It is a very interested question

These links may help you

https://tampub.uta.fi/bitstream/handle/10024/95217/978-951-44-9460-4.pdf?sequence=1

https://cdn.ymaws.com/www.esska.org/resource/resmgr/Docs/2016_DML_full_text.pdf

https://www.uwhealth.org/files/uwhealth/docs/pdf/SM14890_Meniscus_Repair8.pdf

Thank you for the links. I have read the studies you're referencing and similar ones out of the US as well. As the articles point out, the etiology of knee pain is often complex. The presence of meniscus tear may not be directly the source of the knee pain as clearly explained in the studies. However, as clinician, I need a practical approach in designing a simple treatment plan that most patients can follow and adhere as part of their lifestyle when they exercise. I have reviewed many of the exercise routines employed by physical therapists and found that stationary bicycling is always included in their regimen. Bicycling, not only is a good way to strengthen the quads, but also is good cardiovascular workout. I'd like to hear more inputs from clinicians out there who treat patients with knee pain their experience with which treatment plan is the most effective and practical for patients.

Stationary bicycle is an exercise that is recommended by physiotherapists. It helps the strengthening of the muscles as well as the proprioception. General road cycling though has disadvantages. During cycling on the road the person needs to overcome obstacles and negotiate turns. Turning means that the turning bar has to force the leg to abduct and external rotate at the hip and this way to force internal rotation of the tibia in comparison to the femoral condyles. In a diseased knee this may cause discomfort and flare-up of the problems. This is the reason that physiotherapists usually do not allow road cycling although within their treatment include stationary bicycle exercises.

Spot on! Thank you for your response regarding bicycling and giving us an added bonus knowledge of the bio-mechanic of "road cycling". Well thought recommendation. If you would, I'd like to hear your comment and/or recommendation regarding chronic low back pain management. Thanks.

Chromic low back pain has a multitude of causes. A brief recommendation on physical exercises which usually works in many cases is build up of the core muscles.

Lederman_The_myth_of_core_stability

Thanks for your answer. Lederman, in the article above, debunks the validity of core muscle theory. It's explained that there's no relationship between core muscle strength and the cause or the improvement of low back pain. His argument is very strong and based on very compelling research data regarding the core muscles and back pain.

In the general question you place: management of chronic low back pain you received an answer which is general. In this is explained initially the multifactorial cause of low back pain.

There is back pain due to fact joint degeneration or due to scoliosis or due to disc degeneration or spondylolysis or spondylolisthesis or aortic aneurism or abdominal organ illnesses or even due to the will of a person to either feel sick or if the person is after a compensation. You indicated a paper that is well written and has great arguments although there are and there will be other researchers who will agree or disagree. This is the history of research.

For the argument sake lets say we have a mechanical low back pain in an obese patient. Causes are mild multilevel degeneration of discs but not yet degeneration of facet joints. Loads that go on the spine in a standing position is his own weight or the addition of any weight he carries. On top of this we make him to do some simple tasks, as for example keep a carrying load at a distance from his body while standing. I hope we agree that the load going through his back is increased and his back pain will be worse as the moment arm the load is acting upon is increased. In theory we can make him slimmer and the direct load as well as the moment arm of the body mass is getting smaller so this way the load carried from the spine is lesser but still if the load this person is carrying in the hands will increase the load to his back according to the distance he/she is lacing the arm from the body. This is the reason that when we carry something heavy we holding it close to our body (preferably chest level) and we [lace our back in lordosis.

Now a theoretical model allow us to remove this person's abdominal muscles but we still we have been able to keep him erect. He/she is carrying no load. Do we agree that the tension and so the load to his spine will be higher? All the load and tension will be on the dorsal muscles. Now we increase the bulk of his abdominal muscles and we place them back. Do we agree that the load will be lesser? If we remove the fat only from his body in this model we end up with "floppy" skin and "floppy" muscles. Do we agree that the load through the spine will be higher as the muscles are weaker and they lost the tension the fat was providing them? Is this why we insist the patients to loose weight and in the same time exercise?

I my mind all is simple if we know the cause and treat accordingly by thinking in a simple constructive way.

So coming back to the general question placed above, a simple general answer was given, but then we need to know the cause of the back pain and provide an individual treatment. This is why we investigating and treating back pains in a multidisciplinary team.

Very thoughtful and passionate answer. Thank you for your time and sharing your knowledge. Nowadays, with the advancements of science and technology, medicine has become very complex. The practice of medicine has become even more challenging than ever before. I understand there are many causes of back pain as you cleverly mentioned above in your answer. The back pain that are due to non mechanical issues such as underlying medical problems should be addressed separately and accordingly. I like to keep it simple. Chronic back pain that develop after an injury or the normal process of aging is usually either due to discogenic or degenerative joint disease. In my opinion, most chronic lower back pain can be boiled down to the degeneration of the discs or joints or both.

