THE LEG and KNEE INJURIES

– THOMAS E,SPORTS MEDICINE
THE LEG
 Shin Splints 
 ‘Shin splints’ is a blanket description of persistent general pain over the front end of the lower leg. The pain is most often felt on the lower inner side and is worse on dorsiflexion. It can be described as medial and anterior tibial soreness, may also be called tendinitis, and is usually caused by running. The pain is aggravated by exertion and gets worse during the exercise. There is almost always a history of increased activity such as increasing running mileage or dance performance, especially on hard or unsprung surfaces after a layoff, or by unaccustomed dancing, running or long walking. If the soreness is felt close to the shin bone or on the central ridge it may take longer to clear up, as the periosteum may be inflamed or damaged.
 Stress fractures can mimic shin splints as both cause anterior shin pain. If pain persists for longer than an hour after cessation of exercise a stress fracture may be suspected and the patient referred for diagnosis and assessment accordingly. The pain from a stress fracture gets worse to the point where walking is painful and the pain persists even in bed.

 Simple Test for a Stress Fracture 
 There is a simple test to confirm a stress fracture. A vibrating tuning fork placed on the centre of the painful area will cause tenderness in just one spot and signify a stress factor, whereas diffuse pain over a large area does not normally do so.
 A great deal of research has been conducted into this condition, but its cause remains doubtful. In orthodox terms an inability to distinguish the cause of a condition prohibits the development of a satisfactory cure. Fortunately homoeopathy knows no such constraints, and the condition may be prescribed for simply by taking the symptoms and using them to choose the correct remedy.
 The possibility that the pain was caused by trauma should be eliminated early in treatment. If trauma has been the cause, an immediate dose of Arnica in any potency should be given.
 Treatment for Shin Pain
 The athlete must rest to allow the acute condition to settle. An orthotic device which could successfully eliminate the condition may be prescribed by a podiatrist or orthotist.
 The following homoeopathic remedies may help to reduce the pain and inflammation according to the symptoms manifested.
 Agaricus Muscarius
 Pain in the shin bone which appears gradually, and is worse when sitting. Feels as if needles are being pressed into the leg. Nervous twitching and then the leg becomes stiff and cold. Legs feel heavy, violent pains in the leg when crossing them. Itching and cramp in toes and feet. May talk a lot, change subjects rapidly and seem unable to concentrate. Worse in the morning and from cold, better from gentle motion.
 Dosage: One Agaricus 30c. If the pain starts again, resume the remedy.
 Arnica
 Dosage: One 30c tablet as soon as the pain is first felt.
 Bryonia
 If the person is averse to the least motion, not just of the injured leg, and the leg feels worse when elevated and with heat. The person is very irritable and wants to go home, despairs of getting better. There may be some redness and swelling around the painful area. Pain is better from pressure, such as tight bandaging, and he sits holding his leg.
 Dosage: One Bryonia 30c.
 Causticum
 The pain is tearing and rheumatic, with burning. It may feel like an electric shock in the leg. The tendons feel contracted. The leg pain is much worse in the morning in bed, but, strangely, he feels better when he is warm in bed at night. The pain is much worse from getting cold, or having ice treatment. The person is very sensitive to the feelings of others, and very sympathetic. He will probably ask others about their problems rather than have his own dealt with, and will be overworked by dealing with others to the point of exhaustion.
 Dosage: One Causticum 30c.
 Phosphorus
 Inflammation of the periosteum with tearing pain in the tibia. After exhaustion. Worse from any and every exertion. He is tottery and stumbles easily. His legs are heavy and his feet feel stuck to the floor. A very affectionate and sensitive person who cares much for others (but not as much as Causticum). Hates to be alone.
 Dosage: One Phosphorus 30c.
 Rhus Toxicodendron
 Soreness in tibia at night and in bed. The pain is tearing, stitching and shooting, so bad at night that he cannot rest. The leg feels sore and bruised, and as if the flesh was torn from the bone. There may be inflammation and swelling. The person has to keep moving the leg because it feels better when he does, and so he is restless. First movement is painful, but continued movement eases the pain. The pain is worse on cold wet nights. Typical onset is after training, a run or dance session, cooling down and resting. Anxious and very depressed.
 Dosage: One Rhus Tox. 30c.
