In this episode of The ABMP Podcast, Darren speaks with Dr. Ben Benjamin about whether there is referred pain in the knee, some of the most common types of knee injuries, if arthritis is common in the knee, and how practitioners know whether they can help with a knee injury or not.
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0:00:44.9 S1: This episode of The ABMP Podcast is sponsored by Pain in the App, mobile app by Dr. Ben Benjamin. Pain in the App is a new mobile app to learn about the injury process from head to toe. Quiz yourself on the theory behind why injuries happen and what we can do about it, dig into how specific treatments work and why. Get started on Pain in the App with dozens of free questions, then get hundreds more for only $9.99, but be careful, it's addictive. Go to the App Store or Google Play and search for Pain in the App.
0:01:30.3 Darren Buford: I'm Darren Buford, and welcome to the ABMP podcast, a podcast where we speak with the massage and bodywork profession. Our guest today is Dr. Ben Benjamin. Dr Benjamin has been doing pioneering work in the areas of ethics, communication, and sexual assault prevention, writing articles on professional, sexual and business ethics. He is the author of The Ethics of Touch, a textbook used in schools throughout North America to teach ethics and boundaries to massage therapists, as well as other hands-on healthcare professionals. He has been an expert witness in cases of sexual assault in the massage and bodywork field since 2004. In 1974, Dr. Benjamin founded the Muscular Therapy Institute, a school he owned and nurtured for over 30 years. He developed a 150-hour curriculum in ethics and communication skills for therapists in training. He has taught courses in ethics boundaries, sexuality and communication to somatic therapists for over 30 years. Additionally, Dr Benjamin earned a PhD in Sports Medicine, and has dedicated his life to helping people cope with and overcome the pain and stress caused by injury to the body in his muscular therapy sports injury private practice since 1963. For more information, visit benjamininstitute.com. Hello, Ben.
0:02:48.8 Dr. Ben Benjamin: Hi, there.
0:02:49.5 DB: Ben we've got a big discussion today about the knee, prominent in a lot of massage therapist practice and work, so let's just dive right in.
0:02:57.3 DB: Alright.
0:02:58.2 DB: Ben, is there referred pain in the knee?
0:03:00.8 DB: No, there's no referred pain in the knee. When you injure your knee, it hurts where the injury actually is, it doesn't refer pain to other parts of the body like the neck or the low back. There's one exception, kind of, and that's when the injury is deep in the middle of the knee. Now, we know the problem is in the knee when it hurts in the middle of the knee, but we don't actually know exactly where it is. When we're small, when we're little kids, we find out where parts of our body are by touching them, we look at things, we touch a part of our body, and that's how we learn where things are in our physical body. But when it's the knee and it's deep inside, we can't put our finger deep inside the knee, so the pain is experienced as a vague sort of diffused pain, and it doesn't refer anywhere else, but we can't really pin it down, we don't know if it's in the front of the knee, the back, or the inside, the outside, it's sort of... We know it's the knee, but it's very vague, and this occurs when we injure something like the meniscus or cushion ligaments which are in the center of our knee, or various things that cause a lot of swelling in particular.
0:04:15.8 DB: So what does it mean when the knee swells?
0:04:18.1 DB: Well, when the knee swells, it simply means the health and balance of the knee is disturbed, it's upset, the knee is upset. It's letting you know that you should be really careful. It's saying, "Rest me, take care of me. Don't stress me out, or I'm gonna give you lots of pain to let you know." Let's say you injure something called a medial collateral ligament. Now, this ligament holds the medial parts of the knee together. If some of the fibers have micro-tears in them, and the ligament is kinda inflamed. Now, the ligament sends a message to the brain that says, "Protect me," and the brain sends a message to the synovial membrane in the knee joint that says, "Synovial membrane, you are ordered to produce a lot of fluid, so this human does not hurt me any further." The knee is inflamed and it hurts, it's hot and swollen, and its movement is sort of limited. You can't really bend your knee fully, or you can't really straighten it fully 'cause there is all this fluid in it.
