The knee is the abused, misused, neglected until defected (when it defects from you, donates itself to science, and leaves in its absence a glorified door hinge that reduces overall functionality to the joint of a cheap promotional action figurine such as those designed by Hasbro or Mattel), disregarded but absolutely necessary middle man that’s not quite the hip and not quite the ankle.

It lies in a perpetual state of limbo about halfway up or halfway down (which goes without saying, as halfway is halfway whether you were coming or going) the leg. It provides the obvious function of bending (even though most small children know this college physiology text books still tell you, incase you were wondering) but also more subtle functions (related to bending), which, if understood fully would increase the status of the knee to a prince among body parts, not to be thrown aside for a low budget manufactured plastic (or whatever synthetic ceramic polymer they are using) imitation of the real thing.

What the knee is and what it can do for you

If you’ve already had a knee replacement don’t worry, this information still applies to you, and if utilized correctly you will still have an advantage over someone that doesn’t exercise these principles in spite of having a fully functional knee.

The knee is ultimately an anatomical metaphor for stability in a chaotic and ever changing world. Your knee has the ability to soften hard ground. It provides a foundation that can keep us upright even as the earth crumbles from below our feet. If used correctly the knees will keep you steady and unshaken as you move over uneven terrain. An intelligent knee (yep, body parts have minds of their own) sets up a stable base from which we can apply powerful martial or sports techniques. When properly trained the knees allow us to fall from a great height and land uninjured – or less injured – depending how great the aforementioned height happens to be.

Typically when someone loses their balance, barring a problem with the inner ear, or their eyesight, nine times out of ten they were doing something wrong with their knees.

How we walk

The way to immediately start applying the abilities I listed is to begin with walking. Walking is as far as I’m going to go into on proper knee usage in this article, because it relates directly to rehabilitation and almost everyone does it. As for the other functions of the knee listed above, they require more training than I can provide in this article, so I won’t be going into much detail there.

Humans spend so much time learning to do complicated high level tasks; chemical engineering, architecture, musical composition, graphic design, computer programming, brain surgery, quantum physics applications, carpentry, mechanics, long division, dance choreography, synchronized chainsaw juggling (the list can go on and on until heavy eyes or dry heaves lead us to ponder whether or not we should self-diagnose ADD/ADHD and begin a Ritalin regimen).

But simple things that we have to do every day; walking, sleeping, breathing, standing, and sitting most people learn just enough to be good enough to barely scrape by, even though mastery here provides a fertile soil from which the mind boggling complex ‘higher’ skills can come more quickly to fruition.

Make no mistake, we are predatory animals, the fact that we can survive on nothing but fruits, vegetables, nuts, and grains is just a testament to our ability to choose, and our ability to survive. Our eyes are in the front because we focus on our desire and we go out and take it. It doesn’t matter if you’re hunting big game or hunting for blue berries, you’re still hunting.

Though we share the mentality of lions, most people lumber around like elephants, landing with each step on straight legs, forgoing smooth ride Cadillac suspension for rusty springs or stiff planks that treat the knee as though the tibia and fibula (shin bones) have been fused to the femur (upper leg bone). Years and years of bending the knees only after the most opportune time to do so leads to knees that no longer bend correctly, whether the time is opportune or not.

The correct way to walk (hardly anyone does this, even after being told to do so, because old habits die hard, and who has time to practice walking anyway? Its not like people walk anymore) is to bend your front knee throughout the weight transfer between the rear leg and the front leg.

A lot of people learn to do this while they are learning Tai Ji (the second word in Tai Ji is pronounced jee, not chee, and the ji does not mean the same thing as the universal energy qi, or chi) stepping, but you don’t have to be practicing Tai Ji (or even pronouncing it correctly for that matter) to do this, you should be stepping this way with every step.The knee should bend until the weight transfer is complete, and then the other foot is raised and placed in front. When people do this correctly it is though they are gliding along on moving platform. Each step is light and soft, barely audible if walking on compacted earth. There is no exaggerated bouncing up and down of the head with every step that is extremely common and detrimental to the body as a whole.

