Article Review by Evan Peterson PT, DPT
The knee joint is composed of several parts. It contains bone, ligament, tendon, joint capsule, and different types of cartilage. The knee contains 2 distinct cartilages: articular and meniscus. Articular cartilage is at the ends of bones which come together to form the joint. The job of the articular cartilage is to provide a smooth surface that allows for proper gliding on the joint surfaces against one another. The meniscus cartilage on the other hand is designed to help decrease the load placed through the knee joint itself. The meniscus is horse shoe shaped and is comprised of a medial and lateral end. Because the femur and the tibia are both rounded, the meniscus is needed in order to spread out contact forces. This allows for improved shock absorption and knee stability. The menisci are composed of an anterior and a posterior which are attached to the tibia by strong roots. The roots help to provide increased knee stability and decrease amount of tibial rotation. These functions are important to protect the articular cartilage.
A meniscal tear can be either acute traumatic or degenerative. An acute traumatic tear typically occurs in the athletic population and is caused by knee twisting with a planted foot. Degenerative tears are more commonly in middle aged people both male and female. The symptoms of an acute tear are swelling, pain along the knee joint line, and locking or catching.
Root Tear Rehab Options for the Athlete
One option the athlete has is to attempt rehabilitation without surgery. Another option is for the surgeon to trim out a portion of the torn meniscus. The last option is for the surgeon to repair the meniscus. Whenever it is possible, the surgeon will prefer to repair the meniscal root of an athlete, which is based upon the desire to limit future knee arthritis. After meniscal surgery, it is recommended to attend physical therapy in order to address knee range of motion, strength, and neuromuscular knee control. The therapist can also assist in guiding the patient back to performing normal sport activities. After a meniscus root repair, there is a prolonged period of non-weightbearing and restricted range of motion to allow proper healing.
Phase I of Rehab: Surgery until 8 weeks
- Typically begins 3-5 days after surgery
- Toe touch weight bearing with brace
- Gradually unlock brace for 6 weeks; after 6 weeks no brace
- Goal to restore range of motion from 0-90 degrees, decrease leg swelling, and restore control
- Knee extension on bolster, prone hangs, quadricep sets, hamstring sets, straight leg raises, heel slides to 90 degrees
- Progression to next phase
- 8-10 weeks after surgery, pain free gait (no crutches), no swelling
Phase II of Rehab: 8 weeks post-surgery
- Goals are to improve single leg control, normalize gait, and improve functional control
- No forced knee flexion past 60 degrees, no impact activities
- Hip and core exercises, stationary bike tasks, and balance or proprioceptive drills
- To Progress
- Normal gait on all surfaces, functional tasks without unloading affected leg, and single limb stance greater than 15 seconds
Phase III of Rehab: Typically 12-16 weeks post-surgery
- Goals are good control while performing sport and work specific movements with impact
- Avoid excessive post exercise swelling or posterior knee pain with flexion
- Low velocity agility drills, closed chain progressive strengthening including unilateral tasks, begin low amplitude landing drills to prevent excess frontal plane trunk lean and reduce hip adduction during stance
Phase IV of Rehab: 20-24 weeks post-surgery
- Normal multi planar motion performed at high velocities without compensation
- Typical double leg landing mechanics
- Demonstration of adherence and understanding of HEP
- Progressive agility drills with increased velocity from the last phase
- Perform higher amplitude landing drills both bilateral and unilateral
- Reactive drills including cutting and pivoting
- Sport and work specific proprioceptive/ balance exercises
- Continue core and hip strengthening exercises.
- Progressive running program
- Returning to Sport/Work
- The patient must be cleared by orthopedic surgeon as well as the therapist/athletic trainer.
- The patient should be with a 15% deficit when performing all testing such as strength testing, hop tests, and force plate jumping.
Physical Therapy First
At Physical Therapy First, we have skilled therapists who are equipped to guide a patient through their recovery from a meniscal surgery. We take the time to examine the patient and help them to achieve their functional, recreational, and work-related goals. Please do not hesitate to reach out to us if you recently underwent or plan on having meniscal surgery.
Rehabilitation Guidelines for Meniscal Repair of Root and Complex Tears – UW health. https://www.uwhealth.org/files/uwhealth/docs/pdf/Meniscus_Root_Rehab_final.pdf. Accessed February 10, 2022.
Reviewed by Evan Peterson PT, DPT
Mobility over the last several years has been a source of topic when discussing general health and wellness. Many people believe the more mobile a joint is the better off it will be. There are varying degrees to which a joint may be mobile. A hypomobile joint is one in which the bones do not glide or roll as well as one would expect. The opposite is for a joint to be hypermobile. Joint hypermobility is the excess to which a joint has the ability to go through its range. Increased joint play is not always bad, at times it can be advantageous. However, increased mobility may lead to increased risk for injury or be a sign of systemic disease. These diseases are known as Heritable Disorders of Connective Tissue (HDCT). The 2 most common of them is Ehler’s Danlos Syndrome (hEDS) and Hypermobility Spectrum Disorder (HSD).