0:05:22.4 DB: And there's usually more limitation of movement inflection, it means you can't bend your knees so much, and you can straighten it, but you could straighten it more than you can bend it, but both directions have a problem, but bending it is worse, and that's what happens when the knee swells. Now, it's important to remember that tendons do not cause swelling in the knee or any joint in the body, really. Here's what does cause the swelling. In the knee in particular, the big culprits are six of the primary ligaments of the knee when they're injured, the medial and lateral collateral ligaments, the coronary ligaments, and the anterior and posterior cruciate ligaments that are deep inside the knee. These ligaments hold your whole knee together. On the inside that's what makes your knee function, is those six ligaments, and if any of them are injured that's gonna cause a lot of swelling.
0:06:19.0 DB: So other injuries or conditions that cause swelling are injuries to the two meniscus, the two menisci in the knee. They're kind of half-moon shaped, thick cartilages in the middle of the knee, as well as another problem called chondromalacia, which is scraping and grinding of the bones deep in the knee, if the articular cartilage has been worn away. So you can also have swelling of several of the bursa within the knee, and that's a little bit different. There's one, a bursa that's deep inside the knee and that's called the Infrapatellar bursa. When it swells, it's not the joint that's swollen, it's just the bursa that's swollen. And it can limit the knee a bit when it really hurts a lot, when it's really swollen.
0:07:07.8 DB: So if you try to kneel down it's gonna hurt you, and if you try to bend your knee it's gonna be kind of limited and feeling kind of stiff. Another one is called a Prepatellar bursa, and that's right on top of your kneecap, and that can just sort of swell. But it doesn't really limit your movement, it just hurts a bit, and you can't really kneel down on your knee, and the kneecap gets really puffy and it looks like there's sort of a spongy bubble on top of the patella. So those are all the different kinds of swelling that you can have in the knee.
0:07:41.7 DB: Ben, you mentioned it; what is chondromalacia? And is it like arthritis?
0:07:46.4 DB: Yeah, chondromalacia is an arthritis condition of the knee. And here's what happens. The ends of our bones are coated with a teflon-like coating, and we call this the articulating surfaces, or the ends of the bones, and it's called articular cartilage 'cause it's where the bones contact each other. Now, this makes the gliding motions smooth and easy, and there's also a small amount of synovial fluid inside the knee joint to reduce the friction, just a couple of drops. Now, this coating, or articular cartilage, may vary in depth or thickness based on the person's genetic makeup. Now, some articular cartilage is thicker on some people, and some is thinner on other people. Now, if the articular cartilage cracks or erodes, it slowly wears away. Now, when this occurs you hear kind of a crackling or a grinding sound when someone does a deep knee bend, they bend down to get something and you hear a...
0:08:49.2 DB: Or, the kind of a scraping. Now, these are sounds of the grinding of the two bony structures that don't smoothly articulate and glide anymore on one another, as they should. So if the articular cartilage fully wears away on parts of the surfaces of these bones that are facing each other, you get bone on bone, or bone on cartilage contact. Now, when the cartilage is rubbing against something, there's no pain in the cartilage, it doesn't have any feeling. But when bone is rubbing against bone, it's very painful. Or even if the cartilage is rubbing against the bone itself, it's painful at the bone but not on the cartilage. Cartilage has no feeling. So if the cartilage surfaces are just grinding against each other, you get cracking, crackling noise, kind of a grinding noise, but when the cartilage is gone and it's bone grinding against bone, there's a lot of pain in addition to the noise.
0:09:46.6 DB: Ben, what are the most common knee injuries?
0:09:49.4 DB: There are two categories of common injuries. Injuries that require surgery, and soft tissue injuries that hands-on therapy can successfully treat. Let's take a look at what we can successfully treat with hands-on therapy first. So, the patella tendon strain, either tendinitis or tendinosis, is an injury to the knee that hands-on work can easily help. Now, tendinitis, that's if you catch it quickly, that's faster; tendinosis takes a longer time 'cause it's a deterioration in the tendon structure. Now, this particular structure, the patella tendon has seven different places that can be injured. That's a lot in one different structure, one sort of structure. So the patella tendon begins at the base of the quadriceps muscles, just above your knee, sort of where the patella attaches to the tendon. Now, this section is what we call the supra-patellar tendon. Supra, above; patella tendon just goes right into the kneecap. Now, within a few inches, the tendon turns into what we call an aponeurotic sheet, like a flat rubber sheet, which envelops the patella by grasping it on the medial and lateral sides. Now, this part is called the quadriceps expansion, because the tendon expands to hold on to the edges of the patella. Now, there's a medial quadriceps expansion, and there's a lateral quadriceps expansion. The tendon then sort of re-assembles, so to speak, and continues down towards the tibia.
