make changes. But it sounds like this is one area you have already focused on as a couple.

That brings us to the issue of knee alignment and muscle function. It’s a well-known fact that uneven load on the knee joint can wear down the cartilage on one side, resulting in osteoarthritis. What causes this kind of problem? Sometimes it is just the way a person is put together. If the bones of the leg don’t line up exactly evenly and in the middle, problems can develop.

Muscle impairments can also contribute to the start or worsening of knee osteoarthritis. What do we mean by “impairments”? Muscle impairment includes problems with muscle activation (muscle fibers contracting), muscle atrophy (wasting away), and force production.

Force production refers to the ability of the nervous system to fully contract all the muscle fibers. A fully activated muscle must have the ability to fire up all the motor units at a rate that produces optimal muscle function. Failure of any of these factors to function with the correct timing and force can result in knee muscle weakness and the progression of OA.

That brings us back to your original question: what can you do now? The best approach is to work with your orthopedic surgeon and a physical therapist to address all the potential issues (alignment, muscle function). There may be some simple surgical interventions to restore good alignment. Early treatment can often prevent (or slow down) worsening of the problem.

Your wife may need a specific exercise program. The therapist will prescribe a program that addresses any particular anatomic or motor function problems she may have that are contributing to the degenerative process. Sticking with the program is important to get the best results. If you are already in the habit of exercising, that’s half the battle for most people!

Older age (50 or older) and being overweight are two key risk factors for medial meniscal tears. Other potential risk factors studied have included patient age, sex, findings on X-rays, activity level, occupation, and a history of previous injuries.

Research has provided us evidence that it’s mostly intrinsic factors (not lifestyle) that increase the risk of the type of meniscus tears that you mentioned (medial meniscus posterior root tears</i or MMPRTs).

The four intrinsic risk factors with the greatest impact on MMPRTs appear to be: 1) increased age (older than 50 years of age), 2) female sex, 3) being overweight (higher BMI), and 4) lower level of sports activity. The mechanical angle of the knee (as seen on X-rays) was one anatomic feature that also increased the risk of MMPRTs.

These risks are important because we know that meniscal tears can leave a person at risk for early knee osteoarthritis. Knowing what the risk factors are for the tears might help us find better ways to prevent these injuries. And that would mean reducing the risk of early degenerative knee osteoarthritis.

There isn't anything you can do to lower your age but if you are overweight, a weight loss program that includes increased activity would be the first place to start. That would address two of the four risk factors. Angle of the knee may be modified if needed by using orthotics (special inserts made for inside the shoes). A prescribed program of exercise, posture, and alignment supervised by a physical therapist may also be helpful.

Activities associated with an positions such as squatting and the Lotus position have been considered potential risk factors for medial meniscal tears of the knee. As you now know, in assuming the Lotus position, the feet are placed on the opposing thighs. It is a posture commonly used for meditation in the Hindu Yoga and Buddhist traditions. The position is said to resemble a lotus flower to encourage proper meditative breathing.

But it is an extreme position for some people — especially those who did not grow up doing this type of movement and who are starting yoga later in life. The posterior root of the medial meniscus describes the back corner of the meniscus. And specifically on the side of the knee closest to the other knee. This type of meniscal tear results in a piece of cartilage that is separated into two pieces but only attached to the bone (tibia) at one end.

Because of its location, the stress placed on this part of the meniscus could conceivably be greatest when the knee is in the extreme positions of flexion required in the squatting position. The same goes for the flexion and rotation required by the Lotus position.

But as it turns out, a recent study was done comparing patients with medial meniscus posterior root tears (MMPRTs) with patients who had other types of meniscal tears. The patients were all Asian from Korea and had been using these positions all their lives. The results showed that these two positions did not increase the risk for MMPRTs.

What they found was that it’s mostly intrinsic factors (not lifestyle) that make a difference. The four intrinsic risk factors with the greatest impact on MMPRTs included: increased age (older than 50 years of age), female sex, being overweight (higher BMI), and lower level of sports activity. The mechanical angle of the knee (as seen on X-rays) was one anatomic feature that also increased the risk of MMPRTs.

The fact that positions often used by Oriental people did not contribute to the posterior corner tears of the medial meniscus may be because the knee structure adapt to these positions when used from an early age on. We do not know yet if this type of injury occurs more often in those individuals like you who begin using these positions later in life.