Where do we see hypermobility?
A variety of factors can influence who gets hypermobility, including age, gender, muscle tone, joint shape, injury, and systemic disease. More often than not, children are more mobile and as they age they become less mobile. Due to the aging affects on joint mobility, scoring tools must be adjusted to determine the severity. Factors such as injury or training can play a factor in the development in mono-articular joint hypermobility. For example, the article notes swimmers tend to have knee extension hypermobility and gymnasts seem to have greater hip hypermobility.
To identify hypermobility, it is important to examine both active a passive range of motion (ROM) in joints. Several screening tools have also been developed to look for generalized hypermobility. The most commonly utilized is the Beighton scale which is a 9-item list. Scores of 6 or more in 5-year olds to skeletal maturity, 5 or more in adults to 50 years of age, and 4 or more when older than 50, is positive. Along with the screening tool, a 5-part questionnaire is typically attached. This is the 5-part hypermobility questionnaire which asks questions such as “Do you consider yourself double jointed” and “Can you now (or could you ever) bend your thumb to touch your forearms?”. Despite this screening tool, it does not completely rule out generalized or other forms of hypermobility. Specifically, the temporomandibular, shoulder, hip, cervical, and ankle, joints should be paid close attention. Other recommended screening tools are the Upper Limb Hypermobility Assessment Tool (ULHAT) and the Lower Limb Assessment Score (LLAS). The LLAS is the only one of the two which has been validated for the pediatric and adult; whereas, the ULHAT has been validated for adults.
Diagnosing Hypermobility Disorders
The most common diagnosis of hypermobility in the past was Joint Hypermobility Disorder; however, most recently hypermobile Ehler’s Danlos Syndrome (hEDS) and Joint hypermobility (JH) are thought of as a spectrum ranging from asymptomatic JH to hEDS. Filling the middle of this spectrum is HSD. The importance of recognizing HSD is to understand that it may appear in a variety of different ways: localized, peripheralized, generalized, or historic. Historic refers to someone who had joint hypermobility in the past but due to an injury lost their ability to demonstrate increased mobility.
The severity of both HSD and hEDS present across a spectrum and can be complex or present with minimal symptoms. Symptoms typically are musculoskeletal pain, fatigue, dysautonomia, gastrointestinal, urogenital, and cognitive symptoms. Central sensitization has also been found to be a common symptom. Other common findings alongside hEDS and HSD are postural tachycardic syndrome (POTS) and Mast Cell Activation Syndrome. The link between hypermobility and these disorders are not fully understand at this time.
Dysfunction in hEDS or HSD typically are related to pain, fatigue, or psychosocial stress. In children it is common to also have developmental coordination disorder which can persist into adulthood. A key aspect of hEDS is that it is a first-degree family diagnosis which can be picked up in the subjective. Due to systemic symptoms, therapist may need to refer out to other specialists for more well-rounded care. When performing physical aspect of assessment pay close attention to end ranges of motion due to increased risk of aggravating pain. It is also recommended to perform tests such as the LLAS or ULHAT. The author suggests tests, such as the navicular drop test, are indicated to further assess mobility of foot and ankle joints. Therapist should pay close attention to neuromuscular control, balance, and proprioception as these have all been shown to be associated with hypermobility disorders. If finding symptoms of dizziness, chest pain or syncope, therapist should take blood pressure and heart rate. Greater than a 30-beat increase in heart rate upon standing in adults is suggestive of POTS; greater than 40 beats in children. When examining children, it is important to address quality of movements as well which may not be observed when utilizing the BOT-2 or Movement ABC.
Evaluation, Diagnosis, Management
For hEDS to be diagnosed 3 criteria must be met. They must have generalized joint hypermobility, systemic manifestations of a connective tissue disorder, and the exclusion of other reasons for the current symptoms. After diagnosis is made, the therapist must address the severity of the disorder in order to establish if a multi-disciplinary approach is required. One of the most important interventions is education. Patients who understand their triggers for exacerbation can more effectively reduce symptoms when flare ups occur. It is also important to understand various strategies to protect joints as well as manage subluxations/dislocations. Other suggestions are adding compression clothing in order to enhance proprioception. Exercise is the mainstay in management as it has been shown to decrease spinal pain, joint pain, and improved neuromuscular control of movements. Often patients with hEDS respond well to strengthening programs but require gradual progressions in order not to aggravate muscle and tendon. In patients with POTS, it is also important to understand their decreased tolerance for exercise and increased fatigue following exercise. Patient’s should be educated on ways to mitigate symptoms such as fist clenching. It is recommended to begin with recumbent exercises and lower extremity tasks to promote venous return.
As is evident by the above presented information patient with hypermobility disorders would benefit greatly from skilled intervention focusing on a variety of factors. It is important to address each of the impairments through exercise and education. It is also important to recognize when a person requires a multi-disciplinary approach for overall improvement in symptom management.
