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Hi, it is Tom here from Running Physio. Today I want to talk to you about how to help runners that present to you with a meniscal injury in the knee. Now these can actually be quite tricky to treat and we're gonna focus here on those more kind of degenerate, meniscal injuries that you often see in runners, typically are more middle-aged runners that present to us with a sore swollen knee. So we're gonna talk through some steps on how we can treat these runners and get them back to running.

So your typical presentation then, it's often a middle-aged runner who's been running fairly successfully for a while. Maybe they've increased their mileage a little bit and or increased their intensity, and they're coming to you saying that knees sore, maybe they've got a bit of medial joint line pain, some swelling, and it's quite uncomfortable. And now if they run, it's puffy and sore for quite a while. Afterwards and they're wanting some advice in terms of how to address this and getting them back to comfortable running.

Now. In the past, quite often these patients would be offered surgery but we are seeing now actually that conservative management can be as effective as surgical management. So often we want to go with our conservative treatment first before we explore the more surgical options. Also recent research has shown us that actually meniscal tears in runners are really quite common.

And actually some research in asymptomatic runners, runners with no pain found 36% of runners have a meniscal tear with no symptoms whatsoever. So hopefully this is changing our attitude towards these injuries a little bit and saying that we don't necessarily need to rush people off for surgery, nor do we need to say to people that they have to stop.

But obviously this needs to be managed. It needs to be addressed so that they can run comfortably. Now, in that study that found that roughly 36% of asymptomatic runners have a meniscal tear, they had a look at what continuing to run did to these meniscal tears for asymptomatic runners. In particular, they looked at what happened if they trained for and completed a marathon.

And it didn't tend to lead to progression of these meniscal tears. It didn't tend to make them worse. So here's a quote from that study. It's Horga et al 2019. They say marathon running did not result in progression of meniscal tears, and their presence did not affect performance. So this is quite positive then. It suggests to us that a lot of runners are managing to run successfully with cartilage tears, and the available evidence in people who are at least asymptomatic is that running doesn't tend to make them worse. Now, this doesn't mean then that our runner that's come to us with a puffy sore knee, we just say, crack on, keep going. It's not gonna make things worse. That's not the case. We still need to manage this. We still want to get running to a level that the knee can cope with. So I don't encourage runners to keep pushing on to a level that causes things to swell and become sore.

So let's talk about how we might manage this runner then, and the steps I would typically take in clinic. So the first thing we want to do if they've got a painful, swollen knee, is to try and settle that pain and swelling. In my experience, they often will need a rest period from running in order to do that, to allow things to settle. But it will depend on the irritability. If they're able to identify a distance or intensity, they can manage that doesn't flare the symptoms up, that doesn't result in swelling. We may be able to get them to continue to do that, but it often will need to say, let's settle things down for a bit with a break from running and let's replace the running with some non-impact cross-training that the knee tolerates really well.

Maybe some cycling for example. So this first step, we wanna settle things down, some load management or break from running. If the pain is a major issue, I'll often ask people to arrange an analgesic review with their doctor to see what pain relief options there may be to help calm things down. We might look at other forms of pain relief like ice or heat, depending on what they're finding effective maybe using some compression or taping or soft tissue work just to try and settle things down in that painful phase.

And then, that can allow us, when things are settled, to focus on the next steps. So first step, we're gonna calm things down. Secondly, often I want to try and make sure we can restore range of movement in the knee. Now with meniscal injuries, you often will lose some range, particularly end of range flexion and extension.

Now most runners can carry a loss of end of range flexion. We don't normally go into deep knee flexion during running, but we do need the knee to be able to extend fully in most people because that's a very stable position for the knee. And also it's quite important for quad's function. See, step two, I wanna assess range, and in particular, I want to try and restore extension range of movement where possible.

Now here, I might actually go for some hands-on stuff. Now I know it's not particularly in vogue at the minute in in therapy at the moment, it's being pushed out a little bit to some degree. But there are some times where some hands-on treatments can be effective.

So let's say someone's presenting to you with maybe a five to 10 degrees stiffness into extension. They're limited there by lack of range, not lack of strength. I might try some gentle mobs into extension, something really simple like using one hand to gently glide the tibia down towards the bed from anterior to posterior. So we're gently moving them into extension. And obviously we've gotta pick our patients here. If this is really painful, they're highly irritable, it might not be appropriate. often I'm gonna go with a short duration of treatment here, maybe three sets of one minute. And then see how they are afterwards in terms of their range.