Defects or lesions of the articular cartilage (lining the surface of the knee joint) can be treated in several different ways. One of those methods that has become quite popular is a technique called autologous chondrocyte implantation or ACI.

The surgeon uses the patient’s own chondrocytes (cartilage cells) harvested from another area of the knee. Usually the donor cells come from an area that has little weight put on it.

Once the donor cells have been harvested, they are taken to a lab where more cells can be produced from the graft. When ready, the cells are placed in the defect (hole) and then covered over with a patch. The patch can be made of bone (the outer layer of bone called the periosteum) or it can be made of collagen. Collagen is the basic protein building block that makes up most soft tissue.

Collagen patches are quickly becoming more popular than periosteal (bone) patches for one reason. Bone patches tend to hypertrophy (grow too much bone). Patients end up having a second (revision) surgery after the first transplantation. The surgeon goes back in and debrides (shaves) away the excess bone. This type of complication is much less likely with the ACI-collagen patches.

The ACI-collagen patch cost about $1000 more (per patient) but there are far fewer cases of second surgeries needed for graft hypertrophy or graft failure with the collagen material.

Studies have reported a rate of graft hypertrophy as being around 25 per cent for patients receiving an ACI-periosteal patch. This compares with a 10 per cent rate linked with the ACI-collagen patch.

That information added to the fact that a second surgery costs about $8300 more suggests the ACI-collagen patch may be worth the added investment up front to avoid future costs associated with failure or hypertrophy. And that $8300 figure is based on current costs for hospital, surgeon, and anesthesiologist. Surgeries that take place several years down the road will likely cost more.

A recent study from the University of Nebraska comparing the use of ACI-collagen patches with ACI-periosteal patches showed that the ACI-collagen patch for significant knee articular cartilage lesions is cost-effective. There is already evidence to show that half of all ACI procedures are already being done with the collagen product instead of the periosteum.

Significant (deep and wide) injury to the cartilage lining the surface of the knee joint can be treated with a transplantation of cartilage cells called chondrocytes. The transplanted chondrocytes usually come from the patient’s own knee — from another area that has little weight put on it. The procedure is called an autologous chondrocyte implantation or ACI.

Once the donor cells have been harvested, they are taken to a lab where more cells can be produced from the graft. When ready, the cells are placed in the defect (hole) and then covered over with a patch. The patch can be made of bone (the outer layer of bone called the periosteum) or it can be made of collagen. Collagen is the basic protein building block that makes up most soft tissue.

Collagen patches are available in the United States and approved for use by the Food and Drug Administration (FDA) but not for knee cartilage repairs. Right now they are only approved for rotator cuff repairs, tendon reconstruction surgery, and dental procedures. When used as a patch for autologous chondrocyte implantation, it is considered an “off-label” use. As you have found out, European surgeons have unlimited approved use of the ACI-collagen patches for chondral repair.

Studies have shown that about half of all ACI procedures done by U.S. surgeons are already being done with the collagen product instead of the periosteum. This off-label use of ACI-collagen patch for significant knee articular cartilage lesions has been proven cost-effective. It’s probably only a matter of time before enough studies show its value and the FDA approves it for this particular use.

Degenerative knee osteoarthritis (OA) can be treated with physical therapy, medications, or surgery when appropriate. Whenever possible, surgical treatment is done arthroscopically for knee OA, which is less invasive than with open incision surgery. The specific procedure studied is called debridement.

The surgeon shaves away any uneven areas of the joint surface and smoothes any jagged edges in the cartilage. If there are any loose fragments in the joint, these are removed as well. Joint swelling, stiffness, and pain are believed to improve with this treatment but the effect of debridement in the actual degenerative process itself is unknown.

What we do know from studies so far is that knee arthroscopic debridement reduces pain and improves knee function for up to five years or more. Now with the results of a new study, we have another piece of information about results using arthroscopic debridement based on the severity of the OA.

All participants in the study were adults 45 years old or older with a diagnosis of Grade II or Grade III osteoarthritis of the knee (on a scale from I to IV). These grades are based on X-ray findings of severity of the condition. Some, but not all, of the patients were overweight, which may be a contributing factor to the development of OA.

Using arthroscopic debridement, the surgeon removed loose fragments of tissue (e.g., bone spur, pieces of meniscus). A saline solution was used to flush any remaining debris from the joint.

