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Knees, and the crunching noise they make, can be a pain for runners

NEW YORK DAILY NEWS

Monday, November 14 2011, 11:17 AM

Ever since I can remember, my knees have made a crunching noise when they bend. So far, thank goodness, this is still only a noise and pain going down stairs.. I am 36 and started running about eight months ago on a treadmill. I am now up to six miles per run, four days per week, and my right knee is almost always stiff. Not painful, just stiff. So much so that at times, I can’t get past the stiffness to stretch my quads after a run. I want to train to run the NYC Marathon next year; it looks like such great fun. Should I be concerned about the area that seems swollen, even though there isn’t pain, only stiffness?. And what is it? – Sam J., Tampa, FL

“Runner’s knee” is the most common pain runners get. Sports doctors, orthopaedic surgeons, family doctors and internists see this in runners more than anything else. Understanding the real cause makes treatment easy and pain relief possible in a short period of time. It is also called “anterior knee syndrome,” “chondromalacia patella,” and “patellofemoral syndrome,” all names for the same thing.

When it comes to runner’s knee, biology is destiny: Blame your parents, they gave you feet like yours! Anyone whose foot rolls inward (pronation) during a stride is a candidate, but the real high risk for runners are people with extremely flat feet, a large, pronating forefoot, or a so-called “Morton’s foot” (where the second toe is longer than the first, causing an exaggerated pronation). Your parents gave you those feet — not your sport, your activity, or a specific injury.

Of all the aches and pains that one can get, this one’s probably the easiest to get rid of. If you were doing some serious running mileage over the summer, maybe getting ready for a fall marathon, or if pain came on “suddenly” without any apparent injury and your knee started to get sore when you walked up and down stairs, you feel clicking in the knee when getting up or you have felt stiff when you were sitting in a movie, you most probably have Runner’s Knee. It could have happened when you were 12, or 65. And the treatment, which is not complicated or extensive, is the same for everybody, from kids to grandparents.

It all starts with the kneecap. In a perfect world, it rides up and down in the V shaped groove just behind it as you walk, run, or cycle. More typically, though, your foot rolls in, or pronates, as you move from heel strike to toe off, and the kneecap ends up scraping along one side of the groove instead of sliding smoothly up and down the middle.

The cartilage there doesn’t much like getting sandpapered down that way, nor does the back of the kneecap, which begins to weep fluid that in turn produces a feeling of stiffness. The “crunching noise” is the rough cartilage rubbing. And though runners have named the condition, it crops up often in non-athletes, as well as among cyclists and those who play cleated-shoe sports like soccer and baseball, whose footwear can put sideways torque on the knee.

Physicians can diagnose this from the other side of the room: joint hurts, no particular injury caused it, worst going upstairs and downstairs (or walking down an incline or running down a hill which tightens the thigh muscle pulling the kneecap down into the groove causing a painful rubbing), stiffens after sitting awhile, like it needs to be stretched. That settles it.

Despite what you may have read, arthroscopic surgery helps perhaps one out of 100,000 sufferers. Mechanically smoothing the rubbing surface of the kneecap can last for six months or so, but unless your biomechanics have changed, it’s a borrowed time fix. Cutting the retinaculum, the connective tissue holding the kneecap in place to loosen it in the groove, is also only temporary. It eventually scars down tighter than it was before. Sooner or later, you’re back where you started.

Proper orthotics (full length, soft, controlling the forefoot) are the single most important step, since they prevent the roll that caused the scraping in the first place. Runners spend close to 80% of their time on their forefoot; an orthotic must control that area to be effective. The good news is that once you start wearing them, your knee cooperates quickly: The patella cartilage that’s been rubbed down is able to regenerate and heal itself. Just give it the chance. (Note: Orthotics that end mid-arch DO NOT WORK!)

