Treatment options for lower back muscle tear, lower back and knee pain in Singapore
Meniscal pathology is commonly associated with mechanical type symptoms: locking, giving way, and localized joint line pain. Acute tears often happen during a twisting injury to a partially flexed knee, for example during sports. A bucket handle tear can give symptoms of locking and loss of extension. Two of our patients reported a feeling of knee locking before their meniscal tears. Step deformity can occur if there is a large unstable meniscal fragment. LBP and leg length discrepancies are less specific; however, the meniscal tear in one of our patients was done because of persistent pain that had effects on his professional sporting career. He had experienced a traumatic injury during a game of football and had pain and swelling in the subsequent days. He attempted to ignore the symptoms and continue playing, but his knee repeatedly gave way on him. He later found that he had torn his meniscus during that game.
Acute LBP is commonly defined as lasting less than 6 weeks, subacute LBP between 6 and 12 weeks, and chronic LBP is more than 12 weeks. LBP of any duration can be classified as no specific cause or as a possible specific cause, which is likely to be the case with our patients with meniscal problems post-surgical leg lengthening and the low back pain between the two. Many of these types of LBP can be a cause of referred pain from the trunk or proximal musculotendinous pain.
The discussion of lower back muscle injury and lower back knee pain was selected from a clinical examination and therefore is a broad summary of the available research. LBP (Lower back pain) is a key biomedical and public health problem internationally. It has many forms and a large number of factors contribute to it. The topic of diagnosis and treatment of LBP is rarely straightforward, thus a simple way of classifying it that is often used by practitioners is to divide it into acute and chronic based on duration.
Overview of lower back muscle tear
Low back muscle strains are graded from 1-3 depending on the degree of severity. A grade 1 strain is mild and there is minimal loss of strength and movement while a grade 3 strain is a severe tearing of the muscle and causes a complete loss in functional ability. Symptoms usually develop suddenly and include a cramp-like or sharp pain in the lower back, reduced range of movement of the back, and pain on movement. In more severe strains, there may be muscle spasm and the muscle may have a palpable defect. Timing of onset of symptoms can vary from immediately after the injury to a day or two later. In some cases, there may also be referred pain into the lower limb. This occurs due to the strain irritating nerve roots in the lower back and the pain and symptoms will follow the path of the affected nerve. For example, sciatica caused by irritation of the sciatic nerve.
A lower back muscle strain is a condition whereby the muscles of the lower back are damaged due to an injury. It is one of the most common causes of lower back and knee pain in Singapore. The injury can occur through different mechanisms and at any point in life. The lower back is responsible for supporting the weight of the upper body and any sudden forceful movements or inappropriate twisting and bending can cause over-stretching or tearing of the muscle fibers. This may happen during everyday activities such as lifting a child, gardening, or while playing sport. An awkward fall or a blow to the back may also result in a lower back muscle strain.
Causes of lower back and knee pain
The causes of low back and knee pain are very complicated and are not well understood. Conditions describing pain in both areas are often triggered in the lower back. An acute injury or cumulative damage can both cause strain to the ligaments or muscles in the back, which can cause back strains and sprains. This, in turn, may affect the way a person walks, which can then cause imbalances in the joint, leading to knee degeneration over time. Another typical condition is when the lower back discs become herniated or prolapsed. This can cause back and leg pain (sciatica). If the disc bulge is severe enough, it may compress to the point of irritating the nerve root and, depending on which disc is affected, can transmit pain all the way down to the foot. This condition can often be very debilitating and requires immediate treatment. Injury to the back may also lead to osteoarthritis. This occurs when there is damage to the articular cartilage and often leads to the wearing of the joint. This can occur in any joint in the body, including the knees. However, if the back is the area of injury, it may lead to knee osteoarthritis. Finally, poor posture is a very common cause of chronic lower back pain and has often been associated with pain in the knee joints. With any mechanical irregularity, there is increased load and stress to the affected joints, which over time will cause degenerative changes.
