Knee Injury Question (Taekwondo)

[Bruce Lee]

Hi all,

I have been browsing the forum and thought I would post hoping somebody can help me out a little.

I am hoping someone can help to give me ideas on what I should do about my current knee injury.

I used to do Taekwondo twice a week (90 mins) as well as running and strength training. I had been studying Taekwondo for around 2 years; I studied for 1 year took a year off (not due to injury) and then did Taekwondo again for about a year.

About 7 months ago I experienced some knee pain towards the end of a Taekwondo session that involved a lot of twisting/rotating etc, as well as kicking drills, kicking pads and footwork drills.

When I got home my (right) knee was swollen and I applied Ice etc. The swelling and pain lasted about 1 week. I rested for 2 weeks until I got to the stage where I just had a remaining nagging pain and then did another Taekwondo session which I was not able to complete due to the knee swelling again and becoming painful.

Since this second session I have not trained in Taekwondo again.

I visited my GP after the second Taekwondo session. He told me to rest and placed me on a waiting list for NHS physiotherapy and said it would take about 12 weeks so I decided to seek an independent physio.

So far I have seen 3 Physiotherapists.

The 1st guy I saw thought I had sprained/torn my Lateral(?) outer knee ligament and gave me a lot of jumping and lunging type exercises (jumping up to a bench, squat jumps, multi-directional lunges) and resistance exercises (leg extension, leg curl, leg press) to re-strengthen my knee and prepare me for my return to taekwondo. Also he advised using cardio machines.

These kinds of exercises seemed to aggravate my knee, and several times it swelled up slightly and was stiff in the morning (after RICE treatment).

After a couple of sessions I decided to seek a second opinion and saw a 2nd physio. The 2nd guy suggested removing the jumping and lunging and added abduction and adduction exercises. Also he gave me ultrasound and deep tissue massage treatments every 2 weeks thinking I had a tight ITB. He also suggested I re-start running on a treadmill, however the running led to pain in my knee afterwards and it felt sore and swollen afterwards. This was usually somewhat better by the morning.

After about 6 sessions (every 2 weeks) my appointment for the NHS physio came through. This physio believes that I have a cartilage problem and is prescribing Pilates type strengthening exercises for the Quads and Hamstrings. I am following this advice without much benefit but the NHS physio does not want to refer me for any kind of scan etc although we are still not sure what the problem is. I am still in the same position that I was in several months ago whereby I can do some low impact cardio and resistance training but this makes my knee sore (afterwards and in the morning) and I do not feel that my knee could tolerate training at any higher intensity.

What do people think should be my next step?

Please feel free to ask any questions.

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[ATTIreland]

Hi Bruce,

Well done to the NHS physio, who sounds like the most likely of the three to be correct (Taking into account mechanism of injury and the fact neither LCL or ITB sprains/strains typically cause swelling), as from what I've read on this site NHS physios don't seem to be rated highly.

I cant understand however how he is reluctant to send you for a scan. Its been 7 months and while you've been doing inapropriate rehab for most of it by the sounds of it you still are not recovering with conservative treatment (non-surgical) so its time to get a scan and an opinion from an orthopaedic surgeon.

If you have the resources go private, if not keep putting on the pressure for the scan/opinion. A bit of research into Meniscus injuries (what the type of cartilage you've most likely injured is called) will help you argue your point a bit more.

Hope it goes well

[Bruce Lee]

Thanks for responding ATTIreland.

From speaking to the 3 Physios and from my own physical perception of the problem it seems to me that the NHS physio is making the most sense. I find that most staff I deal with in the NHS are pretty good people but generally seem to be suffering from lack of resources etc.

The reason that she has given for her reluctance in sending me for a scan is as follows. She thinks that I will have to see a specialist first and if my knee is unstable when I see him he will recommend more physio before a scan but if I increase the stability and strength in my knee but still am experiencing pain then he will refer me for a scan. Does this sound sensible?

Also I have recently spoken to a friend who is a physio in a different area of the NHS who told me that they use a rule of thumb whereby they refer to specialist/for a scan after 6 physiotherapy sessions. I have my 5th session in a few days so I am about 3 weeks away from my 6th session. If I do not get a referral after the 6th session I shall consider some private treatment.

However I am not sure how I would go about combining NHS & private treatment, for example if I pay for an MRI which reveals the need for an operation that I cannot afford how do I proceed from there.