But orthotics alone won’t do it. You need your other ally, the medial quad, the muscle in the front inside of your thigh that’s supposed to hold the kneecap in the center of the groove. The stronger it is, the better it can do its job. But there’s a rub: Leg extensions usually used to strengthen the quads also pull the kneecap back down into the groove and grind it up some more. No good. But terminal extension exercises (see below), which limit the motion to the last six inches of extension, don’t. Do them daily until the pain disappears, then twice weekly. Both legs, please (do one at a time), even if only one leg hurts. Your knees are a matched pair, and what’s already happened on one side is a good bet for the other some day.

In addition, physical therapy is initially needed to stretch the connective tissue that has tightened laterally, holding the kneecap on the side and not allowing the medial quad to hold it in the center of the groove. There is no substitute for a qualified physical therapist to stretch this retinaculum properly. Once stretched to allow that kneecap to stay centered, doing the exercises should hold it for life.

Knee sleeves, braces, straps, and ACE bandages are out. Think about it: If you compress the kneecap, every motion will press it into the groove. Keep it loose and free. Those devices are making money for someone, but not helping you in the long term.

Will all this cure you? No. You could have your orthotics Super Glued to your feet for a year, and if you took them off, a minute later your inherited biomechanics would resume — and eventually the pain right along with it. But make these exercises a part of your weekly routine, and you can rid yourself of this unnecessary pain forever.

Time for a Quad Job

(Not your usual leg extensions)

1. Sit up on a desk or high surface, stick your leg out straight, drop it about 6 inches and support it with a chair or stool.

2. Fill a gym bag or duffel with weights (books, soup cans, whatever) and strap it to the lower leg.

3. Lift only the last 6 inches (about 30 degrees) to full extension, hold for three seconds, then come slowly back down. Do five sets of 10 reps daily, with just enough weight that you get to five or six on that fifth set, and have to stop. Can’t get there? Take out some weight. Can do all 10? Add a book or some soup.

If you’re at a gym…

Use the leg extension weight machine. Do one leg at a time. Hold your one leg out to full extension with the weight. Then drop your leg down 6 inches and put the pin in to lock it at that point. (Every weight machine is different; have an instructor show you how your machine can limit your range of weight training.) Again, five sets of 10 with as much weight as it takes to get to five or six on the fifth set.

If you do leg presses, again only press away in the last 30 degrees of your knee motion. Bending your knee too far will bring the kneecap into the groove and grind it making you do damage to the knee as you strengthen the muscles!

If you’re a cyclist…

Raise your seat a bit higher than normal. As you pedal, that will help put you into the “good” range of motion above, rather than continuing to abuse your kneecap.

If you think you have runner’s knee, ask your physician:

1. Are my kneecaps tracking laterally?

2. Where can I find a full-length, flexible, soft leather orthotic locally?

3. Do you know of a local physical therapist who sees runners and knows how to stretch out my lateral retinaculum with soft tissue technique?

You can run once you’re in the orthotic. Stop only if the pain becomes so bad that it changes your running form. Once you’ve gotten the program under way (wearing orthotics and going to therapy three times a week), you will feel better within four weeks.

***

Lewis G. Maharam, better known as Running Doc™, is the author of the Running Doc’s Guide to Healthy Running and medical director of the Rock ‘n’ Roll Marathon series and the Leukemia & Lymphoma Society’s Team in Training program. He is past president of the New York Chapter of the American College of Sports Medicine. Learn more at runningdoc.com.

Want your question answered in this column? Write to running doc@nydailynews.com or to the comments section below.

 

 

 

Read more: http://www.nydailynews.com/sports/more-sports/knee-hurt-i-run-stairs-crunching-noise-article-1.977245#ixzz1dhRdkU3K

New York City, NY (WorkersCompensation.com) – The Workers’ Compensation Board (Board) has developed the 2012 New York State Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity (“2012 Guidelines”) for use by medical professionals, carriers, attorneys, and the Board in the evaluation of permanent disabilities. The 2012 Guidelines will replace the existing 1996 Medical Impairment Guidelines and will take effect January 1, 2012. However, for claims that already have at least one medical opinion finding a permanent impairment with a rating based on the 1996 Guidelines on or before January 1, 2012, the Board will determine the claimant’s degree of permanent disability using the 1996 Guidelines.