0:11:23.1 DB: This part is called the patella ligament, because it's going from bone to bone. It's going from the patella to the tibia. However, its function is as a tendon, not as a ligament, because it facilitates movement of the knee, it's not just attaching two bones. I call the attachment to the base of the patella the Infra-patellar tendon attachment. The patella ligament, which really functions as a tendon, is also called the tendon body. Then there are two extra slips of tendon tissue on the medial and lateral sides of the knee, that are called the medial and lateral retinaculum. Now, these two retinacula reinforce the strength of the tendon. All of these structures can be and are often injured and require treatment when there are micro-tears and adhesive scar tissue that is present because you injured something. So I have an entire webinar on that, and that's a good thing to watch on the benjamininstitute.com, if you're interested. 'Cause these are very detailed kind of things. You've got seven different parts that can be injured and all of them are treated a little bit differently. So that's something you might wanna do. So the other commonly injured structures in the knee that hands-on work can effectively treat are the medial and lateral collateral ligaments, and the medial and lateral coronary ligaments, and the hamstring attachments just below the knee.
0:12:47.2 DB: Now, let's go one at a time here. So most people are not familiar with the coronary ligaments, so let's spend a moment on that. The collateral ligaments, most people know. But the coronary ligaments, most people actually never even heard of them. They hold the medial and lateral meniscus in place, and sit on top of the tibia, and they allow movement of the meniscus forward and back, but they're holding them firmly in place. So these are very frequently injured structures, but they usually go without treatment because most people in the healthcare field, not just massage therapist, most doctors, physical therapists have no idea where they are, know what they do and know how to treat them. And it's kind of bizarre, but that's the fact of it. And then we have injuries that require surgery unless the person decides to live with it, and the things that require surgery would be tears to the medial and lateral meniscus, and tears to the anterior and posterior cruciate ligaments which hold the inside of the knee together. The cruciate ligaments are several inches inside the middle of the knee and really cannot be treated by hands-on therapy, and these are some of the most serious knee injuries that generally require surgery.
0:14:08.5 DB: And how common is a torn meniscus?
0:14:10.0 DB: Well, it depends on how you define common. There are at least 40,000 surgeries for a torn meniscus every year in the United States alone, but most people who have a torn meniscus see it more as an inconvenience and don't actually have surgery, only 10% of the people who have a torn meniscus actually have surgery. So that means that there are about maybe 400,000 meniscus injuries each year, and most of them people just decide to live with it. So when a person has a torn meniscus their leg occasionally collapses and the knee then kinda gets stuck in a flex position, they might fall to the ground, they might just catch themselves, and then usually the person can sort of manipulate and jiggle their knee to get it to function again, get it? They sort of twist it and it gets unstuck, but it swells and it's usually kind of painful for a week or two after that, but most people decide to live with it rather than have a surgical procedure.
0:15:12.2 DB: So Ben, if you have a knee injury, are you doomed to have surgery?
0:15:16.2 DB: Well, it depends on what you can live with. Some people live with a knee that's not fully functional and they're okay with that, but if you wanna be fully active and enjoy athletic activities, you will likely have the surgery and recover most of your function provided that the surgery, of course, was successful. Now, many of the surgeries to the knee offer knee replacements, and as we age, some people completely lose their knee function, and knee replacements are an amazing surgical development that helps people to live a more full life in their older years. I just saw somebody yesterday who'd you never know he had a fake knee in his knee, but he was walking around just fine, and before that he was kinda crippled, and really couldn't move around.
0:16:02.5 DB: Let's take a short break to hear a word from our sponsors.
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0:17:40.6 DB: Now, let's get back to the podcast. Ben is arthritis common in the knee?