Finally does anyone have any ideas as to where I can research which type of cartilage I’ve injured as I have currently researched every site I have been able to find myself and 'meniscus' is as far as I have got.

I would really appreciate any help/advice that anybody is willing to take the time to give.

Thanks.

Bruce.

[ATTIreland]

Howdy Bruce,

As you can probably guess I'm Irish so don't have first hand experience of the NHS physios and was only going on the comments of individuals on here so good to hear you think they're good.

Again I'm not familira with UK health system but seeing a specialist first is a common practice here and I can understand her hesitency sending you if there is an unofficial (or official) rule saying you have to go for 6 sessions first.

Unfortunately this is the negetive side of having a public health system. They want to reduce the numbers going for scans and specialists to keep costs down (which is fair enough). In your case though you'll probably have to see specialist and get scan anyway so rather then costing say 2 physio visits+Specialist+MRI your now going to cost the system 6 visits+Specialist+MRI. If they allowed physio's more clinical decision making power then they'd likely save money but its a Doctor-led system so cant see it happening.

Anyway getting back on topic, the way to incorporate private and NHS would be if you got your MRI scan before the specialist visit you'd bring the report and the scan itself (on a disk) in to him which saves on the couple of weeks (months?) you'd spend waiting on an appointment for an MRI in the public system and then getting back in to see him. However there is a fair cost to this route so NHS is probably best way to go at the moment.

As for research check out link below. It has link to loads of info such as treatment and surgical approaches.

Meniscii - Wheeless' Textbook of Orthopaedics

Hope its helpfull

[evphysio]

Hi Bruce and ATT,

I hate to disagree (as I could easily be wrong) but damage to the meniscus probably would not result in swelling of the knee joint as it has very poor vsacular supply.

A quick test to find out if there's a tear in your meniscus is as follows: squat down so both your knees are fully bent over, now try and walk forward. you'll probably waddle a little like a duck (which is why this is called the duck walk test). If you can do both those things (fully squat and duck walk) without any pain then your meniscus are probably intact.

Bruce: does your knee ever "lock" or give way when you're walking?

Ev

[ATTIreland]

Hi Evphysio,

Not trying to offend or anything but are you a chartered physio or are you a physio student/anatomy student?

I only ask because of the way you phrased your reply:"damage to the meniscus probably would not result in swelling of the knee joint as it has very poor vascular supply". It reads as if you havn't seen a meniscal injury in a clinical setting before and are basing your opinion on a knowledge of anatomy only?

You do make reference to the duck walk test and ask about clicking though so I'm not sure what to make of your post.


As far as swelling goes, it is a very common sign of meniscal injury particularly if it comes on a little while after the initial injury, as described by Bruce. (rapid immediate swelling would typically be more associated with ACL tear or patellar dislocation).

As for clicking/locking/giving way/etc, while these are classic signs of meniscal injury they are often absent, so while their presence would definitely indicate a meniscal injury, their absence does not make a meniscal injury significantly less likely (I've found locking/clicking to be more of an indicator of severity of meniscal injury than a significant factor in out rulling them).

Anyway thats just my opinion and you could well be right but I wouldn't be putting any money on it.

[evphysio]

Hi ATT,

No offence is taken as I am physio student adn I did suspect I could be wrong. I wasn't trying to undermine yourself just practicing my clinical reasoning. And I indeed did word my reply as such because I have not seen an acute meniscus injury on placement yet.

So why would swelling occur in a damaged meniscus if there is no vascular damage? (not an argument but a genuine question)

[ATTIreland]

Hi Ev,

Good to see you your keen to practise your clinical reasoning and it'll stand to you when you get out practising.

To answer your question, firstly while its true that the inner third of the menisci are not really vascularised the outer 2/3 are to an extent. Therefore injury to the outer 2/3 can cause swelling from a vascular source. Much of the effusion caused with meniscal injuries is thought to be as a result of increases in synovial fluid secretion to protect injured tissue which is not reliant on a vascular supply.

Again it come back to the onset of swelling seen with meniscal injuries Vs. ACL injuries. With ACL rupture its largely a haemarthrosis (blood) so it happens quickly, while with the meniscal injury the synovial fluid secretion takes longer to become apparent.

Rough clinical guide:
'pop' + rapid swelling = ACL
twist + delayed swelling = meniscus

hope thats of assistance

[evphysio]

thanks for that, a nice rule of thumb.