The 2012 Guidelines address the evaluation of both schedule loss of use awards and non-schedule permanent disabilities. The portion devoted to schedule loss of use awards (Chapters 2-8) is taken unchanged from the 1996 Guidelines. The non-schedule permanent disability sections (Chapters 9-17) are largely based on the work of the Insurance Department’s Workers’ Compensation Reform Task Force and Advisory Committee (Task Force). It includes guidance for medical professionals on how to evaluate medical impairment and physical function and guidance for the Board on how to determine loss of wage earning capacity. It is expected that attorneys, claims professionals, and others will utilize these new standards in an attempt to evaluate and settle claims.

The starting point for determining both schedule and non-schedule permanent disabilities is the finding by a medical professional that the injured worker has reached maximum medical improvement (MMI) and has a causally related permanent impairment. The 2012 Guidelines adopt the Task Force’s consensus definition of MMI.

A finding of maximum medical improvement is based on a medical judgment that (a) the claimant has recovered from the work related injury to the greatest extent that is expected and (b) no further improvements in his or her condition is reasonably expected. The need for palliative care or symptomatic treatment does not preclude a finding of MMI. In cases that do not involve surgery or fractures, MMI cannot be determined prior to six months from the date of injury or disablement, unless otherwise agreed to by the parties.

Task Force Recommendations

The 2007 workers’ compensation reform imposed duration caps for permanent partial disability payments under Workers’ Compensation Law (WCL) §15(3)(w) on claims with a date of accident or disability on or after March 17, 2007. The caps are based on the injured worker’s loss of wage earning capacity. The Task Force was directed to develop new recommended guidelines to assist in the determination of loss of wage earning capacity. Meanwhile, the Board has been applying and interpreting WCL §15(3)(w) in individual cases since it became law (e.g. Matter of Buffalo Auto Recovery, 2009 NY Wrk Comp [80703905].

In September 2010, Superintendent Wrynn submitted to me the Task Force’s recommendations, which provides a three part analysis for determining loss of wage earning capacity:

• Evaluation and ranking of medical impairment
• Evaluation of functional ability/loss
• Determination of loss of wage earning capacity based on impairment, function and vocational factors (including education, skills, literacy, age, etc.)

The recommendations included consensus guidelines for evaluation of medical impairment and functional ability/loss. The Task Force and Advisory Committee could not reach consensus on a methodology for the determination of loss of wage earning capacity.

Determination of Loss of Wage Earning Capacity Under the Guidelines

The 2012 Guidelines adopt the recommended three part analysis for determining loss of wage earning capacity. First, the 2012 Guidelines adopt the Task Force’s proposed impairment guidelines for evaluation of conditions involving the spine and pelvis, respiratory system, cardiovascular system, skin, brain, and extraordinary pain (Chapters 11-17). The 2012 Guidelines also set forth principles for the evaluation of impairment of other body parts and systems (Chapter 17). The impairment guidelines employ objective standards for evaluating and rating medical impairment and are intended for medical professionals. The impairment guidelines include severity rankings by body part/system that use letter grades (A-Z) and a chart that places those letter grades on a scale from 0-6. It is important to note that impairment alone does not equate to loss of wage earning capacity.

The 2012 Guidelines contain a functional assessment component (Chapter 9.2) based on the Task Force’s functional ability/loss guideline, which set forth standards for treating medical providers as well as carrier consultants to measure and report injured workers’ abilities/losses across a range of work-related functions, including dynamic abilities (lifting, carrying, pushing), general tolerances (walking, sitting, standing), and specific tolerances (climbing, bending/stooping, kneeling, environmental).