Really the only time the leg should straighten fully is at the back of the stride, before it is lifted and shifted to the front leg. Momentum and forward thrust comes from the rear leg. Otherwise you continue, as most people, to walk as though on stilts and slippery when wet applies to you so be prepared to take a fall if you’re not paying attention.

I have seen no shortage of day hikers that stomp along the trail leaving deep clumsy prints unaware that the price they are paying for weight loss, a healthy respiratory and circulatory system, and a good view, is the gradual degeneration of the cartilage in their lower back, hips, knees, and ankles – and ultimately a future that may be devoid of hiking.

Learning to step softly, as a tiger that quietly sneaks up on its pray, has the benefit of not only preventing joint damage, but leads to the gradual rehabilitation of knee injuries as well. Every step done in this manner allows the bones to glide smoothly over the cartilage in the knee, pumping in vital blood and nutrients and smoothing out scar tissue and calcium deposits. For advanced injuries acupuncture and manual therapies such as connective tissue acceleration and tui na medical massage are necessary, but for really minor knee pain this small correction in body mechanics is often enough.

Ligament damage

For chronic knee pain it’s typically best to start looking at the tendons and ligaments where healing usually takes the longest. Even for acute pain it’s good to begin with the tendons and ligaments because muscle injuries tend to be minor and heal by themselves fairly quickly, unless extremely severe, like a complete tear.

The four most attention grabbing ligaments of the knee are the lateral collateral (connects the fibula and femur, and lies lateral to these structures), the medial collateral (this one lies medial to the femur and tibia connecting them), the medial comedial (just kidding, there is no medial comedial ligament), the anterior cruciate ligament (connects the front of the tibia with the back of the femur), and the posterior cruciate ligament (which lies posterior to the anterior cruciate, and connects the back of the femur with the back of the tibia).

A ligament tear happens more often in acute injuries than chronic ones. A severe tear of the ligament is pretty simple to diagnose in a clinical setting without the use of diagnostic imaging. These four ligaments provide stability to the knee, each specializing in opposing a specific movement of the tibia (shin bone) relative to the femur (thigh) bone that would lead to joint instability and weakness if the movement was permitted.

To test if a specific ligament is partially or completely torn, the clinician simply moves the knee in a direction it would not normally go given an intact ligament. The anterior cruciate ligament prevents the lower leg from sliding forward (anteriorly) with respect to the femur, and opposes hyperextension (leg straightening beyond the point of straightening). It is impossible to place your shin comfortably on the lap of the same leg with an undamaged ACL, even for advanced yoga masters. If the lower leg can be extended past 180 degrees, or can be pulled anteriorly with respect to the femur it may indicate damage to the ACL.

The posterior cruciate ligament prevents the lower leg from sliding posteriorly with respect to the femur. Sometimes this is injured in car accidents when the shin is struck while the leg is bent, pushing the lower leg backwards with respect to the upper leg.

The lateral collateral and medial collateral each prevent the pendulum side to side swinging of the lower leg (using the knee as a fulcrum) that would be possible if they weren’t intact. The medial collateral prevents lateral flexion of the lower leg, and so if it is uninjured you shouldn’t be able to touch the lateral ankle against the hip of the same leg. The lateral collateral ligament prevents a pendulum swing in the opposite direction.

Admittedly two of the above movements are highly exaggerated. If any of these abominations of flexibility were to transpire the extent of injury would far exceed the associated ligament damage. But small movements in these directions are indicative of preexisting ligament damage, and incidents which force the leg to bend unreasonably tend to injure the ligaments that oppose that particular contortion.

To test for hyper-elasticity and thus a possible tear of these ligaments steady moderate pressure is placed upon the knee to move the leg in directions a fully healthy knee would not allow. Lachman’s test pulls the superior portion of the tibia anteriorly with respect to the femur to test the ACL. Reverse Lachman’s test is similar but pressure is applied posteriorly to test the PCL.

