Notes From a Therapist
I recently retired as a physical therapist treating patients for over 30 years in a variety of settings. I saw patients in the clinic with a wide spectrum of conditions, issues, and injuries. Each individual came through the door with a unique condition and history, as well as a unique personality. Interestingly, over the years, I began to notice some predictable seasonal trends. Although many issues, injuries, and diseases ‘just happen’ or are unpredictable, there are many that can be prevented and avoided.
In this article I would like to address 2 issues that can commonly occur in the spring and often can be prevented.
Issue # 1 — New persistent knee pain and possible swelling, without a reported or known trauma/injury, that has lasted for several days, weeks, or even months.
Symptoms and Reports
Often the patient reported that there was no injury or known reason for the new knee pain. During the interview and in taking a thorough history, there was often noted an old knee injury or issue with knee pain, but no recent ongoing problems or symptoms. They reported any combination of the following: an onset of stiffness, difficulty bending or fully straightening the knee, pain with walking or using the stairs, a clicking or grinding noise, catching of the knee, an ache or throbbing at night, or discomfort after sitting for a period of time. Also, after asking the patient further about any new activities or changes in routine, a pattern emerged of similar reports. Some common examples were reports of initiating or resuming an outdoor walking or running program (often with old or worn-out shoes), weeding the garden or planting bulbs, perennials, or annuals in a kneeling or squatting position, or walking around on the ground on their knees while gardening. Many also reported completing these activities for a good portion of one or several days.
Clinic Exam Findings/Observations
The patient often limped into the clinic or there was an altered gait (walking pattern). At times there was limited mobility of the knee (inability to fully bend or straighten the knee), a palpable clicking or grinding noise, warmth to touch, or swelling. Sometimes there were no visible or obvious signs.
Common Causes
Aggravating factors can be a history of mild to moderate degenerative joint disease or arthritis, an old cartilage or meniscus tear or a degenerative meniscus, or roughened joint surface. The new activity of walking or running, kneeling directly on the knee(s), squatting, or sitting fully ‘back on your haunches’ causes joint and tissue compression and pressure. This can aggravate joint tissue, fluid sacs known as bursas, tendons, or ligaments (more commonly known as swelling in the joint, arthritis, bursitis, and tendonitis). Also as we age, we lose valuable fluid content in our tissues and joints which acts to lubricate joints and tissue and is designed to assist with smooth joint motion; think of how oil and fluids lubricate parts in machines or cars to help keep them running smoothly. With extensive kneeling and squatting, we squeeze some of these fluids temporarily out of the tissues. Even in a healthy joint without an injury, this can explain why it is sometimes hard or takes time to stand up or straighten the knee after assuming an extreme position. With an underlying condition of the knee, the results of kneeling and squatting can be more of a problem or issue.
INCORRECT
Recommendations for Prevention
If you are going to start running or walking, make sure that you have shoes that fit well, have good arch support and adequate soles for shock absorption. Take time to break in your new shoes. Start out walking slowly for 15-20 minutes and gradually build up distance, speed and time (as tolerated) to meet your desired goal. When working in the garden, change your position often and limit kneeling and squatting to 15-20 minutes at a time, take frequent breaks to stand up and walk around, and then resume the project. Break your project up into several days instead of ‘power gardening or weeding’ everything in 1 or 2 days. Also, consider using a foam kneeling pad or gardener’s bench to reduce pressure on your knee(s). Or better yet, find a family member to help (or hire someone) and supervise the project yourself.
CORRECT
Issue #2 — New pain in the shoulder or upper arm at rest or when lifting the arm that has lasted for several weeks.
Symptoms and Reports
The patient often reported persistent shoulder pain that was not going away or was getting worse when lifting the arm up (for example to wash hair or reach for something in the cupboard), reaching behind back (for example to tuck in a shirt), reach across to the opposite shoulder, or even pain lifting a cup of coffee. They often reported a pain or ache that woke them up at night.
Clinic Exam Findings/Observations
The patient often walked into the clinic holding their arm in a guarded or protected position close to their body, or cradling it with the opposite arm. They were apprehensive to move the arm. There was often limited motion and difficulty lifting the arm above the shoulder, reaching out to the side, or behind their back during the exam. For some patients, muscle weakness was noted.
Common Causes
During the history and interview inquiring about any recent unusual activities, the patient often reported recent extensive or prolonged overhead work. At times they couldn’t think of any aggravating factors but with further questioning, a common pattern of reports emerged. As with the knee, there may be an old injury or surgery, an underlying mild to moderate degenerative condition, a calcium deposit or spur, or a tissue tear. This can result in a narrowing of a joint space, space which is important to accommodate tissue (tendons and bursas) when moving or lifting the arm. A very common shoulder condition is known as an ‘impingement syndrome’ which can be an irritation, pinching, or thickening of one or more of the rotator cuff tendon group, or a bursa. Many patients would report common activities of painting, scraping, or ceiling home improvement projects with repetitive arm motions (often overhead), outdoor trimming of branches, limbs, or bushes during a weekend spring yard clean-up project, or cleaning gutters. Another example was lifting or carrying full 5 gallon gas cans for the lawnmower, or reaching to lift them in awkward positions and, at times, hearing a pop or tear.
INCORRECT
Recommendations for Prevention
Avoid prolonged overhead projects. If possible use a ladder or step stool (as long as you are safe) to raise your body in order to keep your arms and shoulders more level with your project. Use extenders or long-handled tools. Keep the project directly in front of you instead of reaching out to the side. Avoid lifting heavier objects in awkward positions or reaching out to the side while lifting. Instead, lift objects directly in front of you, use good body mechanics, and keep objects close to your body or trunk. Rest the arm and let it hang down by your side as needed, take frequent 5-10 minute breaks every 30-45 minutes if getting tired or sore, and then resume your project. Sometimes a project needs to be extended over several days or weeks with less time spent on the activity per day.
CORRECT
First Aid for Knee and Shoulder Pain
Rest for several days or weeks as needed and stop the painful activity. Try using a cold pack on the painful area for the first 2-3 days (20 minutes each session — you can ice several times per day as needed). After several days you can progress to alternating cold and warm or mainly use warmth if it helps. Each individual and issue responds differently — listen to your body. If pain and/or swelling continue for several weeks, you may want to schedule a consult with your physician for further assessment and instruction. If you suspect a serious issue or injury, seek immediate medical care.
In summary, I encouraged my patients to and still encourage people to stay active, keep their bodies moving, and enjoy the outdoors. Whether you have been active all winter, have been sedentary, or are just starting a new or different activity, please be mindful and use good judgment in how you approach exercise, new activities, or spring projects. Many injuries, aches, and pains can be minimized or avoided so I hope this information and these suggestions have been helpful to you. Please enjoy your spring!
