I’m a 49 year old male, 5’8" and about 190 lbs. I’ve been lifting fairly regularly for several years, but more for general health than to achieve big numbers. I think I’m probably near the bottom end of the intermediate range, with fairly recent e1RMs around 320 (SQ) and 360 (DL).
Starting a couple of months or so ago, I noticed the occasional, sometimes sharp knee pain, not just during exercise, but also after sitting for a while, during longish walks, stairs etc. I’m not aware of any specific acute trauma that might have caused the pain. Both the presentation of the pain and its location seemed quite different from the occasional tendonitis-type pain I’ve experienced before. The pain is located on the medial side, near the joint line, and it’s worst near maximum flexion and near full extension (when I flex my quad). I do not have mechanical locking symptoms, but I do have crepitus (in both knees, actually).
I have seen a doctor specializing in sports medicine about this, whose tentative diagnosis was that I probably have a meniscus tear. He recommended getting an MRI just to make sure, but also thought surgery was extremely unlikely to be indicated, and that physio of some kind would be the way to rehab this.
I have read your blog on this topic, as well as your response here. Based on all this, I have some questions I was hoping to get your thoughts on:
- Would you agree that a meniscus tear is the most likely diagnosis for my symptoms?
- It seems like surgery is not a great idea even with mechanical symptoms, so pretty much ruled out for a case like mine. Given that, would you recommend getting an MRI at all, or is the rehab protocol independent of anything the MRI is likely to show, so there is no real point in getting one?
- What is a sensible rehab protocol for a (likely) meniscus tear like this? Is it the same as your published knee rehab protocol for non-specific knee pain?
- More fundamentally, I’m a bit confused about what is causing the actual pain here – is it basically “just” inflammation of the meniscus and/or tissue surrounding it? I.e. is the goal to reduce this inflammation in the hope that the tear will then become asymptomatic? Are anti-inflammtories (e.g. topical diclofenac or ibuprofen+levomenthol) a good idea or a bad idea? Thanks in advance for any information or advice you might be able to provide!
Hi, thanks for the questions and for doing some homework before posting, Mike’s blog and responses are definitely worth the read. I’ll try to answer your questions in the best way I can:
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Would you agree that a meniscus tear is the most likely diagnosis for my symptoms?
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This is hard to say, because the diagnosis made from history, symptom presentation, and any physical examination tests is challenging and not terribly specific. There may be some probable cause of meniscus tear present, based on base rates, and it may provide some sensory input for the overall symptoms, but based on how we view pain as a multifactorial process it’s hard to pinpoint the meniscus in your case.
- It seems like surgery is not a great idea even with mechanical symptoms, so pretty much ruled out for a case like mine. Given that, would you recommend getting an MRI at all, or is the rehab protocol independent of anything the MRI is likely to show, so there is no real point in getting one?
- I would not recommend the MRI based this reasoning. It will not significantly change your prognosis or the plan.
- What is a sensible rehab protocol for a (likely) meniscus tear like this? Is it the same as your published knee rehab protocol for non-specific knee pain?
- Possibly, but I’d be more apt to modify what you’re currently doing, as well as discuss your overall activity outside of the gym and see if there’s any room for modifications there as well. What does your program look like right now, and have you attempted any changes to it over the last few months with any success in symptom management?
- More fundamentally, I’m a bit confused about what is causing the actual pain here – is it basically “just” inflammation of the meniscus and/or tissue surrounding it? I.e. is the goal to reduce this inflammation in the hope that the tear will then become asymptomatic? Are anti-inflammtories (e.g. topical diclofenac or ibuprofen+levomenthol) a good idea or a bad idea?
- This is the million dollar question that is always hard to answer with something black and white. Inflammation can be a factor for pain, but as stated above, it lies in a multitude of factors, especially with pro- and anti-inflammatory processes happening simultaneously throughout your body, so I would not recommend anti-inflammatories here. What I tend to focus on are the modifiable factors that seem to be influencing the pain, the things we can adjust and work on. In this case, and in most, looking at the active elements of programming and general activity is a great start, but can include other areas of work/life-related stressors, sleep, etc. Austin wrote a recent piece on what to do for pain during training that looks at the more practical side of symptom management during training, but gets into some theory as well: Pain in Training: What To Do?
- What’s probably more important than what the pain actually is, is to understand what it isn’t, and in this case, I would not think of it as equating to meniscus damage, but rather an opportunity to re-evaluate current training and activity as a means to balance stressors and prepare you for future activity.
Thank you for this extremely helpful response and the pointer to Austin’s blog.
I had, in fact, changed my routine as a result of all this – most importantly, I’ve not been training for the last month or so, because I was concerned of exacerbating the problem. It’s already useful for me to have the reassurance that pain here need not mean “meniscus damage”. What I’ve been doing so far – which has mostly been laying off various activities – certainly hasn’t seemed to help much. This is really why I’ve wanted to figure out an actual active rehab protocol, because with hindsight, I guess it’s not surprising that laying off hasn’t helped.
Am I correct in guessing that a tentative rehab program might then be something like my normal program, but with initially lighter weights and/or reduced ROM for lifts like the squat? And then to gradually increase load and/or ROM to get back to full functioning?
In your experience, do you find that this type of pain usually fully resolves over time? Or is it something I should just expect to get used to?
Thanks again!