Valgus testing places lateral pendulum pressure on the tibia with the knee stabilized so it acts as a fulcrum to test the MCL. Varus testing applies pendulum pressure in the opposite direction to test the LCL.

All of these ligament-tear-tests are performed with the knee bent to about 20-30 degrees because with a straight knee the other ligaments are also activated and so assist in opposing the movement. In this way the particular ligament in question is isolated during the test.

The patellar tendon is a less appreciated ligament (so unappreciated it is classified as a tendon) that connects the knee cap to the tibia. It is somewhat appreciated by modern medicine inasmuch as it is a favored harvesting spot for ligament grafting of the more popular ligaments (which means it is cut out and put somewhere else, more on this in the next section).

The patellar tendon (which is actually a ligament), and the various tendons of the quadriceps and hamstrings (which are actually tendons) that surround the knee are even easier to diagnose than the 4 superstars. The ACL, PCL, LCL, and MCL have no associated muscle group and so must be diagnosed based on history of the injury, a subjective feeling of instability of the joint as reported by the patients, and primarily by the physical exams described above.

The remaining tendons and ligaments all have an associated muscle group. If they are injured there will be local pain with palpation (and possible swelling) and also pain when the associated muscle group is stretched or flexed. If they are completely torn or ruptured, they lie close to the surface, so the tear will be manually palpable.

Surgery for a torn ligament

One of the drawbacks of surgery for torn ligaments is that the surgeon does not actually repair the damaged ligament. Instead tissue is taken from somewhere else, such as the patellar tendon, and then grafted on to replace the original ligament. It is all well and good to promote stability to the knee by reinforcing damaged ligaments, but what about the stability lost when part of the patellar tendon is removed?

Other tissues may be used in lieu of the patellar tendon, but stability and strength may once again be compromised depending on where the tissue came from. A donor can also provide these tissues, but then there is increased risk of infection and disease transmission. Donor tissue may have become weakened over time depending on how long it was stored.

Recovery time and scar tissue are unfortunate but necessary components of most surgeries. Sometimes scar tissue results in pain and/or numbness that is more debilitating than the original condition that was surgically corrected for.

A study found in 2002 that patients undergoing ‘placebo surgery’ had just as beneficial results as the patients that underwent true surgery for knee pain. Admittedly this surgery was used for osteoarthritis which is wear and tear of the cartilage, but it still points to the fact that surgical results for knee pain are a bit dubious. Perhaps this study should be repeated for ligament tears to see whether or not surgery in that case outperforms the placebo.

Scar tissu

Ligaments and tendons can develop scar tissue, which can happen after a tear, as the ligament heals, or due to poor circulation which leads individual cells within the ligament too die (necrosis). Scar tissue is when the original cells within the ligament don’t line up in their usual neat organized patterns but rather overlap in a heap of whatever it takes to fill in a gap as fast as possible. Scar tissue is sometimes followed by calcium deposits, but like scar tissue, calcium deposits can result from poor circulation as well.

Usually surgery is only necessary in the case of a complete tear of one of the ligaments, or in the case of a compound fracture. Acupuncture, Tui Na, and Connective Tissue Acceleration provided at Roots of Eastern Medicine Acupuncture Clinic are excellent alternative (but should be mainstream given their track record) effective techniques to treat minor tears, scar tissue, and calcium deposits in the four knee ligaments.

Calcification of the medial collateral ligament is known as Pelligrini-Stieda syndrome. Who knows why these two didn’t diversify to include the other ligaments of the knee, as far as I know calcification here isn’t named after anyone. If anyone asks, I’ve got dibs on the lateral collateral ligament. Immortalized as a defect of the fragile human condition still means forever, no matter how you spin it.

I’d say define Benjamin Krieg syndrome as calcification of the rest of the ligaments in the body (yet unnamed by a specific syndrome), but I don’t want to appear too greedy, especially after Pellegrini and Stieda were so magnanimous as to share amongst the two of them (count them; one, two) just one (count it; one, that’s all, just one) ligament.