 Ruta Graveolens
 This is the prime remedy for shin splints when the pain typically comes on after exercise, walking or running. The pain feels as if it is deep in the tibia and the person feels as if he should walk gently about indoors. Walking in the open air makes him worse. The pain may be eased during the day. The legs may feel weak, so weak that he cannot get out of a chair, and the ankle may be swollen. The leg feels bruised, sore and aching, and there is restlessness with intensely weary painfulness. The pains may be worse from lying, sitting and cold, and better from warmth. There may be hard nodules in the periosteum.
 Look out for some depression about his condition, and a feeling that he will not improve. He may also be dissatisfied with himself and with his treatment. The Ruta patient may wake frequently from sleep after vivid confused dreams and yawn a lot, and stretch out his arms and hands.
 Dosage: One Ruta 30c.

Stress Fracture of the Tibia 
 Stress fractures are among the most common of all sports injuries. They are most commonly found in the lower legs of runners who experience pain along the medial border of the tibia while training. The pain begins insidiously but as training continues it intensifies so much that running has to be reduced or stopped entirely. It is difficult to differentiate clinically between the inflammation of shin splints and the more severe stress syndrome or fracture. Pain from shin splints is usually present at the start of training but may disappear during exertion, only to return several hours later (see Rhus Tox.).
 Gymnasts develop stress fractures of the wrist, and cricketers may develop them in the lumbar spine. Dancers develop them in the foot. They are partial or complete fractures of bone, and are called stress fractures because they are caused by repetitive strain during sub-maximal activity. The bone is unable to react favourably to the stress imposed by such activity.
 The two types of stress fracture are fatigue fracture and insufficiency fracture. The former is most often encountered in runners.
 The latter is most often seen in post-menopausal women, and women with menstrual irregularity or disorder. Both types may be treated with homoeopathic remedies according to the presenting signs and symptoms.
 Remedies for Stress Fracture of the Tibia
 All the remedies listed above for shin splints can be considered for treating stress fractures according to the symptoms. If the pain persists for more than two weeks, the patient should be referred to a doctor for diagnosis.
 Arnica
 As soon as the pain becomes noticeable start taking Arnica. Arnica will be needed when the person tends to decline treatment or put it off and says, ‘I’m OK. I’m fine. I don’t need to be seen.’ The pain starts after overexertion, or unusually increased activity or exercise – for example, when a recreational runner decides to increase his mileage from ten to twenty miles a week, and runs mainly on roads. The pain tends to start as a mild ache after a run, and he tries to ‘run through it’. If there has been any trauma to the shin, Arnica is essential.
 Dosage: One Arnica 30c.
 Nitric Acid
 The tibia is painfully sore, especially in a small spot. Look out for the person who indicates the pain by putting one finger on the spot. He does not want you to touch the spot because it hurts, but steady pressure ameliorates. Jarring hurts too. The ankles may be weak and crack when he walks. There may be a sensation of a splinter. Look out for discoloured, distorted toe nails. This may be the sort of person who feels driven to train or work, often too hard, and becomes anxious and irritable if he cannot.
 Dosage: One Nitric Acid 30c, three times a day for a week.
 Rhododendron
 Drawing, tearing pain in tibia. Feels as if he has a weight on his foot. Feet are cold. Better from heat, and better immediately he starts moving. (Rhus Tox. is better after the first few movements.) Slight exertion makes him exhausted and weak. Sensitive to storms and changing weather.
 Dosage: One Rhododendron 30c, three times a day for a week.
 Rhus Toxicodendron
 Aching pain on first movement, relieved by continued movement. Pain during rest after exertion.
 Dosage: One Rhus Tox. 30c taken before and after training.
 Symphytum
 When a stress fracture has been diagnosed, and while the person is resting.
 Dosage: One Symphytum 30c taken three times a day for two weeks will promote healing.
 Chronic Compartment Syndrome
 Compartment syndrome occurs when muscle pressure increases to a level that inhibits blood flow within the muscle compartment. It is invariably exercise-induced, and the patient complains of aching or cramping pain, tenderness, tightness and possibly weakness in the anterior muscle or deep in the posterior muscles. The pain seems to come on after about twenty minutes of running or exercise, and is relieved when the exercise stops. There may be numbness and/or tingling along a nerve traversing the compartment.
