Guest Case: Meniscus or Spine?

A patient I saw recently served as a powerful reminder of how important considering spinal mobility is for managing lower extremity conditions. Patient is an 18yo male dancer, who has been dancing “for as long as he could remember” and until recently had been dancing for several hours a day most days of the week. A few days prior to seeing me, he said that he had been dancing, performed a move with some twisting, and afterwards started having sharp pain in his left knee.

Given the way his pain started, meniscus and other passive structures of the knee seemed like reasonable culprits. Lachman’s, Anterior/Posterior Drawer, Lever Sign and Valgus/Varus stress testing were all negative. Jumping over some of the other objective data, what was most striking to me about the patient was that he was positive for all five of the cluster of meniscal tests1:  (1) history of joint locking, (2) joint line tenderness, (3) positive McMurray’s, (4) pain with flexion overpressure and (5) pain with extension overpressure. According to the study, being positive for 5/5 tests leaves specificity at .99, which the ol’ SpIN-SnOUT tells us means that my patient likely has a meniscal tear of some kind.   

He had limited knee extension and tibial internal rotation on the left, so I first worked to restore those with mobilization and then repeated movements. Repeated knee extensions provided some mild relief, as did IASTM, which I performed on the anterior and posterior knee. If I moved his left tibia in to internal rotation, he reported an immediate increase in symptoms, so I didn’t even try further mobilization. He tested slightly weak for hip and knee strength on the left, so I gave some fairly standard hip strengthening exercises (clamshells, side-lying abduction, etc.).  For homework, I gave him repeated long arc quads, 15 every hour that he was awake, in an effort to re-establish symmetrical knee extension.

When he returned for his second visit, his pain was about the same. This is where it gets interesting. Having recently been thinking about the connection between issues of the spine and issues in the lower extremities, I looked at his global extension – limited. Not a huge limitation, and he was already pretty mobile as a dancer, but it was enough of a limitation to be noticeable. So, I trialed repeated press-ups in prone. After 20 reps, his pain went from a 7/10 to a 4/10. After another 20, 1/10. Because the pain was unilateral and his side-glide to the L was limited, and because I wanted to try to eliminate the pain if possible (gettin’ greedy, I know), I also trialed repeated side-glides to the left (i.e. loading the left), but this didn’t produce any noticeable change. So, I gave him hourly repeated press-ups to do when he was at home, and standing extensions when he was at school or didn’t have a place he could easily lay down prone.

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Now, you’d think he would be compliant after we essentially eliminated his pain with the press-ups, but alas, he was not. He didn’t do the press-ups almost at all and his pain was back to where it was before. So, I manipulated his lumbar spine and had him perform repeated press-ups, and this time his pain was gone. I gave him a stern talking-to about doing his homework, and showed him how to make a lumbar roll so we could add to the amount of time he was spending in lumbar extension, and sent him on his way.

Since that appointment, he has been almost pain-free. I say “almost” because – and this is, in my mind, confirmation of the contribution of the lumbar spine to his problem – he said he had a little flare up after he took a road trip and forgot his lumbar roll. From looking at his normally sitting posture, I knew that meant many hours of significant lumbar flexion. However, he knew well enough at this this stage in his therapy to know that he could manage that with repeated lumbar extensions.

So, what do I think there is to be gleaned from this patient experience? For meniscal issues, at least consider the spine. While it is not the only, or even the first, thing to consider – the limitations that are closer to the presenting complaint (like lack of terminal knee extension, then tibial IR limitation) still take priority in my mind – considering the lumbar spine may be of great benefit to your patient. Some it might help, some it might not. Since seeing the patient I’ve described above, I’ve had two other patients who were also positive for all five tests of the meniscal cluster: one was also significantly helped by mobilization and repeated motion of the lumbar spine but the other’s pain was eliminated instead by repeated knee extensions and repeated tibial IR. Helpful for some, maybe not for others, but definitely worth considering, even if your symptoms are somewhere else.

-Harrison

Reference:
1 Lowery DJ, Farley TD, Wing DW, Sterett WI, Steadman JR. "A clinical composite score accurately detects meniscal pathology." Arthroscopy. Nov 2006; 22(11):1174-1179.

Bio: Harrison is a third year Doctor of Physical Therapy student at the Downtown Phoenix Biomedical Campus of Northern Arizona University. His professional interests eclectic but largely center around the intersection of neuroscience and orthopedics and how they can inform each other to produce more effective care for patients.  He is also currently enrolled in the OPTIM program for Orthopedic Manual Therapy (COMT).

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