So recheck their range, see if it's getting better for them. Now if we've managed then to get a bit more extension range and often we do in the session. This is part of the reason why I like this technique. It's often quite effective to get more extension range back. We want to then maintain that extension range. So I will use the rest of that session time working on getting people to do isometric holds at end of range extension to maintain that range wherever we can. So it might be, we'll do some of that in a close kinetic chain position potentially where they've actually got their foot fixed and they can push back into extension.

And the advantage of that is it can often get into that end range positioned again cause you've got something to push against. But the disadvantage is you'll get glute max involved as well because it'll extend the hips. You might find the quads get let off a little bit with that. So I'll often also do some open kinetic chain things, seated in the extension, really get them to try and work on working the quads and achieving end range of extension within that session, almost to fire those muscles up a bit because we know the presence of swelling can inhibit quads function. It isn't just that, we'll mobilise the knee and then off you go, let's look at maintaining that range of movement and actually getting the muscle functioning well within that range, and then ask the patient to take those exercises away and do them regularly at home. For me, if it's about range of movement, it's little and often that we need. It's not like your strength prescription where we might suggest three sessions per week. I'll often ask someone to do these types of exercises two or three times a day to regularly extend the knee and hold it in that position to maintain the range and maintain the quads function.

So we might do some hands on stuff. We might give people some exercises to help them maintain that extension range, but then we also want to look out for their movement patterns and extension avoidance is sometimes a thing here. So if it's painful and stiff to extend the knee, people learn to avoid knee extension. So here's an example of that then. So we, I see this really regularly for patients in clinic with these types of problems. You look at them in standing in this example, they've got all their weight through their good leg on their right side, and they're flexing the other leg because you just can't get back into the extension. So if we do achieve that range, maybe with our hands on stuff and some exercises they're doing. I would get them into standing and get them practicing it in standing and make them aware that they've got this movement habit so that actually they're using their range and getting back into their more normal movement pattern again.

So hopefully we've calmed things down a bit in our sort of first steps. You've got the pain and swelling under control. We then looked at restoring range, particularly into the extension, then I would look to try and move on to build strength. Now, the reason I'm doing it in this way is we know the quads are really important for the knee and it's very difficult to strengthen them up if you haven't got full range of the knee.

So if we get that full extension first, then that allows us to go on to look at our strength work. Now this is gonna be dependent on your findings. Obviously your assessment will guide the rehab, but typically we would want to have a look at quad strength. And I'd want to include both open and closed kinetic chain options again.

The open kinetic chain stuff like our seated knee extension machine as an example, is great at working the quads more in isolation. The close kinetic chain stuff probably is a little bit more replicating function though, so we might include some squats or leg press work, alongside some seated knee extension work on the machine, or even sometimes just using bands.

Have a look at whether they need to do some strength work in the glutes, the hamstrings, the calf, see where their rehab needs are. Now, the advantage of strengthening up, those are the muscles, particularly things like the glutes, the hamstrings and the calf is you can often have other exercises which don't load the near huge amount that are really well tolerated alongside one or two that are targeted at the knee, so it won't feel too much for them to do.

Now, when we are trying to get them back to running, broadly speaking, we might be looking to achieve roughly 70 to 80% strength of their good side compared to their current weaker side. So those would be the kind of measures we are looking to achieve.

We've restored range. We're building strength. Also important to improve impact, control, and tolerance. Now, in my experience with runners, with these type of meniscal injuries, it's impact that's especially provocative. I've had some runners who are super strong, lifting very heavy weights in the gym. They can do anything. You ask them to do in that environment with weight, but as soon as you add impact, that's what flares their symptoms. Probably because of the role of the meniscus, obviously. It can manage impact and stability of the knee. So in preparation for return to running, I'll often want to bring in some form of impact work, typically short duration, so maybe starting as little as 30 seconds.

And then thinking about the demands of their sport and particularly the type of stresses the knees exposed to. So in running, we know we need to manage both horizontal and vertical forces at the knee. So maybe including some exercises that are addressing more of those vertical forces, shallow range jump squats or jogging on the spot, and some that are focusing more on the horizontal.