 The athlete should be discouraged from training ‘through’ the pain, as prolonged muscle soreness and pain can occur. There are two homoeopathic remedies that may help:
 Hepar Sulphuris
 Cramping, sore pain in muscle, very tender and sensitive to touch. Aggravated by running, especially in cold conditions and when the legs are cold. Relieved by rest. A very irritable, chilly person who notices draughts.
 Dosage: One Hepar Sulph. 30c, taken before training.
 Nitric Acid
 Painful soreness in the region of the tibia. A sensation as if there is a splinter in the muscle, sore to touch. The muscle feels as if is sticking to nearby tissue. The jarring of running aggravates the pain. Anxious about the injury.
 Dosage: One Nitric Acid 30c, taken before training.

 Calf Muscle Tear 
 A tear in the gastrocnemius muscle is typically experienced by the older squash or tennis player or dancer who suddenly lunges, stretching his back leg in the process. He may describe the onset as being a sensation of ‘unzipping’ across the muscle. The injury is sometimes described as ‘tennis leg’, and even a mild tear will cause tenderness and seriously affect walking. A gross tear will generate considerable haemorrhage and subsequent swelling, pain and hardness. The foot cannot be dorsiflexed and the typical walking action is that the non-weight-bearing foot cannot be brought forward of the other foot. There is a risk of further bleeding after about ten days when the newly formed scar tissue is very vulnerable to further tearing. The injury may be mistaken for a deep vein thrombosis, which could be life-threatening and must be referred to a doctor.
 If older performers warm up with stretching exercises this disabling injury can largely be avoided.
 CASE 17
 A tennis player aged 45 was stretching well forward for a forehand stroke. He felt ‘something give’ in his rear leg. I saw him leave the court. He was limping badly, and unable to bring his left foot forward of his right when it was weight bearing. He had refused help, saying he was OK, and had tried to continue the game. He described the trauma as if a zip had been opened across his calf. l applied crushed ice with a crepe bandage in the changing room and gave him one Arnica 30c. There was still severe pain as he limped back to his car.
 I advised RICE and hourly doses of Arnica. He rested and continued treatment for the following day. The day after he was able to walk again without much pain.
 Arnica
 Dosage: One Arnica 30c, three times a day until improvement begins. Two or three doses should also be taken about eight  to ten days after injury to avoid the possibility of further bleeding.
 Bellis Perennis
 If Arnica does not relieve the pain, and the pain is deep in the muscle and unbearable. The Bellis person tells you he is injured and needs help, does not like the idea of ice if he is still hot from activity, but finds that the ice treatment is very effective and relieves the pain.
 Dosage: One Bellis 30c every few hours for a day. Depending on the symptoms, Ruta and/or Rhus Tox. may also be required until fully recovered. Bryonia will help the patient to move the limb if he finds this difficult or painful. Refer to Chapter 10 for details.

THE KNEE 
 CASE 18
 James is a recreational skier. Towards the end of his holiday he fell on a very steep slope. He thinks he may have hit a rock with his knee. It was very painful. He limped back to the valley and packed ice around the joint. His knee was too swollen to ski the following day, and he ended his holiday very disconsolate and depressed. The day after his return he saw his GP who diagnosed a torn medial ligament, and prescribed an immobilising strapping, mild pain killers and crutches.
 James’ wife is a patient in my practice. She is a very determined woman. Despite his reluctance to make a fuss and assurances that he was OK, she persuaded him to call me. I gave him Arnica 30c to take every hour for a day, and followed this with Ruta 30c, three times in one day. He immediately felt less depressed, and allowed his wife to remove his strapping and take back the crutches. With physio-therapy and exercises he was back at work and exercising fully within a week.
 The knee is the most frequent source of injury from sports, especially in contact sports and running. The former produces traumatic injury, the latter, over-use injury. The knee is the second most frequent site of injury in dancers. Incorrect technique and outward rotation produces pain, swelling and inflammation of the ligaments. Pain from knee injury may be referred to the hip from the knee. An accurate history of the condition is essential.
 Much has been written and discussed about knee injuries, enough to make the knee almost a speciality of its own. In homoeopathic terms the various pathological causes of pain, immobility, stiffness, swelling and other disease produce symptoms that will help you to choose a remedy to help the patient heal more effectively. Specific diagnosis may be less important than how the injury occurred, when the pain is worse, the type of pain and how the patient feels about his injury. We will, however, look at potentially helpful remedies through the main injuries that will bring athletes to your clinic.