What would it look like if I became the hoarding capitalistic despotic baron of ligament calcifications, especially after Pellegrini and Stieda set the bar of precedence so unfathomably low?

My soap box (skip this if you only want to learn about the knee)

Why should calcification of all of the ligaments of the body should be lumped together into one big all inclusive syndrome? Well, barring a systemic disease such as gout or rheumatoid arthritis which may both eventually lead up to calcium deposits (note that the key word here is eventually, neither of these begins as calcification per say, but can lead to that eventually if unchecked), for the most part the treatment of calcium deposits of the ligaments is typically the same regardless of where you are in the body. You must do a therapy that increases the circulation of blood within the ligament in question. That’s all. The body does the work after that point.

Modern medicine has gotten so technical with its MRIs, full body scans, barium swallows, radiation mediated chemotherapy, drugs that selectively increase high density lipoproteins while decreasing their low density counterpart, selective serotonin reuptake inhibitors, muscarinic nicogenic pathodiatides (yeah, I made that last one up, but look for it coming soon to a pharmacy near you) that now it all but ignores basic pathophysiological principles. Don’t let them fool you here, it happens all the time; if circulation is poor you don’t heal. If circulation is good you do heal. That’s it. But treatment according to this principle is easier said than done.

I hope you can see that this is a manifestation of the same issue listed above in the walking section. People tend to set their sights so high up to the top of the mountain that they overlook the heaping foundation of dirt that makes those heights possible. Often they climb to a theoretical high and then look down to realize there is nothing left to stand on. I’m not saying modern medical doctors don’t understand these principles, they do, it’s just seldom applied to orthopedic conditions.

The reason medicine today has gotten away from the basics is that they are easy to understand, but not so easy to apply. Memorizing an encyclopedia’s worth of disjointed facts is pretty much worthless in teaching you to treat patients according to simple foundational principles; in fact, it may be detrimental, as it puts you into the same aforementioned predicament.

Learning to treat patients according to the basics is similar to learning to paint portraits, or play music. It takes hands on practice and an intuitive sensitivity that is hard to teach without first being experienced.

OK, modern medicine uses this principle a little bit, but only inasmuch as they say if something doesn’t have good blood flow (and is damaged) you should cut it out, if it has good blood flow you can leave it alone (this is usually the case for meniscus injuries, which I will discuss later). Increasing blood flow to areas largely devoid of blood flow is unfortunately not usually considered.

A lot of alternative practitioners have incomprehensible abilities but get disrespected from time to time because they don’t know some factoid, like the tensor fascia latae (TFL) is the muscle that attaches the hip to the illiotibial (IT) band (which you don’t need to know to apply the poor circulation rule anyway). And then there are those that know about the IT band and so assume that now they are experts in the care of leg pain even though their hands-on technical skill is either limited or non-existent.

The majority of orthopedic patients don’t have anything going on that can be visually detected, their problem must be felt. Nothing shows up on MRIs, X-rays, or cat scans. Most of my patients have reported the following experience with their primary doctor in this case: He either blames the patient’s mind: “there’s nothing actually wrong with your knee, but let’s put you on effexor (an antidepressant) to get your brain up to speed” or he rides the inflammation scapegoat train to freedom: “looks like its inflamed/tendonitis/arthritis, take two aspirin and call me in the morning/let’s inject you with cortisone.”

But even when a problem can’t be seen, it can be felt, and a practitioner tempered by experience can treat the affected area, increase the circulation and ultimately lead to an amelioration of symptoms. When a problem can be seen by the naked eye, or with complicated technical machinery, the aforementioned practitioner is often still necessary, as the seen is often complicated by the unseen. By treating the invisible condition dominos fall and the visual condition fades as well.

I learned to treat most orthopedic conditions before learning the technical jargon with which to explain what I was doing. This was actually helpful, because instead of being misguided by a lot of the misnomers, misinformation, misdirection, and other misses off the mark that I came across later, I was able to look at current theories objectively, and see if they made sense based on experience I had.