0:17:45.7 DB: Yeah, arthritis in the knee is pretty common, but let's talk about what that really means. You can have a temporary arthritis called traumatic arthritis, or you can have a long-term sort of arthritis called osteoarthritis, that develops over many years, and there are 10 or so other kinds of arthritis that are disease conditions, but let's just focus on those two, so the traumatic arthritis, which goes along with an injury and osteoarthritis, which is kind of an arthritis in the knee that you can... The knee gets stiffer and stiffer, and that's why most people end up having surgery. So when a person injures a ligament in the knee, any ligament, it sends a message to the brain to tell the knee to produce fluid, to fill up the knee with fluids so that you don't hurt yourself anymore. This is a type of arthritis that is temporary and protective. If the ligament injury is successfully treated by hands-on kind of work, this swelling just disappears by itself.
0:18:48.1 DB: However, if the person does not seek treatment or does not recover naturally, this irritation of the joint is what we call arthritis. And it can last for the person's entire life and makes her all sorts of problems to leading an inflammation in the knee and not doing anything about it causes a breakdown and deterioration of the knee joint structure, how it shows up is that the person really can't bend their knee fully, they can't really bring their heel to their buttock, which you should be able to do in a normal knee, and this also sets the person up for more injuries to other structures in the knee because they haven't taken care of the original problem, and so they're a little bit limited in what they do, so all of the ligament injuries in the knee will cause this temporary traumatic arthritis and results in swelling as a signal to the person that they have to do something to take care of the problem and be careful until it's fully gone. If they do not seek treatment, the joint may seriously deteriorate and become a chronic problem.
0:19:52.9 DB: Another common cause of arthritis is loose ligaments in the knee. Now, some people are born with their ligaments a bit longer than they should be for optimal health. Ligaments should be tight. Most gymnasts have this condition of loose ligaments, which makes them very, very flexible, and therefore they're good at gymnastics or they're good at yoga, or their body is incredibly flexible, however, this over-flexibility makes them very vulnerable to all sorts of injuries, and usually it's not just the knees that are loose, all their ligaments in their whole body are loose.
0:20:29.9 DB: So if the ligaments in the knee are not tight, it's easy for the bony surfaces to bang into each other and get damaged. 'Cause things are sort of rocking around, it's like if I went into your house secretly and I unscrewed the hinge on your door halfway and then you kept using the door and it kept banging around, it would break eventually. So that's what happens in a knee that has loose ligaments. It leads to early osteoarthritis of the knee, which means that the under surface of the patella and the contacting surface of the femur they deteriorate prematurely, causing constant irritation and swelling in the knee. Now, this often gets better and worse over the course of the person's life, if it's raining or gonna rain it gets worse, and if it's in there in a dry climate, it might get better and it usually gets worse as they age.
0:21:18.8 DB: Ben how do you know if a client needs a knee replacement?
0:21:21.7 DB: Well, a knee replacement is usually needed when there is disabling pain and loss of function in the knee. It's usually a combination of loose ligaments, severe osteoarthritis, or multiple injuries in the knee, which has caused a deterioration in the knee joint. Knee joint replacements are usually very successful surgical procedures. It's really a personal decision when a person has that kind of pain and inconvenience and it gets really bad enough, they have a knee replacement. And of course, the doctor has to think that it's the right time and in terms of their age to have it. And this of course, is between a patient and their doctor, I would never recommend any replacement, it's out of my scope of practice. But if I can't help them in hands-on therapy, there's nothing for them, I would recommend they see a physician and see what options there are, and that's certainly one of them. It's an option that's been very, very successful for many people.
0:22:18.2 DB: And how do you know if you could help the person's knee injury or not?
0:22:21.6 DB: Well, this is an important question. It's my belief that any therapist who wants to work with injuries should be really pretty expert at assessment, and if you don't know what's wrong, it's very difficult to skilfully treat it, then you're just kinda guessing. The knee is one of the easier places in the body to figure out what's going on. One reason for that is the tests are really simple and there are no referred pain issues in the knee, like the shoulder or the neck or the low back. So, if it hurts you on the medial side of the knee, you have a couple of choices. If it hurts you on the lateral side of the knee, there are only a few choices. That's not to say that it can't get complicated, which of course it can. Some people have multiple injuries, and that can be really tricky. So you start out with a very detailed history of the person's knee, and there are many clues of what's going on with a person's knee that you learn in the history, for example. If you learn that the client has pain at the front or anterior portion of the knee when climbing stairs it's likely that their problem is in the patella tendon mechanism, which we discussed a little bit earlier.