Anterior Knee Pain 
 Anterior knee pain can be due to many conditions. The diagnosis may be chondromalacia patella, patellar malalignment syndrome, infra-patellar tendinitis, Osgood-Schlatter disease or similar. Whatever the pathological diagnosis may be, you can prescribe homoeopathic remedies according to the symptoms presented by the patient. Over the years homoeopaths have found certain remedies to be effective for specific conditions, but these will only work when the symptoms fit.
 Patellofemoral Pain (Runner’s Knee)
 Runners notice an insidious onset of an ill-defined ache localised in the anterior knee behind the knee cap. The pain may sometimes be felt along the medial or lateral edge of the patella and is aggravated by downhill running. There may be complaints of swelling or of sudden weakness with a feeling that the knee ‘gives way’.
 This anterior knee condition affects the posterior surface of the patella and may be incorrectly seen as a precursor to osteoarthritis, or as a sign of cartilage damage. A more apt description would be to call it ‘runner’s knee’. It happens to runners who have increased their mileage, new joggers and runners, marathon runners, young athletes and dancers, tennis players, footballers, and dancers.
 Typically the performer feels pain in or behind the patella and decides to ‘work through it’. After a strenuous bout of activity, the pain characteristically develops after rest following activity the day before. The knee becomes stiff after being in one position for a long time while sitting or lying. It is very painful on standing up from sitting. Squatting and kneeling are painful, and the pain is worse when walking downhill or down stairs.
 Runner’s knee may arise from muscle imbalances, unusual foot biomechanics and imbalance, one leg being abnormally shorter than the other, or a wider than normal pelvis. Orthotics prescribed by a podiatrist or orthotist can help to resolve all these conditions.
 Rest from painful activities is essential. The person may benefit from static exercises that brace the quadriceps, alternative, non-weight-bearing activities like swimming and cycling as long as they do not produce pain, and bandaging, rest and elevation.
 The homoeopathic remedies listed overleaf will probably eliminate the need for anti-inflammatory drugs, but if the pain and swelling are still troublesome after some days, refer to a professional homoeopath, who may suggest other remedies.
 Arnica
 Give Arnica if there is bruising pain or aching, and to help overcome the trauma. Look out for the person who says, ‘I’m OK. I’m fine,’ is sensitive to touch, and wants to be left alone.
 Dosage: One Arnica 30c, three times a day for two days.
 Bryonia
 There is hot red swelling around the patella and the person does not want to move his knee or any other part of his body, preferring to lie quietly. Better from pressure on the knee, likes to have it bound up tightly and kept cool. The knee feels weak and bends under him. It is effective in conjunction with Rhus Tox. (see below) if the pain is worse on first movement, then eased by continuous movement, and then gets worse again with continued movement.
 Dosage: One Bryonia 30c, three times a day for not more than two days, or until the pain stops.
 Calcarea Carbonica
 This remedy can be useful when the cause of the condition is suspected to be pronation of the feet from weak ankles. The pain is worse when rising from a seat and when sitting. There may be weakness and trembling in the limb, and the feet may be cold and flabby. The person may be fair and well built, prone to putting on weight too easily, and hates cold. He is worse from exertion. If you bind up this person’s knee he will become worse.
 Dosage: One Calc. Carb. 30c, three times daily for a week can help to relieve the pain. Stop when the pain eases.
 Chelidonium
 Pain, burning, and stiffness in the right knee, especially in the patellar tendon. The knee is very sore to touch, and the limb feels heavy and paralysed. Worse at 4 a.m.  and 4 p.m. , and from motion. Tired. Better from hot bathing.
 Dosage: One Chelidonium 30c.
 Nitric Acid
 Pain in the patella that makes walking difficult, and extends to the tibia. Worse from cold, touch and jarring. The pain is like a splinter. Look out for someone who may be taciturn and quarrelsome.
 Dosage: One Nitric Acid 30c.