Importance of seeking treatment in Singapore
The physiotherapist would first need to assess the extent of the tear, then he would have to administer the appropriate treatment. This would involve a mixture of different modalities, e.g. ultrasound and interferential current to reduce pain and muscle spasm. Then followed by specific soft tissue massage to help the tight and knotted muscles to relax. The last and vital stage to this would be to strengthen the muscle with specific therapeutic exercises. These exercises are not to be confused with general exercises and are highly specific in nature to only target the affected muscle. It requires a strong and active participation of the patient, and the physiotherapist is there to ensure the right technique and monitor progress. This is a very effective way of treatment, but it may be time-consuming, but this is just the nature of how muscle tears should be treated. The only setback is if patients can take time off work or can afford to see a physiotherapist often.
One of the ways of lower back muscle tear treatment is through physiotherapy. More often than not, it is best that physiotherapy is done in a clinic. This is because machines and modalities are more accessible, and the physiotherapist can closely monitor the progress of the patient. Step to Recovery Physiotherapy is highly recognized for providing the best physio and best treatment for lower back muscle tear in Singapore. This is the most recommended treatment, especially when the pain is located at the back only and has not radiated down the leg.
The importance of seeking lower back and knee pain treatment in Singapore is crucial when it comes to dealing with lower back muscle tear post-diagnosis. This is especially so when it is causing severe lower back and referred pain down the leg. At its severe state, it is almost impossible to leave it untreated, and prolonging it would only mean worsening of the condition. The course of the treatment and the efficacy would highly depend on the severity of the tear and pain. It is either done through physiotherapy, rehabilitation, or in worst cases, surgical intervention.
Non-surgical treatment options
From the physician’s perspective, treating a lower back muscle tear is of primary importance. The better acute muscle injuries that are diagnosed and treated, the quicker the recovery and the less chance of it becoming a chronic problem. When diagnosing a lower back muscle injury, the physician may use an MRI, myelogram, CT, or bone scan to confirm the nature and location of the injury. Treatment may involve several steps but most commonly rest and activity modification is the first stage. This allows the injury to have a better environment to recover, and some severe cases of muscle tears will require bed rest for 1-2 days. It is very important not to have prolonged bed rest, however, as this can lead to a deconditioning of the musculature and delay recovery. Physical therapy and exercises are the second phase for most acute muscle injuries. In some cases, heat and cold may be used in addition to these modalities. A recent randomized control trial for low back pain and muscle injuries has shown that continuing with normal activities and movement results in better long-term results than medical treatments and bed rest. This has led to an increased emphasis on PT and exercise programs to increase the patient’s functional capacity in spine injuries. Acute back injuries often do well with instruction by a PT and a home exercise program. This can progress to a more comprehensive gym and pool program or Pilates for lumbar stabilization and functional enhancement. The goals for exercise therapy are: improved flexibility to avoid re-injury, increased strength and endurance, cardiovascular fitness, and overall improvement in functional capacity. Proper instruction is needed for passive treatments such as massage, ultrasound, and acupuncture, with indication for use of these being to advance the exercise program.
Rest and activity modification
Rest is usually the initial treatment of choice for a muscle tear, which would reduce the intensity of pain and swelling. Activity is not stopped in an absolute sense, as this can lead to deconditioning and both physical and psychological issues. Instead, a modification of the activity is employed. If the tear is mild, this could mean just a few days off of the aggravating activity. In more severe cases, rest will be for a few weeks. However, complete rest and immobilization is not recommended. During the acute stage of a severe muscle tear, where there is significant pain and swelling, rest is important, and using a walking aid such as crutches may be necessary. This is employed in an effort to change the environment within the injured tissue to improve its capacity to repair itself. In the past, complete rest and immobilization were advocated for muscle tears. It is now known that this could actually be detrimental to the muscle and lead to a prolonged recovery. This is because complete rest will cause the muscle to shrink and waste away (atrophy), and the muscle would also shorten and become tight, making it more susceptible to reinjury when a return to activity is made. Immobilization has also been shown to have negative effects on the strength of the injured muscle. It is for these reasons that mobilization and flexibility exercises for the injured muscle should begin as soon as possible after the muscle tear, but not without an assessment from a qualified physician or therapist. This is to ensure that the correct timing and type of mobilization is employed to promote the most effective and efficient recovery of the injury muscle. This will also be related to the extent of tissue healing. In the later stages of muscle tear healing, a stretching and flexibility program would be employed to lengthen the healed tissue and its effective muscle.