Everyone was followed at regular intervals for two years. Patients with grade II (less severe) OA did just fine with this type of treatment. But patients with grade II (more severe) OA did not fare as well. X-rays showed ongoing joint degeneration within the year following the debridement procedure in the patients with grade III OA. These patients did experience improvements in symptoms (less stiffness, less pain, more motion) but they were unable to maintain the results.

Arthroscopic debridement is considered a stop-gap measure. It seems to yield the best results when the disease has just started and the joint surface is not damaged or worn unevenly. Treatment of this kind is also more likely to be successful when the patient is not overweight. Patients who exercise and strengthen the legs seem to do better, too.

Most experts recommend the patient follow a program of exercise and use arthroscopic debridement to buy them some time before needing a knee replacement. The decision to have surgery is an individual one — usually considered after at least a six-month program of conservative care is unsuccessful in reducing pain or improving function.

Diathermy was indeed a very popular modality used by physical therapists 30 years ago. But with the invention of new technology and new techniques, it eventually fell out of favor. But there has been renewed interest in this form of deep heat just in the last five years or so.

Diathermy uses high-frequency energy to move ions, distort molecules, and create eddy currents. The result is heat that reaches deep into the soft tissues and connective tissue. The patient experiences pain relief, decreased joint stiffness, and decreased muscle spasm. Diathermy can also reduce swelling and promote healing in the joint.

Studies show that short-wave diathermy (preferred over microwave diathermy) heats tissue up to five centimeters below the skin surface. This compares to one centimeter depth for heat packs placed on the skin. The diathermy heating elements can be placed directly over clothes so there is easy application without undressing or the use of messy gels as with ultrasound.,

A recent study comparing different modalities in the treatment of chronic pain from knee osteoarthritis showed that all forms of heat or electrical treatments gave the same benefit. Diathermy equipment is expensive so therapists may opt for a less expensive but equally effective approach. It is a useful treatment tool when large areas of muscle need treatment. It should not be used over a metal implant such as a knee replacement.

There is no cure for chronic pain caused by knee osteoarthritis. But there are ways to help reduce the pain and improve function. Physical therapy modalities such as diathermy, interferential current, electrical stimulation, and exercise can be very helpful.

To help support this statement a group of researchers from four different health care centers in Turkey conducted this study. They compared the effectiveness of each of these treatment tools. They used pain levels, measures of stiffness, ability to walk 15 meters, range of motion, and use of pain medications as measures of outcomes for 203 patients.

The patients were divided randomly into one of six groups. There were three active treatment groups (transcutaneous electrical stimulation or TENS), interferential current or IFC, diathermy) and three “sham” groups. TENS and IFC provide an electrical current designed to inhibit pain messages from going up the spinal cord to the brain. Diathermy is a form of electromagnetic therapy that produces heat deep in the soft tissues.

No one administering the treatment or receiving the treatment knew whether the treatment was real or a sham. The combination of random assignment and lack of knowledge of the treatment type makes this study a randomized, double-blind, controlled study.

Everyone in the six treatment groups received their therapy every day Monday through Friday for three weeks. They also received education and exercise from their therapists making the overall treatment approach a multimodal one (in other words, a group of different treatments combined together).

Comparing their measurements before and after treatment they found that everyone in all six groups made significant improvements. The use of Tylenol was much lower in the true physical therapy groups and much higher in the sham treatment groups. There did not appear to be any difference among the different modalities. TENS, IFC, and diathermy all delivered the same amount of pain relief.

In summary, the results of this study show that a combination of physical therapy modality, education, and exercise gives the best improvements in patients with chronic pain, stiffness, and loss of function from knee osteoarthritis. Education and exercise provided more improvements in pain and function up to six months. The use of modalities seemed to give the most improvements in the first three months following treatment.

There are many possible reasons for residual pain after getting a knee replacement. Surgeons don’t always know why some people continue to experience this type of pain. Here are a few known ideas as well as a few current theories.

The two broad categories of pain-inducing factors following knee replacement surgery are patient and implant. Patient anatomy (e.g., shape, location, or angle of the knee cap) and gait (walking) pattern are two contributing factors.

A proper match between the patient and the implant is also important. Using an implant that is too large for the patient is called overstuffing. Putting the implant in place with good alignment is essential to restoring full, normal, pain free motion.

Studies show a gradual reduction of knee pain over time following knee replacement. This can take up to one or even two years for some people. But in approximately 10 per cent (one in 10 patients) persistent pain is reported. And like you, many of those patients have good motion and function. It’s just the pain that decreases their satisfaction with the procedure.