I agree with you regarding obesity. An example of excessive front load which may cause back pain or problem to the spine is heavy breasted women. Many of those women elect to have breast reduction operation to help manage their symptom.

I believe that general aerobic exercises are very beneficial in relieving day to day symptoms of chronic low back pain due to disc or joint disease. People can choose which aerobic exercise they prefer and that is easiest to adhere. My rationale behind the exercises is simply because aerobic exercises have multiple health benefit to different organs from bones and muscles to the cardiovascular system. Some "feel good" hormones are also being produced as byproduct of the exercise. People with back pain often complain of the their back being very stiff. The stiffness could often be due to the tightening of the para-spinal muscles that are guarding the spine from any sudden or further movement. The initial presentation of an acute injury to the back no matter what the etiology is usually accompanied by muscle spasm to the back, the para-spinal musculature, which cause even more pain due to the spasm. I've never seen of any "core muscle" involvement during the presentation. Aerobic exercises may help the para-spinal muscles to put the guard down and back into its relax and resting state effectively reducing or even eliminating the pain.

Thank you for the answer. I agree with you in all subjects but as part of any exercise there are potential core exercises and these could assist further. as there are possibly within the "package". Aqua-aerobics could be most beneficial as there is "no gravity". I do not think that there are any great differences between the final approaches. Once more thank you for sharing you thoughts.

Yes, I like your idea with aqua-aerobics. I utilize that form of therapy quite often especially among much older patients or obese people that have difficulty doing other form of exercises. Unfortunately, most therapist in my area do not include aqua therapy for various other reasons including the availability and accessibility to the swimming pool. Yes, core muscle strengthening is one way to feel and look good at the same time.

Platelet rich plasma or PRP has also been used to treat various musculoskeletal injuries and pain due to the tendons and ligaments to the disks in the spine. The treatment is quite common even though it is not yet mainstream. Many famous and high profiled athletes including Tiger Woods have received the treatment. I would like to hear comments and personal experiences regarding PRP injection as another option to treat pain due to various musculoskeletal pathology.

Simple stretching in the form of full flexion and extension is also important in the management of meniscus derangement to maximize the capacity to glide more easily during weight bearing and ambulation. The ability to fully extend the knee will help during ambulation without compromising the movement due to pain or derangement.

Pain can be both the symptom of the degenerative joint due to cartilage loss and can also be the modulator of the diseased joint. As a consequence of the degenerative process in the joint, pain is created to send signals that the joint is no longer healthy. The pain created by the diseased joint will have big implication in the disease process going forward. Depending on the amount of pain experienced during movements, it will undoubtedly influence the amount of physical activity and the kind activities that can be tolerated. Although the level and intensity of pain may be subjective and vary among individuals, the threshold that an individual will bear the pain will determine the timing when the physical activity will be altered. Once the physical activities are altered from normalcy, both physical and structural changes will occur in and surrounding the joint. The surrounding muscles may not be used as required to do activities to compensate for the pain which will result in atrophy and weakness. As a result of the surrounding muscle atrophy and weakness, structural change in the joint will most likely occur due to less or no protection from the muscles on the weight that is being transferred and loaded onto the joint. This event will cause more damage to the joint and is the beginning of the vicious cycle of worsening condition in the degenerative joint. From this analysis, it is clear and of paramount important to exercise the joint and the surrounding muscles that control the joint. Water therapy can be started first if weight bearing is too painful. Stationary bicycle is both practical and safe to increase the joint mobility and muscle strength. Physiotherapy specialist should be consulted if there's any question or doubt regarding the correct and proper exercises to adjust to certain comorbid conditions on individual basis .

Research has shown in people with knee osteoarthritis, low-intensity cycling is as effective as high-intensity cycling in improving function and gait, decreasing pain, and boosting aerobic fitness.

As the knee joint degenerates whether through injury or genetic predisposition, the joint space and the connective tissues will also continue to worsen. A tear or damage in the meniscal cartilage will eventually affect the articular cartilage which is a major contributor to pain and the loss of normal function. The loss of joint space and diminished amount of cartilage left to accommodate for both cushioning and gliding of the joint are the main characteristics of the degenerative knee joint or knee osteoarthritis. Modified activities and certain exercises such as bicycling that are pain-free should be emphasized to avoid inactivities and deterioration of general health. Depending on the level of pain, loss of function related to routine daily activities, and quality of life, there will be limitations in what conservative measures such as exercises and other therapies can achieve in eliminating pain and restoring function. Cartilage regeneration may offer hope if the claim and result are both legitimate and repeatable across the population. In the absence of the ability to restore the joint space and cartilage, total knee arthroplasty known as TKA or TKR is the last option for people who are suffering from this condition.