Avoiding Meniscus Surgery

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1 Avoiding Meniscus Surgery Robert Tarantino February 9, NY CTTC-1 1

2 WARNING THIS MATERIAL DOES NOT CONSTITUTE MEDICAL ADVICE. IT IS INTENDED FOR INFORMATIONAL PURPOSES ONLY. PLEASE CONSULT A PHYSICIAN FOR SPECIFIC TREATMENT RECOMMENDATIONS. 2

3 Table of Contents Abstract 4 Knee Anatomy 5 Bent Knee Knee Anterior View 6 Straight Knee Anterior View 8 Meniscus From Side 8 Meniscus From the Top 9 Anterior Knee Muscles 10 Posterior Knee Muscles 11 Menisci 11 Knee Exercises 13 BASI Block System Conditioning Exercises 15 Conclusion 18 Bibliography 19 3

4 Abstract Approximately six week before I was scheduled to take my BASI final practical exam I experienced a knee injury while windsurfing. My MRI indicate that I had both a lateral and radial tear of the medial meniscus. My doctor recommended surgery but said that he saw no reason to keep me from taking my final as long as I protected the knee with a compression brace. Four days after my injury I was once again practicing for my exam. I was fortunate to be working with Shari Nyce, an experienced BASI instructor, who was careful to keep me from further aggravating my knee. After each session I would ice my knee till the pain subsided, I did this again before I went to bed and wore a knee brace to keep from hurting my knee while I slept. After two weeks of preparation for my test, my pain was significantly reduced and I was able to dispense with the icing. However I did continue to use the brace for exercise and sleeping. After I completed my BASI test I continued to focus on strengthening my knee muscles. I was able to dispense with the knee brace and my pain diminished so much that I decided not to have the surgery. 4

5 Knee Anatomy Here is an image of the front of the right knee, opened from top to bottom and with the kneecap (patella) flipped over, showing its undersurface. The image is illustrative, rather than fully accurate, as usually the knee needs to be bent to allow one to look straight into the cavity of the knee joint like this. You can see the shiny white cartilage that covers the end of the femur bone. As the knee bends and straightens this makes contact with the shiny white cartilage at the back of the patella (kneecap) as the two surfaces slide over one another. This contact between the femur and the patella is known as the patellofemoral joint. The femur also makes contact with the top of the tibia bone, and this contact is called the tibiofemoral joint. It makes contact at the two rounded ends of the femur - the condyles. As the knee bends and straightens these two condyles roll over on the joint surface below. 5

6 Strong ligaments are present to stabilize the joint. In the image you can see the cruciate ligaments in the centre of the joint between the two condyles, holding the femur and tibia in relation to one another, but also allowing the joint to bend and straighten. Sandwiched between the rounded condyles of the femur and the flattened top (plateau) of the tibia are the menisci - shock absorbers that fill the space and allow smooth movement of the joint. Bent Knee Knee Anterior View From the front of the knee, the white shiny joint cartilage is exposed as the knee is bent. 6

7 As the knee is straightened, the rounded ends of the thighbone (condyles) roll over and the important joint cartilage is tucked under and protected. The thighbone is correctly called the femur The shinbone is the tibia The kneecap is the patella The long thin bone on the outer side of the shinbone is the fibula The proper name for the two knee cartilages is menisci (singular is meniscus) The proper name for the gristle is cartilage The two cruciate ligaments are right inside the knee The two collateral ligaments are on the outer sides In this illustration, you can see that the kneecap (patella) is actually within the substance of a tendon - the tendon of the quadriceps muscles (the lap muscles). You can see the cruciate ligaments within the joint and the collateral ligaments on the outside. The menisci - shock absorbers that fill the space and allow smooth movement of the joint - are sandwiched between femur and tibia. 7

8 Straight Knee Anterior View When the knee is straight, the rounded condyles are rolled over onto the flat surface of the tibial plateau, so the white cartilage (gristle) of the femur largely disappears from view. In the straight-leg position, the patella sits above the joint line, above the trochlea of the femur (the underlying groove in which it rides). Meniscus From Side The meniscus is a wedge-shaped cartilaginous shock-absorber, which exists between femur and tibia on either side of the joint. Each knee has two menisci. The meniscus on the inner 8