You didn’t mention any other disturbing symptoms. There are some people who report crepitation (crackling sensation heard and/or felt). Further studies have been recommended to find out what is causing these residual symptoms.

In the meantime, don’t hesitate to go back to your surgeon for a follow-up visit. There may be something quick and easy that could help you. Perhaps you just need some help adjusting the walk you walk or a strengthening program for a muscular imbalance.

It could be your surgeon will know right away what the problem is and how to fix it. In some cases, revision surgery to change something is required so keep that in the back of your mind as a possible solution. You won’t know until you have your knee re-evaluated.

Pigmented villonodular synovitis (PVNS) is a benign disease of the joint synovium. Benign in this case means that the condition is confined to the area of involvement. It doesn’t spread or travel to other parts of the body. It does not cause death but disability is possible. The synovium is the layer of soft tissue that lines the joint. It has a clear fluid that helps lubricate the joints.

Symptoms usually include joint swelling of a single joint (knee, hip, ankle, shoulder, elbow — in that order) with pain and loss of motion. Pain and loss of motion get worse as the disease progresses. X-rays often show lytic lesions (bone eaten away).

But lytic lesions of the bone can be caused by cancer so an MRI and biopsy are required to make an accurate diagnosis. In the case of pigmented villonodular synovitis (PVNS), MRI findings are clear. This is because the tissue contains iron deposits called hemosiderin and the MRI signals clearly show these lesions. Synovial fluid removed from the joint was yellow, another clue as to the diagnosis.

Surgery to open the joint and remove the tissue, a procedure called synovectomy is usually required. By completely removing all diseased tissue, pain free joint motion can be restored. There is a fairly substantial recurrence rate (between 40 and 46 per cent). This means the problem can come back again.

Some experts believe successful treatment without recurrence is possible. The joint must be carefully and thoroughly cleaned of all diseased tissue (right down to the bone). Radiotherapy (radiation to the area) is sometimes recommended. No one really knows what causes this disease or the best treatment for it.

It appears that early treatment and follow-up are the best keys to successful treatment. Recurrence can be minimized with successful removal of all diseased tissue. The natural history (what happens without treatment) is clear: the tissue continues to grow, destroying the joint and bone around it. The affected person develops severe pain, loss of motion, and loss of function.

We appreciate how distressing it is to lose a parent and find yourself reviewing medical decisions that may look questionable in hindsight. It’s often like they say, “Hindsight is 20-20” meaning that it’s much easier and more accurate to look back over time. With perfect vision and clarity, we see what would have worked best. But in the day-to-day decisions, we don’t always have such a luxury.

Knee replacements are becoming increasingly common among all age groups (young to old). At age 72, some adults are still very hale and hearty and active enough to want the knee replacement. Reducing knee pain and improving function also improves quality of life.

Sometimes that life is cut short and the full benefit of the surgery is lost. But given today’s increased longevity (many more adults than ever before are living into their 90s), a knee replacement at age 72 could have conceivably provided your father with an extra 20 years of improved knee function.

With no sure way of knowing who might live the longest to derive the most benefit, patients are rarely denied medical services in this country based on age. And in our country, there isn’t always an easy price tag that can be placed on patient satisfaction. Patient satisfaction with knee replacement surgery is high based on pain reduction, improved function, and increased ability to participate in sports and recreational activities.

So many young people (especially athletes) injure their anterior cruciate ligament (ACL), it has become a major concern among sports health professionals. Girls and women seem to be at greater risk than their male counterparts. Much research has gone into trying to understand the risk factors in order to prevent this potentially disabling injury.

Research has shown us there are many potential risk factors for ACL injuries. These are broken down into two distinct groups: intrinsic and extrinsic factors. Intrinsic refers to something within us such as the effect of hormones, genetics, and cognitive factors that might contribute to anterior cruciate ligament injuries.

Extrinsic factors (outside ourselves) include previous injury and other things like the weather, shoe wear, playing surface, time of year, indoor versus outdoor play, and even the amount of rainfall for outdoor events.

With females it’s easy to think the major difference is hormonal and look for a connection with the menstrual cycle. Some studies have attempted to see if females are more likely to injure their knees at a particular time in the menstrual cycle. It’s also possible the risk is no different over the course of time for females. But due to a variety of study designs and differing ways of analyzing the data, no consensus or agreement has been made.