 Rhus Toxicodendron
 The knee feels worse on first movement, rising from a seat or in the morning, but is better with continuous movement. There is sore pain and stiffness at night so that the person cannot find a pain-free position in which to sleep. The knee is worse when laid on. The person is restless and exhausted by the restlessness. The pain may come on after strenuous activity, and especially at night during wet, cold weather. Better from hot bathing and from heat in general. Look out for the person who is anxious and depressed about the injury.
 Dosage: One Rhus Tox. 30c.
 Zinc
 Pain in the patellar tendon while walking. Feet and legs are very restless. Cannot keep them still. The pain comes on after a very exhausting performance or event, and the person feels totally exhausted, both mentally and physically. Likes the knee to be bound up tightly. Hard pressure and massage relieve the pain. He moans or calls out with pain, and may repeat the questions you ask before replying.
 Dosage: One Zinc 30c.

Haematoma 
 Arnica
 Arnica 6c, 30c, or 200c, given immediately, or soon after the traumatic injury, and repeated for six doses will prevent bruising, haemorrhage into the bursa or capsule, inflammation and subsequent problems.
 Infrapatellar Tendinitis
 Overuse such as long-distance running, fell-running, hopping, kicking , dance or squatting may cause inflammation and pain in the infra-patellar tendon. This is particularly at risk after strenuous exertion, and during severe exertion, especially squatting with weights, when cold and not warmed up well. The pain does not usually prevent exertion, but continued use may lead to scar tissue which in turn produces adhesions, and possibly bone spurs. Early diagnosis and treatment are obviously desirable.
 The patient should not participate in activities that cause pain, and should stretch the quadriceps gently but effectively as part of a good warm-up before exercise. Take whichever of the following homoeopathic remedies fits the symptom picture most closely.
 Arnica
 See previous page.
 Rhus Toxicodendron
 Very stiff on first movement (see above). Pain in the head of the tibia, worse at night in bed, and after walking.
 Dosage: One Rhus Tox. 30c, three times a day for two or three days. See also Chelidonium and Zinc in the Runner’s Knee section (page 000).
 Ruta Graveolens
 Stiffness, soreness, aching, bruised pain in the tendon with great restlessness, bursitis, cracking in the knee. Pains are worse when walking in the open air. The knees are weak and give way when descending and ascending stairs. Comes on as a result of over-exertion, made worse by cold, lying, sitting and more exertion, and better from warmth and massage. The person seems tired, cranky, moody, fretful and depressed about his condition.
 Dosage: One Ruta 30c, three times a day for two or three days to relieve the pain and to assist healing.
 Osgood-Schlatter Disease
 This painful condition affects active, sporting adolescents and dancers who may have grown recently. Its cause is repetitive strenuous exertion that causes pain, stiffness, inflammation and swelling in the knee, especially in the tubercle of the tibia, which may become detached. The pain is worse when the knee is stressed during repetitive activity, when kneeling, running, jumping and descending stairs.
 Rest from all activity except for moderate walking and non-competitive swimming and cycling, together with ice treatment, will often reduce the symptoms in three weeks or so. If the pain is not relieved in three weeks, immobilisation may be needed.
 Causticum
 The pain is tearing and rheumatic with burning. Worse when sitting and better from continued walking. The tendons feel contracted with cracking and tension in the knee, especially when descending. Stiffness felt in the hollow of the knee. The pain is much worse in the morning in bed, but, strangely, he feels better when he is warm in bed at night. The pain is much worse from getting cold, or having ice treatment. The person is very sensitive to the feelings of others, and very sympathetic. He will probably ask others about their problems rather than have his own dealt with.
 Dosage: One Causticum 30c as needed to relieve the pain. If it is effective, it can be used throughout the time it takes to heal.
 Natrum Muriaticum
 Wrenching pain in knee, like an ulcer in the tubercle, when walking and standing. Restlessness and jerking of legs, cracking in knees during movement. Worse from heat and exertion. Hates sympathy.
 Dosage: One Natrum Mur. 30c, as necessary for pain.
 Rhus Toxicodendron
 See above. Especially if there is cracking in the knee, if the pain follows unusual exertion, and on first movement.
 Ruta Graveolens
 See opposite.
 Symphytum
 If fragmentation of the tubercle is suspected or diagnosed. There is excessive neuralgic pain, stitching pain when bending the knee, worse from touch.
 Dosage: One Symphytum 30c, three times daily for two weeks. This remedy acts as a bone healer. Its old country name is ‘knitbone’.