Physical Therapy First
We here at Physical Therapy First are trained to examine a variety of patients who presents with symptoms related to hypermobility. At PTF, therapists are experienced utilizing scales, such as the Beighton scale, and work with patients to create exercise routines appropriate for the individual. We understand the many factors that may present themselves in a person with hEDS and can tailor strategies to decrease pain and improve functionality. If you are someone who was diagnosed with hEDS or feel that you are hypermobile and have increased pain, please do not hesitate to reach out to the therapists at Physical Therapy First.
Simmonds, J. V. (2022). Masterclass: Hypermobility and hypermobility related disorders. Musculoskeletal Science and Practice, 57, 102465. https://doi.org/10.1016/j.msksp.2021.102465
Article reviewed by Evan Peterson PT, DPT
Foot pain is a common injury experienced across the population in both the athletic and non-athletic population alike. There are many different causes for foot pain, but one in particular is often misdiagnosed or missed. Cuboid syndrome is one cause of lateral foot pain which is thought to arise from a change in the arthrokinematics of the calcaneocuboid joint. The author of this article states this condition may be brought on insidiously or after a traumatic event.
The Cuboid and It’s Mechanics
The cuboid is surrounded by a variety of other foot bones on the lateral side of the foot. Its borders are the navicular, the calcaneus, the 4th and 5th metatarsals, and the lateral cuneiform. The cuboid is part of the midtarsal portion of the foot and moves in tandem with the navicular. Though it has a variety of motions, the calcaneocuboid joint typically rotates medially or laterally (inversion or eversion). Due to the congruence of articular surfaces, the cuboid is relatively stable but it also has the support of ligaments as well as a fibroadipose labra between the calcaneocuboid joint and cuboid-metatarsal joints. Another stabilizing feature is the peroneus longus tendon wrapping underneath the cuboid. The cuboid acts as a pulley system for the peroneal tendon to allow for efficient eversion during the late stance phase of gait to propel the body forward. The mid tarsal joint plays a large role in allowing the foot to be both a mobile adaptor and a rigid lever for push off. When the foot transitions its weight from lateral to medial, it creates the windlass effect giving the foot enough energy to push off effectively.
What Causes Cuboid Syndrome?
Although a distinct reason for the cause of cuboid syndrome is uncertain at this time, several pathologies have been suggested as culprits. Causes proposed are excessive pronation, overuse, and inversion ankle sprains. The actual mechanical movement of the cuboid is isolated eversion while the calcaneus is in an inverted state. The unwanted cuboid eversion may be caused by improper peroneus longus muscle firing causing an eversion moment on the cuboid. In turn, causing incongruence between the calcaneus and the cuboid resulting in pain.
There are a multitude of factors that could predispose someone to cuboid syndrome such as ill-fitting shoes, midtarsal instability, and being overweight. A study showed 80% of patients with excess pronation had cuboid syndrome due to the increased moment arm of the peroneus longus. Because the calcaneocuboid joint has a labrum, it may become impinged and restrict motion.
The prevalence of cuboid syndrome is not fully understood but it appears to be most common in ballet dancers with foot/ankle injuries or those with plantarflexion/inversion sprains.
What to Look For
Pain is often broadly felt along the lateral aspect of the foot. There may also be bruising, redness, and in some cases a prominence may be felt along the plantar surface of the foot. Patient may be tender to palpate along the peroneals, the cuboid groove, or the extensor digitorum brevis muscle. The patient may also have pain with resisted eversion as well as painful or decreased push off during gait. Although there is no gold standard for cuboid syndrome testing, the author suggests two procedures to rule in the possibility of cuboid syndrome. Either the midtarsal adduction test or the midtarsal supination test. The adduction test stabilizes the calcaneus while the mid tarsal joint is distracted medially and compressed laterally. The supination test adds compression into inversion and plantarflexion. Pain may also be elicited with dorsal or plantar cuboid movement with surrounding joints stable. The therapist must rule out fracture or dislocation of the cuboid, calcaneus, 4th and 5th metatarsals, plantar fasciitis, sinus tarsi syndrome, and several others.
Treatment of Cuboid Syndrome
It is recommended to perform manipulations upon initial presentation of cuboid syndrome. The two techniques most commonly used are the cuboid whip and the cuboid squeeze. The cuboid whip is performed with the patient in prone and the patient’s foot resting in neutral. The therapist then will “whip” the foot into plantarflexion and inversion while thrusting thumbs into cuboid. The cuboid squeeze is performed when the therapist stretches foot into maximal plantarflexion and maximal toe flexion. The therapist will then push the cuboid dorsal. Manipulation should only be performed when bruising subsides or the patient has no other contraindications for manipulation. Following manipulation, if successful, the therapist can implement taping techniques, lateral wedge, and foot intrinsic strengthening.
Physical Therapy First
If you are someone who recently had an ankle sprain or have been experiencing lateral foot pain, reach out to Physical Therapy First where you will be examined by a physical therapist trained in the techniques to pick up on and address cuboid syndrome.
Durall, C. J. (2011). Examination and treatment of Cuboid syndrome. Sports Health: A Multidisciplinary Approach, 3(6), 514–519. https://doi.org/10.1177/1941738111405965