Scientists have discovered receptor sites on the anterior cruciate ligament (ACL) for hormones such as estrogen and progesterone. Just the presence of these places for hormones to attach to cells suggests hormones may influence ligaments. But what the connection is or exactly how these hormones affect the ACL is a big unknown right now.

There may be some anatomic reasons for this. For example, women have a different shape to the bone structure forming the knee. The female ACL is more elastic and less stiff than the male ACL. Female athletes move differently than male athletes and with that difference comes a difference in muscle activation patterns.

The area of genetics is still being researched. Genetic factors associated with ACL tears have been identified in two studies. There are specific genes associated with ACL tears but these are considered rare. Observations that family members often share similar ACL injuries have led to some studies to examine this more closely. It appears that there is a much higher rate of ACL tears in family members of those who have been injured. So your family situation may reflect those findings as well.

It’s highly likely there are multiple factors involved in ACL injuries among females. Whether this is a combination of intrinsic factors, extrinsic factors, or both remains to be proven. More studies are needed to really examine each of these factors individually and also when combined together in different ways. With more information about risk factors, it might be possible to screen athletes for risk and use prevention strategies to avoid such injuries.

Lower leg (below the knee) pain accounts for more leg problems than anything else (other than knee problems) in both competitive and recreational athletes. What starts out as an acute (short-term) problem can become chronic (long-lasting) without the proper diagnosis and treatment.

A recent study from the Vanderbilt Orthopaedic Institute in Tennesse reported five common causes of lower leg pain in athletes. These conditions include 1) medial tibial stress syndrome, 2) chronic exertional compartment syndrome, 3) stress fracture, 4) nerve entrapment, and 5) popliteal artery entrapment syndrome. Long-distance runners and military personnel seem to have the most lower leg injuries.

All five of these chronic lower leg pain problems are caused by weight bearing, repetitive or compressive forces, and overexertion or overuse from activities such as running. Continuing activities that bring on leg pain or make leg pain worse is an important risk factor for acute pain becoming chronic.

Other risk factors for these conditions include female sex, anatomy (e.g., flat feet, hip internal rotation), and previous injuries. Eating disorders and loss of bone density are additional risk factors for bone fractures. And being overweight contributes to delays in recovery. Continued exercise and overtraining resulting in increased muscle bulk can lead to impingement (pinching) of a nerve or blood vessel (entrapment).

As we mentioned, before treatment can be determined, an accurate diagnosis must be made. The physician starts with a good patient history including training history (number of sessions per week, length of each session, intensity of sporting activity), training surface, and footwear. Any recent changes in any of these variables may be an important part of the history.

Depending on your symptoms, diagnostic imaging can include X-rays, bone scans, and/or MRIs. For more specific identification of problems involving compartment syndromes, pressure testing can be done. To test for nerve compression, electrodiagnostic studies can be ordered. The diagnosis helps direct treatment.

Most often, conservative (nonoperative) care is the first line of treatment. Recommendations for conservative care include rest, the use of ice, antiinflammatory medications, and possibly taping, splinting or casting the lower leg.

Physical therapy is an important part of the recovery and rehabilitation for these conditions. The therapist will address posture and alignment, flexibility and stretching, activity modification, and strengthening. The therapist is also integral in guiding the athlete in selecting proper shoe wear and getting back into an appropriate and effective training schedule.

Some conditions such as stress fractures, requires rest before rehab. The athlete is put on crutches and a nonweight-bearing status. Load is taken off the bone until healing can take place. This means no sports or recreational activities until cleared by the physician.

But don’t panic or jump to conclusions about yourself. These are just some of the most common possibilities for lower leg pain. The first step is to see your primary care physician, orthopedic surgeon, or physical therapist for an evaluation. It could be something as simple as shoe wear or training technique.

“Shin splints” also known as medial tibial stress syndrome or MTSS is a common cause of lower leg pain in weightbearing athletes. Dancers and runners seem to be affected most often. Overuse in an athlete with flat feet, hip rotational imbalances, and hyperplantarflexion (toe pointing downward excessively) are the biggest risk factors. Being overweight seems to delay healing in anyone with this problem as well.

The first thing to do is determine the cause of this condition. A physical therapist can help you with this. The therapist will examine you for potential biomechanical, postural, or anatomic causes of malalignment that could be contributing to the problem. Muscle tightness or weakness will be evaluated as potential features of your problem.