9 side is called the medial meniscus and the one on the outer side is the lateral meniscus. Each meniscus is curved like a pair of horns - the front bit is called the anterior horn, and the back bit is the posterior horn. In this illustration - looking at a bent knee from the front - the meniscus has been pulled out to the side so that you can better appreciate its shape. The meniscus accommodates the incongruity between the rounded end of the femur and the flat surface of the tibia. Here is a photo taken during arthroscopy. Note that it is the opposite meniscus from the one pulled out above. Meniscus From the Top From above the meniscus, the complex anatomy can be clearly appreciated. 9

10 In this illustration, one is looking down onto the top of the tibia (shin bone), and able to see both medial and lateral meniscus in relation to one another. The fact that they are different shapes is important. The medial meniscus is larger and C-shaped, while the lateral meniscus is smaller and O-shaped. The medial meniscus is tethered around the edges, while the lateral one is able to slide around more - so the medial one is more often the victim of tears. Anterior Knee Muscles The quadriceps muscles dominate the front of the knee. The 'quads' are the muscles making your 'lap'. The proper name for the quads is 'quadriceps femoris'. If you sit down and put your hands on your lap, then spread your fingers open - under your fingers are the bulky quadriceps muscles. The image on the left is not great but it shows that the patella exists within the substance of the quadriceps tendon, the fibrous bit at the bottom which attaches to the tibia (shin bone). ' 10

11 Quadriceps' means '4 heads' - the muscle is actually four separate muscles which work together to straighten (extend) the knee: vastus lateralis vastus intermedius (under the rectus) vastus medialis rectus femoris Posterior Knee Muscles Above the knee joint at the back the 'hamstrings' dominate. The three hamstring muscles are the biceps femoris, the semimembranosus and the semitendinosus muscles. Menisci The menisci are the shock-absorbers of the knee - wedged horizontally in between the femur and the tibia. They fill in the space between the rounded ends of the femur bone and the 11

12 flattened ends of the tibia bone upon which the femur sits. Menisci are squeezed between the rounded ends of the femur (the femoral condyles or rounded ends of the thigh bone) and the flat upper surface of the tibia (the tibial plateau or upper surface of the shinbone) - so they are difficult to see, and hard to explore. A single meniscus is shaped like a squashed orange segment lying on its side, wedged between the long bones of the knee. Each knee has a medial meniscus and a lateral meniscus. The medial meniscus is on the inner aspect of the knee and the lateral meniscus on the outer aspect of the knee. The medial one is the one more commonly injured. The two menisci differ in shape and mobility. Look at this photo of two real meniscus just before being used for transplant. The lateral meniscus (left of photo) is more O-shaped and quite highly mobile, able to slide forwards and backwards with knee movement. There is a tendon (popliteus tendon) passing along one edge, which breaks the attachment to the capsule of the joint, and this adds to the mobility. 12

13 The medial meniscus (right of photo) is quite different. It is larger and more C-shaped, and tightly bound to the capsular structures and to the medial collateral ligament along the outer rim. It moves very little with the movement of the knee. It is this inflexibility which leads to the medial meniscus being torn more frequently than the lateral meniscus. The lateral one can move and absorb impact, while the medial one simply rips. In a primary tear of the meniscus, there is usually a twisting force with significant torque. A skier with tight bindings may have the full rotatory torque of the ski applied to this small structure. A footballer kicking a ball at an angle will have his full weight transmitted through the one knee via the meniscus. Degenerate tears occur in association with arthritic disorders where there are destructive chemical substances being released into the joint cavity. The joint surfaces and the menisci undergo destructive alteration and start to break down and fragment. There is usually no directly associated injury. Knee Exercises The following exercises were used to strengthen the muscles around my knee joint. It is my belief that while it is not possible to heal a meniscus injury with Pilates, it is possible to significantly reduce the pain by surrounding the knee capsule with strong anterior and posterior muscle tissue. Three to four times a week I would do a combination of these exercises. I felt that the reformer exercises put more emphasis on my hamstrings and the chair exercises put a greater emphasis on my quad muscles. 13