Physical therapy and exercises
Aquatic therapy is another form of exercise that has been proven to be advantageous for patients suffering from lower back pain. The use of water and specifically designed activities facilitate increases in strength, flexibility, and endurance, but with less discomfort as a result of the buoyancy of water. An RCT (randomized controlled trial) studying the discharge rates of patients receiving land-based exercises compared to aquatic exercises indicates that aquatic therapy may also speed up functional recovery and reduce time lost from work. However, there are no differences in the reduction of back pain and depression in patients.
Physical therapy, consisting of exercising and stretching, is a viable option for treating lower back muscle tears and acute back injuries. Usually, a special program is designed to target the affected muscles in the lower back where the tear has occurred. If this is done correctly, research has shown a more rapid and efficient recovery when compared to rest or activity modification alone. In a recent study, patients suffering from an acute episode of lower back pain were allocated to receive active physical therapy, manual therapy, or advice, along with follow-up treatments for up to 8 months. Patients receiving active physical therapy showed the most significant improvement and a lower rate of reoccurrence over the first year. Exercises such as the “lumbar stabilization” exercises have been proven to help strengthen the lower back in an attempt to reduce further episodes of back pain due to muscle tears.
Pain management techniques
Being involved in a soccer match, he was running across the field trying to catch up with the ball. Taking one aggressive leap to make a powerful shot, he felt a sharp pain in his lower back shortly followed by weakness on his right leg. Ignoring the pain from the injury, he was taken off first for a rest then decided to proceed with the competition. At half-time, the pain worsened and the weakness was getting worse. He finally decided to sit out the rest of the game. Matt (not his real name) is a 28-year-old business executive who loves soccer. After seeking advice from his colleague who is a doctor, and a thorough examination, Matt discovered that he had acute muscle tear in his lower back. He was also diagnosed with an associated disc prolapse. His doctor had recommended at least 3 weeks of medical leave, and to avoid surgery with the hope that it will recover with medical therapy. The following discussion explains some effective non-surgical means of treatment that will be most appropriate for Matt’s condition, specifically for the muscle tear in the lower back. This will also be valuable education for anyone else with a muscle tear in the lower back. Although it would be rather focused on the acute muscle tear, there is also significant relevance for treatment of new onset exacerbation of chronic lower back pain with acute flare of pain. This is because the symptoms experienced can often be very severe and incapacitating.
Use of supportive devices
A corset is relatively rigid and offers more restriction of motion when compared to a brace. It is often recommended by medical professionals if a patient has had a compression fracture in the lower spine. Compression fractures typically result in significant pain and can lead to a loss of height of the spine. The goal of using a corset with a compression fracture is to stabilize the fracture, decrease pain, and prevent further height loss of the spine. This can be accomplished by wearing the corset throughout the day, and taking it off at night before going to bed. A brace can be used for similar conditions, but may not be as effective at stabilizing the spine, and is usually more uncomfortable to wear than a corset. Both braces and corsets should be used with caution, as there is a risk that the body will become accustomed to the support, and the muscles in the back and abdomen will weaken due to lack of use. A corset and a soft brace are usually not worn any longer than one month because of this risk.
Supportive devices can provide an effective intermediate step between bracing and full activity. Medical supply stores and many drugstores carry a wide variety of back-support devices. A short-term benefit can be achieved through the use of a corset or brace, which can provide an external support to the muscles of the back and help to keep the spine in a more stable position. This can be particularly helpful in the acute period immediately after injury when pain is inhibiting a person’s ability to move.
Surgical treatment options
Unlike lower back muscle tear pain, surgery will be the initial treatment for knee pain, especially with significant loss of cartilage where there is bone-on-bone contact. This type of treatment is an attempt to relieve the pain, allow patients to maintain or increase their activity level, and delay the development of osteoarthritis to a more crippling disease.
Evaluation for surgical intervention is not considered for lower back muscle tear and lower back pain because medical treatment should be enough, and surgery is not really recommended. But, in a severe condition, a patient with lower back pain that causes leg pain with nerve irritation or a patient with significant lower back pain that has not improved after 6 to 12 weeks of nonsurgical treatments should consider surgery. Because this type of lower back pain is more likely to be coming from the disc, and there are some specific conditions where surgery is the appropriate option for treatment.