0:23:30.4 DB: If the person has pain going downstairs and the weather affects the pain level in their knee, it's probably in their joint, something like probably chondromalacia. Once you take a detailed history and you have a really good idea of what's possibly going on in the person's knee, there're usually just three or four things that you're gonna be looking at and there are about 18 different assessment tests that one performs to figure out what's wrong with somebody's knee. And once you figure out what the problem is, it's easy to decide if you can treat it or not. If it's near the surface of the body in a soft tissue like a ligament or a tendon, it's easy to treat. Some medial collateral ligament and you know how to find it, and if it hurts, it's easy to find, and you know how to treat it, you treat it. And if it's a structure that's deep within the knee, that you can't really treat it, but you would probably know who to send the person to, if you had the assessment knowledge and the anatomy knowledge of what the appropriate treatment would be.
0:24:33.1 DB: So when I see a client, I send them to a practitioner who can help them. If I can't help a person, I know who to send them to. So that person gets to the other therapist or doctor or whoever it is, get some help, and they actually start referring me people for the rest of their life because they knew that I knew enough that it wasn't me that could help them, that I wasn't the best person to help them, but I knew who to send them to. For example, if I discover that somebody has a bursitis of the knee, which can be very, very painful, hands-on work does absolutely nothing, and actually it can make it worse. But one injection can take it away in one day.
0:25:12.7 DB: Then how do you know what the best treatment for a knee injury is?
0:25:16.4 DB: Oh, this goes back to what I said earlier, if you're gonna treat people with injuries, you should know how to assess them. Otherwise, you're kind of guessing, shotgun approach. Now, if you know how to assess injuries to the knee, you will know the best course of treatment. Whether it's what you do or whether it requires a referral to someone else. And it's rarely one type of treatment. It's usually a combination of a few things that people usually need, for example, if you have a torn meniscus or a ruptured anterior cruciate ligament, it's gonna be very difficult to function normally without surgery or a severe curtailment of your activities. After surgery, you need rehabilitative exercise. This is vitally important to get your knee function back, massage therapy can aid and be part of that rehabilitative process as well. If a person has an injury on or close to the surface of the body, I would choose hands-on therapy, including friction therapy, myofascial therapy, followed by massage and exercise therapy. Now, this would be if you had an injured tendon or a ligament or fascia, hands-on therapy is usually very effective if performed with skill and patience. It's not a miracle, quickly. Usually, you see the person a couple of times a week, it might take a month or two, but it's very effective. Now what's important is to match the appropriate treatment to the injury, whatever it is.
0:26:38.5 DB: And Ben, should clients stop exercising while being treated for a knee injury?
0:26:43.0 DB: Well, that depends on two... A few factors. That depends on a few factors. If the exercises that people are doing are causing pain during or after those activities, they should be stopped for a while. However, if the person doesn't exercise, the likelihood of atrophy is very high. Therefore, I suggest that clients keep exercising with the type of exercise that supports them and their healing rather than hurts them. And that means they might have to find something different that they're not used to doing, to do. Let me give you some examples. So for example, if you can run four miles before your patella tendon starts to bother you, well, then I have people run three and a half miles, as they're starting treatment, for a while, and increase the mileage slowly as the treatment progresses. Now, atrophy begins to take place rather quickly when there's an injury, so it's important to maintain the person's strength through exercise that doesn't hurt. So let's say the person can't even walk a half mile without pain. Well, in this case, I would recommend gentle aquatherapy. This means wearing a float belt or a noodle or something like that, holding on to it, a very inexpensive investment, and then you go into the water, five or six feet of water, and you run, several times a week, and you can run for half an hour, an hour.
0:28:02.6 DB: As long as there's no pain, because you have no impact. This allows the body to maintain strength and increase it without putting stress on the knee. Or I would have the person ride a stationary bike with very little resistance to start, to be built up over time as the treatment progressed. So in short, the answer is, if you can do so, if you can exercise without pain during or after the exercise, do it. If you can't, you have to wait a while. And find some kind of exercise to do, even if it's minimal, while in the treatment and rehabilitation process.
0:28:39.1 DB: Ben, what are the injuries that you would definitely refer out to a physician?