 Collateral Ligament Injuries
 The medial collateral ligament (MCL) helps keep the knee stable by resisting external rotation of the tibia and valgus forces. MCL sprains are tension injuries that are usually the result of a blow to the lateral aspect of the knee. Orthodox treatment includes lightweight support and aggressive early rehabilitation. Sometimes, in combined injuries, the cruciate ligaments require surgical reconstruction. Braces may be worn, but their effectiveness is uncertain.*
 An application of external force to the leg and twisting in extension, during a tackle in rugby, or resistance to rotational force are often causes of MCL injury. When, for example, a footballer is tackled while his boot is fixed in the pitch, enough stress is produced on the ligament to cause traumatic stretching or tearing to the medial ligament. Injuries to the lateral ligament are not as frequent as to the medial. The same homoeopathic remedies will work for both.

CASE 19
 A footballer aged 26 had received a full-weight tackle on his left leg while it was extended. He felt something tear in his knee, and had to leave the field. The knee was strapped up with an elastic bandage, but he felt nauseous, cold and shocked. He felt too bad to join in when his team mates had a post-match beer, and lay in the dressing room with his leg elevated.
 The following day his knee was swollen, painful and immobile. He was unwilling to move, and simply wanted to lie still.
 He consulted his GP, who diagnosed a ligament tear. He prescribed an anti-inflammatory drug and strapping to immobilise the joint. The club physiotherapist called me about him because a few days later he was still in shock and nauseous and wanted to go back to work. I met him at the club, and his first words were, ‘I’m OK. I just want to get back to work, and start playing again.’ He was very unwilling to have anyone treat his knee. He sat with his leg elevated on a chair. He totally rejected the physio’s suggestion of static quadriceps exercises. He had not slept well since the injury because he felt bruised all over, and the bed was too hard. He moved his leg away as if to protect it whenever anyone came close.
 I gave him one Arnica 200c immediately, and told him to take one later for the shock, nausea and pain. He allowed the physio to examine his knee and to treat it a few minutes later. He was able to start static exercises the following day, but was still reluctant to move much. One Bryonia 30c helped him to move without pain.
 Three weeks later he was fully weight-bearing but his joint mobility was still less than 90 degrees of flexion without pain. There was a notch on the ligament, The swelling was almost totally reduced. His leg felt weak, and as if it would give way when he stood. He was ‘fed up’ with being injured, and was not sleeping well because of pain in his knee. He felt it would ‘go out’ if he moved in bed.
 He took one Ruta 30c, three times daily for one week, and continued physiotherapy. The improvement was dramatic. Three days after starting Ruta his mobility improved to more than 90 degrees and he could begin active weight-bearing exercise. He was playing again two weeks later.
 If this player had had ice applied and taken Arnica immediately after injury he could have avoided the shock and much of the swelling and immobility. Recovery would have been even quicker.
 First-Stage Remedies (immediately post-trauma)
 Arnica
 Dosage: One Arnica 30c, as soon as possible after the injury. Give two or three doses an hour apart.
 Bellis Perennis
 If Arnica does not relieve the pain after two or three doses. The person cannot tolerate cold in any form. The knee feels better from heat and hot applications. The pain and bruising is deeper than in Arnica and may be felt up the front of the thigh. He moves impulsively.
 Dosage: One Bellis 30c, two or three doses.
 Bryonia
 Even the idea of moving is painful. He does not want to move, talk, change position, go to the toilet, wash or anything. He would like a hot bath because it will improve his knee, but the idea of getting to the bathroom is too painful. Although his knee is painful, hard pressure on it and tight bandaging relieves the pain. You will find this remedy will be helpful for most traumatic injuries where the pain is immobilising.
 Dosage: One Bryonia 30c will help him to get moving. Repeat as necessary.
 Second-Stage Remedies (longer-term remedies)
 Rhus Toxicodendron
 Give Rhus Tox. at any time during the recovery if the symptoms fit and the person needs it, especially if you suspect that adhesions are slowing recovery.
 If the knee feels worse on first movement, rising from a seat or in the morning, but is better with continuous movement, there is sore pain and stiffness at night so that the person cannot find a pain-free position to sleep, and the knee is worse when laid on. The person is restless and exhausted by the restlessness. The pain may come on at night during wet cold weather, and is better from hot bathing and from heat in general. Look out for the person who is anxious and depressed about his injury.