The 2012 Guidelines also include new guidance on how to determine loss of wage earning capacity (Chapter 9.3). They set forth relevant medical factors (impairment and functional ability/loss) and vocational factors (education, skills, English language proficiency, age, etc.) that the Board should consider in evaluating the impact of a permanent impairment on a claimant’s wage earning capacity. They provide general guidance regarding the impact of medical and vocational factors on an injured worker’s earning capacity. The 2012 Guidelines do not overrule Matter of Buffalo Auto Recovery, but rather provide additional assistance on how to calculate loss of wage earning capacity and implement WCL §15(3)(w).

Benefit Rates for Non-Schedule PPD

The 2012 Guidelines also clarify that the three part approach to loss of wage earning capacity (disability) applies in determining the benefit rate in pre- and post-reform non-schedule permanent partial disability claims.

Source: http://www.workerscompensation.com/compnewsnetwork/news/nywcb-announces-2012-nys-guidelines-for-determining-permanent-im.html

By Pete Kuhnmuench

The insurance industry in Michigan supports House Bill 4936, which would make changes to the state’s auto no-fault law to ensure that the system is sustainable for consumers well into the future.

Michigan’s auto insurance no-fault law is unlike any other. It mandates that all drivers purchase unlimited, lifetime medical benefits. That means there is no cap on payouts for medical treatment of auto accident injuries.

The cost of providing these high medical benefits has been increasing at a staggering rate. The average Personal Injury Protection claim has gone up 166 percent from 2000 to 2010.  In 2010, the average medical claim was $36,245. That is out of line with other no-fault states. New Jersey’s average cost per auto no-fault claim in 2010 was $16,000. All other no-fault states have average claim costs under $10,000.

Those high costs result in Michigan consumers paying more for auto insurance than in surrounding states. The average premium in Michigan is $1,032, while the average premium in Ohio is $693; Indiana, $700; Illinois $798; and Wisconsin $641.

If the Legislature adopts House Bill 4936, consumers would get to choose the level of medical benefits that best fits their needs, just like they do for other decisions in their lives. The legislation still would mandate the highest medical benefits in the country. Consumers could choose $500,000, $1 million or $5 million. Currently, the next state with the highest mandate is New York, and it requires consumers to buy only $50,000 in medical coverage.

Another provision of the bill would implement a medical fee schedule similar to one already in existence in Michigan’s workers’ compensation insurance system. The workers’ compensation medical fee schedule has been touted for keeping workers’ compensation insurance rates low in Michigan. Medical providers are involved in the process that determines the fees provided for in the workers’ compensation reimbursement schedule.

For years, Michigan drivers have been paying more than their fair share for medical costs. Hospitals in Michigan charge no-fault carriers more to make up for lower payments made by government-funded programs.  For example, an X-ray is billed nearly three times the rate under no-fault than it is billed under the workers’ compensation system. This has significant impact on auto insurance premiums paid by Michigan consumers.

Those opposing the bill say any amount less than unlimited for medical benefits will bankrupt everyone and force them into the state’s Medicaid system. If this were true, then states with lower medical requirements (which are all other states) would have a lot more bankruptcy filings and  more of their population on Medicaid rolls. That is not the case.

Those opposing the legislation are not concerned about Michigan residents, but their own bottom line. The current Michigan auto insurance no-fault system has the highest benefits in the country. Under House Bill 4936, Michigan consumers would still have the highest benefits in the country.

Pete Kuhnmuench is the executive director of the Insurance Institute of Michigan in Lansing

Source: http://www.mlive.com/opinion/flint/index.ssf/2011/11/another_view_changes_to_states.html

Predictive models spot problems early

November 6, 2011 – 6:00am

A new generation of predictive modeling tools is rolling out in the workers compensation market, which experts say could make claims adjustment and management more of a science.