0:28:42.8 DB: Well, first of all, I would always have a physician see a client who has any injury to the knee, or any injury in the whole body. That would be right at the beginning, always. And sometimes people have seen a bunch of doctors, you might not, but if they haven't, I insist that they do that. So if somebody had really severe pain, I would send them out of the office and I would have them go immediately. Also any structure that's deep inside the knee, I would refer out. If that's what's causing the problem. Now, one easy injury that can be treated by injection is bursitis, as I mentioned earlier; one anti-inflammatory injection can get rid of bursitis in the knee that's been there actually for years. And I don't know any other treatment that could do that.
0:29:25.8 DB: There's also a prepatellar bursa, on top of the kneecap, and the infrapatellar bursa. Those I would definitely refer to a doctor, because you can't do anything with hands-on therapy. Now, if somebody has a swollen knee that swells very, very quickly and it's very hot to the touch, I would make sure they got to a physician really fast. Because this sometimes means that there's blood inside the joint and not just synovial fluid. When you get an injury and you get swelling as a result of that injury, it usually takes an hour or two, at least a half hour. But if it happens in five minutes, that means it's often blood in the joint, and if this condition remains there too long, the person could be susceptible to infection in the knee, which is a very serious condition.
0:30:13.6 DB: Ben, can there be pain in the knee that's not coming from the knee?
0:30:18.0 DB: Yeah, there can. The knee itself, as we've mentioned, does not refer pain elsewhere. However, pain can be referred to the knee from two different places. Pain can be referred to the knee from an injury to the hip joint. In this case, if you have the skill to test the hip joint, it will produce the pain in the knee when you're testing the hip, 'cause it refers pain usually down the inside toward the knee. There are six or seven tests of the hip joint that are easy to learn. The various low back ligaments can also refer pain to the knee. The pain is usually in the thigh as well as in the knee in both of these cases, when it comes from the hip joint and when it comes from the back. But it can feel like the injury's in the knee to the average person, even if it's referred from the back. So when this is the case, if you find the ligament that's referring the pain to the knee and treat it, the pain in the knee will disappear. So, in these two cases, the pain in the knee and the thigh often come and go, they don't just stay there.
0:31:23.5 DB: Ben, it sounds like you really like working on knee injuries. Why is that?
0:31:27.7 DB: Well, I like it because it's very straightforward and not confusing. I often tell people to study the knee first, because it's easier to test and treat than injuries to the neck or low back or shoulder, which can be more complicated. So the tests are fairly straight forward and the treatment is pretty clear as well. The only part that's tricky is having good palpation skills, knowing how to find everything. The therapist needs to be able to locate all the possible injured sites with their hands, and that takes some training, either in person or online. You gotta be able to put your finger on the medial collateral ligament, the lateral collateral ligament, the coronary ligament, etcetera. If you can't find the thing and you can't put your finger on those structures, you can't really treat them successfully. But if you have those skills, and you learn the assessment skills, you can do it really well. If you don't know how to assess and find the coronary ligament, which requires the knee to be bent at a 90-degree angle, you just put the foot down, you turn the foot out, or in, and then you go to the top of the tibia, you go to the top of the tibia, and it sits right on top of the tibia on the medial side, on that shelf and on the lateral side, and that's where you treat it.
0:32:39.1 DB: So when I work privately with practitioners who are trying to get certified in the knee, they do a pretty good job, even if they've studied on a webinar or a DVD or whatever, because it's not very difficult to do. So that's why I like it, because it's easy to assess, it's easy to treat, and people usually have a lot of success very quickly, which is an important part of learning.
0:33:01.6 DB: We wanna thank our guest today, Dr. Ben Benjamin. To find out more information about Ben, visit benjamininstitute.com. As always, thank you so much, Ben, for joining, and thank you for all that amazing information.
0:33:13.9 DB: Thank you.
0:33:22.7 S1: Members are loving ABMP Five-Minute Muscles and ABMP Pocket Pathology, two quick reference web apps included with ABMP membership. ABMP Five-Minute Muscles delivers muscle-specific palpation and technique videos, plus origins, insertions and actions for the 83 muscles most commonly addressed by body workers. ABMP Pocket Pathology, created in conjunction with Ruth Werner, puts key information for nearly 200 common pathologies at your fingertips and provides the knowledge you need to help you make informed treatment decisions. Start learning today. ABMP members, log in at abmp.com and look for the links in the featured benefits section of your member homepage. Not a member? Learn about these exciting member benefits at ABMP.com/more.