If we're looking at horizontal forces, we might be looking at forward jumps, forward bounding forward hopping potentially, but trying to address both vertical and horizontal forces. Short duration, because we don't want it to be too provocative. I might then gradually ramp that time up. So in total, over a period of time, they're getting up to around about three minutes of impact altogether.

Now there's a reason for that because when we come to the return to running for these patients, I might start with as little as three minutes. And if we built impact tolerance of around about that time during our rehab, we are preparing them for that return to run process. Now, of course, every runner is different.

As I said, some runners will be able to load manage, and by that I mean reduce the running to a manageable level rather than stop altogether. So we might not need to be quite so conservative with them.

So hopefully we've settled pain, we've restored range, we've built strength, and we've introduced some impact control. We want to have as part of this, some criteria for return to running, so we know the person's likely to cope with it.

So things I would look out for then is we want a quiet knee. So by that, a knee that is no longer swelling, ideally no effusion. If you're doing things like your sweep test, zero effusion. We may sometimes accept grade one effusion with a sweep test if this is a knee that has had some level of pain-free swelling for a while and it's otherwise really comfortable.

We want it to be non irritable, so no pain with walking at least half an hour with climbing stairs and with most activities of daily living. And we do want that full knee extension. So we know the quads are functioning well.

In terms of strength, as I said, we're aiming for roughly 70 to 80% limb symmetry index. And this is not based on any particular study. There aren't really studies out there that I'm aware of specific to meniscal injuries in runners, but on other areas of research and generally with these types of injuries. So once we're achieving those things they are really comfortable with the knee. They've got the strength, the control, the impact tolerance as well.

That's the other test we want. As I said, we want to build them up so that they've got some impact tolerance. Even simple testers should be able to jog on the spot for a minute, pain free. That's when we can start to think about reintroducing the running. Now, often we'll start with a small amount, as I said, three to five minutes because we don't know what the response is gonna be like from the knee afterwards.

It might feel comfortable during, but then afterwards we might actually see the swelling and pain. So if we have a measured amount, if we say, go and do three minutes nice and slow, let's see how the knee responds, we can then see, yep, tick, it's coped with that. Now let's look at how we progress on from there. Typically, it's gonna be a relatively slow progression in someone where you suspect an intraarticular issue, like a meniscal injury. It needs to be gradual and we need to make sure there isn't increase in pain and swelling afterwards. Now other things to consider here is we know that the knee health and joint health in general is affected by our general health and wellbeing, particularly things like weight management.

So that might be something to discuss with the patient as well. Gait retraining might be an option, so it can be worth assessing their gait if they're tending to over stride with a low step rate, and there may be some benefits in increasing that step rate, typically by about five to 10% because that can reduce the stress on the knee. If they're running with a lot of hip adduction during the loading phase of running, that too may place a bit more stress on the knee, so we might look at cues to try and address that as well.

Final thought on this is time scales. It's not common for these to recover really quickly. It takes time to settle the symptoms, to build the strength, to build the running tolerance and get them back to the level they want to be. So usually, I will allow at least three months of rehab, three to six months, in some cases to really get the chance to build people back in.

But if they're not improving, then it is worth considering an onward referral. Some patients actually may benefit from surgical intervention, particularly those that aren't responding to our conservative management, also those with more mechanical symptoms. So if they have persistent locking, persistent giving way, persistent loss of range in the joint, that would also make me want to consider a surgical opinion earlier in that process.

It doesn't always mean surgery, but sometimes just teaming up with a surgeon that you know and work with quite well can get their opinion as to options outside of conservative management, even other things that might be considered before surgery. So I hope that gives you a bit of an overview in terms of how we might try and manage some of these meniscal injuries in running.

Just to wizz through those steps that we've talked about. First of all, we do need to settle the pain and swelling often with a short break from running potentially replacing and running with cross-training until it settles. And we also want to try and get that range of movement back, particularly in the extension. And then look to build strength around the knee based on wherever they're weak essentially. But particularly those big important muscles like the quads, glutes, calf, and hamstrings. We want to build some impact, control and tolerance in there so that it prepares them for the impact in running and then set some return to running criteria so we know that they're actually ready, that they're comfortable, quiet knee and they're coping with impact. And then it's gonna be a graded return, starting quite often with a small amount and gradually building the volume first before we add in intensity.

Thank you very much for listening in today. As I said, I've put a link to our free webinar series. Do check those out and if you've got any comments or questions, do let me know. I look forward to speaking to you again very soon. Bye for now.