Evaluation for surgical intervention
When a patient has significant low back problems and there is some thought that a surgical procedure may be helpful for management of their back pain, it is important for the patient and the physician to have a clear understanding of the goals and expected outcomes of the surgery. There are different types of surgical procedures that are done for low back pain, but the most common is a surgical fusion of the front part of the spine which is essentially a weld that is done at the front of the spine with or without removal of the disc. The goal of the spinal fusion is to stop the motion at a painful motion segment. Other surgical procedures include partial removal of the disc and or other bony and soft tissue compressive lesions on the nerves. It is well accepted that back pain is a complex problem that often has multiple issues some of which are not completely understood. An exact anatomic cause for the pain is often times not identified. Studies of discography, a test where a needle is placed into the disc space and dye is injected, have shown that people with no back pain often have abnormal discs on MRI, and people with a lot of back pain often have normal looking discs. This makes it very hard to identify which patients will do well with surgery. Overall the patients who are most likely to benefit from surgery are those with leg pain (radiculopathy) from a disc herniation that is impairing their ability to function normally and those with a verifiable structural abnormality on MRI that is source of their back pain.
Types of surgical procedures
The most common surgical intervention for a muscle tear is a repair. The surgeon who performs the repair may or may not have a specific interest in musculoskeletal problems. This repair can be either an open surgery or a minimally invasive arthroscopic surgery. The method of the repair generally depends on the surgeon’s experience and preference. Most importantly, it is the specific details of the tear that will determine what kind of a repair will be performed. For instance, a minor tear of the muscle or tendon may be sutured while a complete tear at the musculotendinous junction may require re-anchoring the muscle to the bone. The latter is typically done with bone anchors in a procedure which has shown good results. Unfortunately, a chronic tear of the musculotendinous junction with retraction of the muscle is difficult to treat. This is because the muscle loses its ability to contract and thus cannot generate the necessary force to bring about healing. Healing of the muscle and scar formation is required in order to increase the tensile strength. A muscle forgets how to work when it stays inactive too long and this leads to further atrophy. Often, a muscle needing retraction repair will end up requiring a muscle transfer which is a complex procedure and not commonly done in Singapore.
Rehabilitation after surgery
Rehabilitation should start soon after surgery before the back begins to stiffen. The patient may require a short stay in the hospital if done in a decompression. If a spinal fusion has taken place, an extensive program of physiotherapy will be required. This shall consist of posture education, upper body conditioning, flexibility exercises, and finally a cardiovascular program. Effects of surgery on a patient psychologically can slow the rehabilitation process. It is important that the patient sets goals of which he would like to achieve as this helps push the patient on. During the rehabilitation process, it is important the patient avoids certain postures and positions. Prolonged sitting should be avoided, as well as sitting with the legs out straight. It is better to sit in a reclined position or L-shaped sitting with the legs supported. Lifting and twisting should be avoided at all costs. Finally, any heavy impact activities or movements from end range should be prevented. Overall, the success of rehabilitation from surgery to eradicate leg pain has a success rate of 75-80%, and 70% of disc reoccurrence can be prevented with patient compliance on advice given.
Specialized treatment centers in Singapore
It is important to be aware of the best available facilities and options when it comes time to seek treatment for a lower back injury. Singapore has been identified as one of the emerging medical tourism destinations. The Ministry of Health or MOH has identified medical tourism as one of the service sectors which can be developed as part of its strategic plan to help give the economy a much-needed lift. Lower back injuries, such as muscle tears, can easily be diagnosed in most general hospitals, which are the initial referral centers for any patients suffering from physical or traumatic injuries. General hospitals with facilities for X-ray, such as Tan Tock Seng Hospital, National University Hospital (NUH), and Singapore General Hospital (SGH), should be the places to start looking for medical treatment. Available specialists in the area of diagnosis for musculoskeletal conditions and injuries are the radiologists. NUH and Tan Tock Seng Hospital have specialized departments of Diagnostic Radiology, and Singapore General Hospital has a department of Radiological Sciences, all with well-experienced diagnostic and interventional radiologists. Usually, muscle tear injuries will not need invasive treatment and can be managed with analgesics, physiotherapy, or, in some cases, corticosteroid injections. General hospitals usually do not offer any orthopedic consultancy that is aimed at higher levels of sportsmen to improve their sports performance. Any injury requiring an orthopedic or sports medicine specialist should seek diagnosis and treatment in a restructured orthopedic hospital, e.g. Changi General Hospital and Tan Tock Seng Hospital.