14 Equipment Exercise Muscle Focus Objective Cadillac Parallel Heels Hip extensors Cadillac Parallel Toes Hip extensors Cadillac V Position Toes Hip extensors Cadillac Open V Heels Hip extensors Cadillac Open V Toes Hip extensors Cadillac Single Foot Heel Hip extensors Cadillac Single Foot Toes Hip extensors Reformer Parallel Heels Hamstrings Reformer Parallel Toes Hamstrings Reformer V Position Toes Hamstrings Reformer Open V Heels Hamstrings Reformer Open V Toes Hamstrings Reformer Single Leg Heel Hamstrings Reformer Single Leg Toes Hamstrings Reformer Prehensile Hamstrings Hamstring strength and stretch, Knee extensor strength Hamstring strength and stretch, Knee extensor strength Hamstring strength and stretch, Knee extensor strength Hamstring strength and stretch, Knee extensor strength Hamstring strength and stretch, Knee extensor strength Hamstring strength and stretch, Knee extensor strength Hamstring strength and stretch, Knee extensor strength, Wunda Chair Parallel Heels Hamstrings, Quadriceps Quadricep strength, Hamstring engagement Wunda Chair Parallel Toes Hamstrings, Quadriceps Quadricep strength Wunda Chair V Position Toes Hamstrings, Quadriceps Quadricep strength Wunda Chair Open V Heels Hamstrings, Quadriceps Quadricep strength, Hamstring engagement Wunda Chair Open V Toes Hamstrings, Quadriceps Quadricep strength 14

15 Equipment Exercise Muscle Focus Objective Wunda Chair Single Leg Heel Hamstrings, Quadriceps Quadricep strength, Hamstring engagement, Wunda Chair Single Leg Toes Hamstrings, Quadriceps Quadricep strength Reformer Hamstring Curl Hamstrings Knee flexor strength, Hip extensor strength Reformer Single Leg Skating Gluteus medius Hip abductor strength, Wunda Chair Hamstring Curl Hamstrings Knee flexor strength, Wunda Chair Frog Front External rotators of the hips Quadricep strength, External rotator strength There are some exercises that are contraindicated for meniscus injuries. In general, these would be exercises that put side stresses on the knee joint. Also, most of the exercises that required kneel ing with most of the weight on the knees are also not recommended. Examples would be; Single Leg Skating, Jumping Series, Side Over on Box, and Side Split. BASI Block System Conditioning Exercises The following program is what I would recommend if someone came to me with their doctor s recommendation to try Pilates exercises to strengthen their knee following a meniscus tear. Equipment Exercise Muscle Focus Objective MAT Pelvic Curl Abdominals, Hamstrings MAT Spine Twist Supine Abdominals MAT Chest Lift Abdominals Spinal articulation, Hamstring control, Pelvic lumbar stabilization Spinal rotation, Pelvic lumbar stabilization, Abdominal control with oblique emphasis Abdominal strength, Pelvic stability 15

16 Equipment Exercise Muscle Focus Objective MAT Chest Lift with Rotation Abdominals with oblique emphasis Reformer Parallel Heels Hamstrings Reformer Parallel Toes Hamstrings Reformer V Position Toes Hamstrings Reformer Open V Heels Hamstrings Reformer Open V Toes Hamstrings Reformer Single Leg Heel Hamstrings Reformer Single Leg Toes Hamstrings Abdominal strength with oblique emphasis, Pelvic stability, Wunda Chair Parallel Heels Hamstrings, Quadriceps Quadricep strength, Hamstring engagement Wunda Chair Parallel Toes Hamstrings, Quadriceps Quadricep strength Wunda Chair V Position Toes Hamstrings, Quadriceps Quadricep strength Wunda Chair Open V Heels Hamstrings, Quadriceps Quadricep strength, Hamstring engagement Wunda Chair Open V Toes Hamstrings, Quadriceps Quadricep strength Reformer Hundreds Prep Abdominals Abdominal strength Reformer Hundred Abdominals Abdominal strength, Pelvic lumbar stabilization Reformer Coordination Abdominals Abdominal strength, Pelvic lumbar stabilization Hip adductor strength, Reformer Frog Hip adductors Knee extensor control, Pelvic lumbar stabilization Reformer Circles (Down, Up) Hip adductors Hamstrings Hip adductor strength, Pelvic lumbar stabilization Hip adductor strength, Reformer Opening Hip adductors Hip adductor stretch, Pelvic lumbar stabilization Reformer Bottom Lift Abdominals Hamstrings Spinal articulation, Hip extensor strength Reformer Bottom Lift with Abdominals Hamstrings Spinal articulation, Hip Reformer Extension Standing Lunge Hamstring Stretch Series Hamstrings Hip flexors extensor strength Hamstring stretch, Hip flexor stretch 16