Modeling has been available in workers comp for years, but insiders say newer versions are more accurate in identifying problematic indemnity claims before their losses spiral out of control.

“I think everyone is always looking for that Holy Grail of information,” said Paul Braun, managing director of casualty claims for Aon Global Risk Consulting in Los Angeles.

Liberty Mutual Group Inc. launched a new predictive model this year that uses up-to-date data to calculate whether comorbid health conditions and psychosocial issues—such as obesity, depression or job dissatisfaction—could hinder an injured employee’s return to work.

Though a model Liberty Mutual introduced in 2006 considered such data, its revised VantageComp model is better at identifying claims that start small and grow slowly into larger indemnity losses, said George Neale, executive vp and general claims manager in Boston. Claim adjusters use the new data to point workers to resources that can help them recover faster, he said

“Slow-emerging claims are the ones that are a challenge for us in workers compensation,” Mr. Neale said. “And if you can understand those earlier, you can do something about them.”

He said the new model will be successful if it helps Liberty save at least 5%, or $100 million, on the $5 billion in workers comp claims it pays annually.

More insurers are using predictive models to help stem costs for workers comp claims, according to a survey earlier this year by New York-based consulting firm Towers Watson & Co. Of more than 100 insurance executives participating in the survey, 32% said they use predictive models in workers comp, up from 18% in 2009.

Aiming for accuracy

Companies also are continuing to tweak the tools to improve accuracy.

Aon’s Mr. Braun said companies are working to find data that pinpoints why some claimants take longer to recover than others with similar injuries and are evaluating whether previous data collection methods were accurate. Successful models use that information to actively help patients get well, he said.

Aon’s Early Claim Intervention model has shifted in the past two years to help adjusters better identify claims that will result in larger-than-expected losses. Mr. Braun said the brokerage recently analyzed seemingly simple medical-only claims that became complicated indemnity losses, and uses that data to spot other claims that could follow the same troubled trajectory.

Claims flagged through the process are sent to Aon’s most experienced adjusters, who then connect claimants with health care providers that can speed their recovery.

“You get them to the right doctor and get them to the right treatment instead of letting them linger,” said Mr. Braun, who estimates the model has helped reduce workers comp costs by 15% for its clients.

Atlanta-based third-party administrator Broadspire Services Inc. adapted its E-Triage model six months ago to help claims adjusters better determine whether smoking, obesity and other factors slow worker recovery times.

Gary Anderberg, Broadspire’s Philadelphia-based practice leader for analytics and outcomes, said social issues also play an important role in Broadspire’s newer mathematical formula. For instance, the more family members a claimant typically has, the less likely he or she is to return to work.

“If there are preschool-age children in your home, the fact that you’re home on a workers compensation claim may mean you don’t need to pay for babysitting,” Mr. Anderberg said. “And that can be a nice thing.”

He said Broadspire’s model, launched five years ago, is updated continually with new data. A version being developed by the TPA will allow its adjusters to predict how many days an injured worker will stay off the job and use that guideline to help prevent excessively long work absences.

Reed Group Ltd., a disability case management services firm in Westminster, Colo., released a new version of its MDGuidelines predictive model for workers comp cases in February.

Its model, used by various insurers and employers, predicts the recovery time for claims based on factors such as geography, comorbid conditions and job satisfaction. Reed Group then suggests medical resources that can hasten recovery times.

Dr. John Seymour, president of guidelines for Reed Group, said the model can help reduce a claimant’s time off work from an average of 55 days to about 30.

“We’re always striving to get that employee back to work as soon as possible,” Dr. Seymour said.

Companies expect predictive models to keep evolving as insurers and administrators discover new ways to calculate workers comp risk.

Broadspire’s Mr. Anderberg said he believes competition among companies will drive significant advances in predictive modeling in the next several years.

“There are a lot of good people out here, and some really creative thinking is going into it,” Mr. Anderberg said.