Sometimes a period of rest and nonweight-bearing using crutches is needed to take strain off the tissues and before healing can take place. This means backing off from any sports, dance, or other recreational activities involving the lower legs. Taping the lower leg may be helpful.

Shoe inserts (off-the-shelf or specially made for you) may be recommended. The therapist is also integral in guiding the athlete in selecting proper shoe wear and getting back into an appropriate and effective training schedule. Stretching and strengthening activities are often an important part of rehab and recovery.

With symptoms in both legs, there is always concern the condition will develop into a compartment syndrome. Tightness of the fascia (connective tissue) and thickening of the muscles from overtraining can lead to pressure on the blood vessels. In such cases, medical treatment (possibly surgery) is advised. If there is any danger of this, your therapist will refer you to a physician right away.

Most athletes with medial tibial stress syndrome (MTSS) or shin splints respond well to conservative (nonoperative) care. Once the cause of the problem has been addressed, the symptoms go away and the condition is resolved. Some people have a tendency toward developing the problem again but with careful monitoring and treatment, return of this condition can be prevented.

Hamstring injuries are usually sudden and acute with a known event or injury. A slow, gradual onset of symptoms such as you describe might be coming from something else. In order to make a decision about the best treatment approach, you may want to see your primary care physician or an orthopedic surgeon. He or she will perform various clinical tests and possibly order imaging studies. X-rays, ultrasound, and MRIs often offer the best diagnostic information with hamstring injuries (or to rule out other possibilities).

The approach to treatment of acute hamstring tendon/muscle injuries depends on the type and extent of injury. A strain or sprain is different from a full or even partial rupture. Sometimes the tendon pulls away from the bone where it attaches, taking a piece of the bone with it. These are called avulsion injuries and may require surgery.

Bleeding into and around the muscle is common with avulsion injuries. Pressure on the sciatic nerve from blood in the area can cause a tingling sensation along the back of the thigh. You didn’t mention other symptoms such as numbness or tingling down the leg.

Mild strains or hamstring tendinopathy often respond to conservative (nonoperative) care. Tendinopathy refers to a chronic injury with reactive edema (swelling), thickening of the tissue, and scarring but no active inflammation. Care is usually provided by a physical therapist who will focus on posture, alignment, core strengthening, and soft tissue mobilization. When appropriate hamstring stretching and strengthening may be included in the program.

When preparing for an event like a full marathon, it’s always wise to listen to your body and find out what’s causing the painful symptoms. Early intervention may prevent a worsening of the problem and get you back in full training once again.

It is good to pay attention to previous or old hamstring injuries. Without being overly pessimistic, you should know that studies do show that athletes who have injured their hamstring tendon or muscle are twice as likely to reinjure the same tendon/muscle. The older you are and the more you weigh, the higher the risk for a hamstring tear. But weak hamstrings, imbalance in leg muscle strength, and tight hip flexors also increase the risk of a hamstring strain.

What can be done to help athletes like yourself get back to their sports or other desired athletic activities? The first thing NOT to do is stretch the acutely injured tissue. With the hamstrings (a muscle all athletes spend time stretching), stretching after an acute injury only lengthens the time it takes to get back into action. It sounds like you are past the acute phase so supervised stretching may have a place in your rehab program.

In the acute phase, stretching does not seem to lengthen muscle fibers during healing. Scar tissue forms as part of the natural healing process. And that scar tissue links up with muscle fibers causing stiffness in the tendon-muscle unit. Researchers are still looking for better ways to lengthen injured/healing hamstring tissue.

In the meantime, studies show it makes much more sense to focus on core training, which will increase trunk stabilization and greatly reduce the risk of reinjury. Agility training is another valuable approach in preventing hamstring reinjury. Eccentric training (starting with the muscle contracted and in a shortened position and moving into positions of elongating the tissue) has some benefit but remains under investigation.

There is evidence that reinjury is greatly reduced when a program of agility and trunk stabilization is completed (compared with traditional rehabilitation with hamstring stretching and strengthening). One test that has proven reliable in predicting safe return to activity is called the active hamstring flexibility test. The athlete lies on his or her back with one leg in a knee extension splint. The splinted leg is quickly lifted up off the table as far as it will go.

The test is done on both legs. The amount of hip flexion is measured and compared from side-to-side. Equal movement without pain or apprehension in the presence of normal hamstring strength is a good sign the athlete is ready to return to the field or stage. You may want to ask your coach, athletic trainer, or physical therapist to test you before resuming full sports activity.