PHYSICAL THERAPY

now and then while playing tennis, running or hiking. After a few weeks the pain settles on the inside of the knee and is more con- stant. There may be slight swelling or maybe not. The person begins to notice pain as he begins an activity, then the pain goes away and an hour or so, after finishing the activity it hurts again. The pain mysteriously disappears in the midst of activity because the ligament warms up (and this often relieves the pain). Eventually the person can no longer do certain strenuous activities without pain.

In both these cases the problem is the same - a torn medial or lat- eral collateral ligament. This mysterious injury has many personal- ities. It can come on quickly with mild, moderate or severe pain or it may develop more slowly and be either mild or moderately painful. No matter how it starts it often lingers for a long time, causing confusion by coming and going. The medial collateral lig- ament injury usually prompts the phrase “my dodgy knee”, as the pain has a habit of appearing and disappearing mysteriously. When the injury results from trauma, it’s easy to understand what caused it. When it appears slowly, the causes are subtle and often inter- locking: poor leg alignment with knees turned-in or out; excess muscle tension, which leads to early fatigue; or loose or stretched ligaments caused by old sprains or poor stretching exercises.

PRINCIPLE: SCAR TISSUE AS THE SECRET OF CHRONIC PAIN Sometimes the acute pain of an injury disappears completely and the patient is never bothered by it again. Sometimes pain becomes a chronic problem. Most people do not realise that the cause of most chronic pain from soft tissue injuries is the initial poor healing of the injury. Adhesive scar tissue forms, binding the originally damaged tissue to the adjacent soft tissues. Scar tissue formation is normal when soft tissue injuries are repairing. When scar tissue forms in the appropriate places, it is the biological glue that holds torn fibres together. However, if this healing process occurs in a random fashion, the scar tissues form a jum- bled mass of adhesions that tear on normal movement.

Scar tissue within the musculo-skeletal system forms primarily in ligaments, tendons, muscles, fascia and joint capsules. When scar tissue forms in the fascial tissue, it often binds the skin to its underlying fascia, limiting the movement of the skin. If this abnormal scar tissue is placed under tension, the nerve endings in the skin and the underlying fascia are stimulated, producing pain. Fascia also lies deep in the body, where its purpose is to envelope and to provide a gliding surface for muscles, tendons, ligaments and other structures.

Putting tension on this scar tissue in the deeper fascia again stimulates local nerve endings and produces pain. Methods of fas- cial release can be employed with beneficial results. However, until all the abnormal adhesive scar tissue is removed from all of the affected structures, a pain-free state cannot be achieved.

Movements that excessively stress the damaged tissue result in re- injury. This re-injury results in the formation of more adhesive scar tissue. Understanding how to encourage the correct healing of tissues prevents these complications. Breaking the cycle of tearing and re-tearing of adhesive scar tissue is the key to effec- tive treatment.

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Application: Scar tissue and chronic pain at the medial and lateral knee A complication of torn collateral ligaments is the “dodgy-knee” syndrome. In one way or another, the ligament has been sprained, and though there are brief reprieves and the person begins to think, “It’s gone, I’ve beaten the problem”, the pain then returns. It can recur with what was seemingly a simple activity such as helping a friend move some boxes up a flight of stairs, squatting for five minutes while weeding in the garden, running a mile every other day for two weeks, or making a dash to catch the bus. Troublesome adhesive scar tissue that keeps re-tearing is the key to understanding this mystery.

When the knee bends and straightens, the collateral ligaments normally move freely across the bone on the medial and lateral sides of the knee. If a collateral ligament is injured and heals properly, the scar tissue that’s formed within the ligament does not interfere with its free movement. However, if the injury does- n’t heal well, scar tissue may form a matted scar within the liga- ment or between the ligament and the bone where it is not sup- posed to be attached.

This scar tissue often acts like glue, adhering the ligament to the bone so that its free-sliding movement becomes more limited. If activities are strenuous and jarring, or involve twisting, the scar tissue does not hold and tears repeatedly. When a ligament warms up during activity, pain often diminishes or disappears temporar- ily. An hour or two later, when the ligament has cooled down, the pain intensifies or returns. This cycle of poor healing and scar tis- sue re-tearing can happen hundreds of times over many months or years. In its most extreme form the ligament completely ruptures and the knee becomes unstable. This event tends to only occur in very serious accidents or severe falls. If it does occur, the person should see a doctor immediately.

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