So to get to the point, you just rode an elaborate tangent to come to the conclusion that doctors should be injected with experience before their brains are inundated with a thick impenetrable theoretical bog from which there is no escape and no return (hopefully that wasn’t too anticlimactic for you).

Only a mind unclouded by blind faith in preconceived notions about anatomy and molecular biology can successfully develop the ability to detect issues that modern technology fails to uncover. Adventure lies in setting aside what you think you know to reveal something deeper.

A lot of you email me asking how to choose a practitioner, and I’d say this is a good way; ask them what came first, their book smarts or their street smarts, then decide yourself whether or not you want them to treat you. Sometimes clinical experience guides wise doctors out of Alice in Jargon Land, but this unfortunately tends to be the exception rather than the rule.

Meniscus injury

Connective tissue acceleration applies so excellently here because the whole conundrum presented by this injury to modern medicine is immediately addressed.

Small hints of truth creep into mainstream medicine’s understanding of this tissue but I would like to add a little more.

The meniscus is two sections of C-shaped cartilage, one lateral and one medial, that lies between the femur and the tibia to cushion them, provide a smooth surface for them to glide over, and to allow the weight born between them to be distributed evenly. It can be torn or otherwise injured due to chronic stress, but more often due to acute trauma that puts a large degree of torque on the lower leg with respect to the upper leg.

Usually a tear that is closer to the outer borders of the meniscus heals without invasive procedures such as surgery, whereas injuries or tears to the inner portion are typically referred to for invasive techniques if the injury significantly interferes with normal activity. The torn portion in this case is cut out. The rationale behind this dichotomy is that the outer portion of the meniscus has a decent blood supply, whereas the inner portion is largely avascular (no blood vessels).

You know however if you’ve been paying attention to me in this or other articles that connective tissue acceleration is designed for that very predicament, as it pumps blood into areas that typically don’t receive it, such as the tendons, ligaments, or in this case, the articular cartilage. Proper usage and treatment of the knee will get the blood to go where it needs to go without the introduction of scalpels and laughing gas.

Bursae

The bursae are fluid filled sacs that help cushion the knee and allow smooth movement. Typically these are injured more from direct pressure or trauma to the knee itself. Housemaid’s knee (pain just beneath or directly on the knee cap which is aggravated when trying to kneel) comes from kneeling on the prepatellar bursa too often.

Bursae are diagnosed and treated somewhat similarly to the tendons, in that pain is usually recognized by local palpation, and acupuncture as well as medical massage techniques are applied locally to the pain.

When you need to go to the hospital

Hopefully you already know that if you have a broken bone you should get to the hospital. They will set your bone; perhaps put a pin in it so that it heals nice and straight as opposed to nice and crooked. Say what we will about modern western medicine it has a track record of doing an excellent job with emergencies and acute injuries for the most part.

If you have knee pain that began as a cut or tear in the skin, or if you are also running a fever, get to the hospital as soon as possible. This is very likely an infection and you need to take some antibiotics. Chinese medicine employs herbs that treat bacterial and viral infections as well but get your antibiotics first, then come in if you want to take herbs too.

After you get your bones set, or get on your antibiotic regimen, Chinese medicine is a great tool to shorten healing time and reduce side effects from these more invasive procedures. In China acupuncturists work very closely to surgeons in the hospital for this reason, ultimately taking on a role similar to physical therapists.

Knee supports

Ultimately, if you need some device to stabilize your knee, then your knee has not yet been fully rehabilitated. These are ok for times while the knee is extremely unstable, but sooner or later the knee should be strengthened to the point where these are no longer necessary. Too much time given to the usage of such crutches eventually weakens the stabilizers of the body to the point that no activity can be performed without the aforementioned crutches.

A final word

Chinese medicine provides excellent strategies to rehabilitate injured knees and educational tools to restore grace to your movements and prevent future knee mishaps. Make an appointment today to put the life back into your lower limbs.