17 Equipment Exercise Muscle Focus Objective Reformer Reformer Reformer Reformer Reformer Reformer Reformer Cadillac Cadillac Scooter Knee Stretch Series Extension Arms Supine Series Adduction Arms Supine Series Up Circles Arms Supine Series Down Circles Arms Supine Series Triceps Arms Supine Series Mermaid Prone 1 Push Through Series Prone 2 Push Through Series Abdominals Latissimus dorsi Latissimus dorsi Latissimus dorsi Latissimus dorsi Triceps Abdominals with oblique emphasis Back extensors Back extensors Trunk stabilization, Hip extensor strength, Knee extensor strength Shoulder extensor strength, Scapulae stabilization Shoulder adductor strength, Scapulae stabilization Shoulder adductor strength, Shoulder extensor strength, Shoulder mobility Shoulder extensor strength, Shoulder adductor strength, Shoulder mobility Elbow extensor strength, Scapulae stabilization Spinal mobility, Scapulae stabilization Back extensor strength, Shoulder extensor control, Abdominal control Back extensor strength, Shoulder stretch, Abdominal control and stretch The above program consists of thirty-four exercises which should fit nicely into a one hour private session. The combination of reformer and wunda chair footwork puts emphasis on both the posterior and anterior muscles of the knee. It was my experience that while both pieces of equipment strengthened both sets of muscles, the reformer footwork did a better job of strengthening the hamstrings while the wunda chair exercises were better for the quads. Also, the reformer frog, circles and openings strengthened the secondary muscles of the knee. These would be the sartorius, gracilis, popliteus gastrocnemius and plantaris muscles. 17

18 Conclusion Fortunately for me, I had a simple choice, I could either give up my pilates program and risk not completing the BASI program or with professional guidance take it easy and see if I could keep the pain to a minimum. Fortunately I was able to complete the program and over time, the pain went away. I can t say that what I did would work for others but, I think it s worth a try. Even if it simply delays the surgery it may be useful. Before the 1980s a meniscus tear would often be cured by the complete removal of the meniscus. This resulted often in the complete wearing away of the cartilage at the knee joint and very painful bone on bone contact that would often result in total knee replacement. Who is to say that in a few years better medical procedures won t provide a more complete solution for a torn meniscus. Since tearing my meniscus in September and passing the BASI test in October, I have not experienced any pain or discomfort in my knee joint. I do my Pilates routine at least three to four times each week and have practiced gone through all of the BASI exercises, even those that are contraindicated for knee joint issues. 18

19 Bibliography About.com:Orthopedics. 1 Feb 2008 < Biel, Andrew. Trail Guide to the Body. Colorado: Books of Discovery, 2005 Calais-Germain. Anatomy of Movement. Washington. Eastland Press, 1991 Clippinger, Karen. Dance Anatomy and Kinesiology. Illinois: Human Kinetics, 2007 ExRx.net Home.2Feb 2008 < Halpern M.D., Brian and Laura Tucker. The Knee Crisis Handbook. New York: LifeTime Media, 2003 Isacowitz, Rael. Pilates. Illinois: Human Kinetics, 2006 Johnson P.T., Jim. Treat Your Knees. California: Group West, 2003 Klapper M.D., Robert and Lynda Huey. Heal Your Knees. New York: Evans & Company KNEEguru Home. 1 Feb 2008 < Long MD, Ray. The Key Muscles of Hatha Yoga. Unknown. Bandha Yoga Publications,

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