Top hospitals and clinics for lower back injuries
Among the well-known public healthcare institutions in Singapore, the Singapore General Hospital (SGH) has a comprehensive range of specialist clinics that provide multidisciplinary care for spinal problems. The most developed is the University Spine Center which uses a patient-focused multidisciplinary approach to treatment. It is uniquely positioned to provide extensive non-operative and operative management of spinal problems. Non-operative treatment includes pain management, physiotherapy, and rehabilitative medicine. Surgical options are comprehensive, with the full spectrum of open and minimally invasive techniques. SGH is fortunate to have 6 fellowship-trained spinal surgeons who have been developing their sub-specialty practices over the past decade. These surgeons have a strong relationship with the Department of Orthopaedic (NUH), and it is through partnership that they are able to provide the full gambit of spinal care. Closely affiliated with SGH is the National Neuroscience Institute (NNI), which has neurosurgical specialists who manage complex spinal problems from the occiput to the cervical spine. Management of these patients is widely done in conjunction with orthopaedic spinal surgeons. In 2009, there is planned provision to centralize (NIH) the neurosurgical and orthopedic spinal services to the new ACADEM, which will be invaluable in research, education, and patient care. The other public institution with a spine specialty is Tan Tock Seng Hospital (TTSH) Department of Orthopaedic Surgery, which has a well-developed spine service. Although there is no dedicated spine clinic, varied spinal problems are managed through the different subspecialty clinics, and the department has a strong collaboration with Rehabilitative Medicine in providing comprehensive spinal care during the patient’s rehabilitation phase. The new TTSH spine ward has been planned to provide greater care and privacy for patients with spinal problems. This will be in line with their vision to create a dedicated spine unit in the future.
Expert medical professionals in Singapore
In Singapore, musculoskeletal treatment is developing quickly and becoming more evolved. There are several musculoskeletal centres in Singapore, a mix of public and private. These centres would definitely be beneficial in the long term for people with musculoskeletal injuries. The public institutions would raise awareness and the standard of treatment for musculoskeletal injuries in Singapore. The private institutions would feel the impact of the heightened awareness and standard of treatment. As such, these institutions may feel the need to improve by keeping up with the advancements in musculoskeletal treatment technology and methods. However, at present time, it would still be safe to say that the better treatment is provided at the private institutions due to the various limitations in the public sector.
Availability of advanced diagnostic and treatment technologies
Advanced Diagnostic and Treatment Center in Singapore (ADTC) was established with the aim of providing patients with a one-stop, comprehensive state-of-the-art facility for the detection, treatment, and rehabilitation of back problems. It is borne out of an awareness of the significant progress made in the field of spinal medicine and surgery and the gap in Singapore in terms of facilities to manage these conditions. Anecdotal evidence suggests a significant number of patients traveling overseas for the medical and surgical management of their spinal conditions. ADTC aims to change that. Diagnostic technology has significantly advanced such that it is now possible to definitively identify the source of a patient’s back pain. This is particularly necessary for patients with disc prolapse, failed back surgery, or degenerative conditions of the spine. High-field MRI scanning is a non-invasive way to visualize the internal structures of the body. It provides an incredibly detailed picture of the spinal anatomy and is commonly used to assess back pain. Open scanning systems have now been developed to cater to those who may be claustrophobic or unable to tolerate confinement in the narrow cylinder of a traditional MRI scanner. Early detection of vertebral compression fractures can now be identified with a specialized type of whole-body scanner (Dexa Scan) which is able to measure bone density. This is immensely beneficial for patients with osteoporosis. Unfortunately, more than 2/3 of vertebral fractures are asymptomatic and their diagnosis is often overlooked.