 Dosage: One Rhus Tox. 30c, three times daily for two or three days.
 Ruta Graveolens
 The person seems tired, cranky, moody, fretful and depressed about his condition. I have found that Ruta has the immediate effect of making the person believe he will recover when he is most depressed and despondent about his injury. He begins to want to get better, to exercise and have treatment, and he adopts a much more positive attitude. Stiffness, soreness, aching, bruised pain in the tendon with great restlessness. Pains are worse when walking in the open air. Knees are weak and give way when descending and ascending stairs. The condition is aggravated by cold, lying, sitting and exertion, and better from warmth and massage.
 Dosage: One Ruta 30c, three times a day for two or three days.
 Long-Term Effects of Knee Injury
 If the injury continues to bother the athlete or dancer and affect his performance long after he should have recovered, the following remedies may prove useful.
 Calcarea Carbonica
 The knee may continue to swell following exertion some time after the injury, perhaps when the athlete or dancer has started activity again. He or she may express doubts about recovery, and becomes depressed about it. May be naturally flabby and inclined to put on weight easily, but works hard at fitness. Look out for cold feet and a flabby handshake.
 Dosage: One Calc. Carb. 30c. Two doses will help to reduce and prevent swelling. One Calc. Carb. 30c before each match, class, training session or performance until the possibility of further swelling has disappeared.
 Calcarea Fluorica
 This a very specific remedy for pain and tenderness over the medial ligament associated with calcification and possibly ossification in the ligament. It is sometimes needed following repeated medial ligament sprains or haematomae from direct blows. The pain is worse after rest and relieved by moving a little (not as much as Rhus Tox.), and by warm applications.
 Dosage: One Calc. Fluor. 30c or 200c, daily for not more than two or three weeks.
 Chelidonium
 Continuing stiffness and swelling in the right knee, worse from exertion. This athlete or dancer may be lethargic in his or her approach to training and playing, and inclined to be ‘liverish’ in the morning.
 Dosage: One Chelidonium 30c.
 Pulsatilla
 Continued swelling, comes and goes without pattern. Hot and painful swelling, or cold and white. Pain comes and goes, and may wander to other limbs or places. The athlete or dancer is disinclined to stand for long. Dislikes warm, stuffy rooms. Much better in the open air.
 Dosage: One Pulsatilla 30c.
 Silica
 This remedy can help to eradicate scar tissue, and may be used to release adhesions. The athlete or dancer may have lost self-confidence after injury, and believes he cannot succeed or perform well. He may hide this feeling with obstinacy and a kind of determination. Very sensitive to drafts, and likes to wrap up well. Rough, yellow, brittle nails.
 Dosage: One Silica 30c.
 Warning: Do not give Silica above the 6c potency if the patient has synthetic tissue of any sort in his body. A replacement hip, or a polytetrafluoroethylene (PTFE) repair to a cruciate ligament, even a pacemaker, may be rejected following Silica in potency of 30c or higher.
 Strontium Carbonicum
 Continued oedema long after knee injury. Gnawing pain into the bones. Sprained and puffy knees and ankles. Burning, gnawing pains. Limb feels immobile and weak.
 Dosage: One Strontium Carb. 30c to reduce the swelling.
 Iliotibial Band Syndrome (Snapping Band)
 Lateral knee pain is a frequent problem among distance runners. Iliotibial band syndrome is the most common cause and results from the iliotibial band rubbing as it slides over the lateral femoral epicondyle.
 There is a developing feeling of tightness and often a burning pain over the lateral aspect of the knee while running. The pain typically comes on after the same distance has been run each time. Walking may not be painful, although climbing or descending stairs may be.
 Running long distances on a cambered road where the feet are always angled to one side may cause friction between the iliotibial band and the axis of the knee. The iliotibial tract may become swollen and thickened. Pain may also occur over the trochanteric bursa. In severe cases there may be a sensation of a ‘snapping band’ on the lateral side of the knee. Look at the possible causes such as worn-down shoes, cambered road running, or varus which could be corrected with orthotics, and eliminate them if possible. Raked stages may contribute to the condition in dancers.
 Arnica
 If the cause is overexertion such as a recent major increase in running distance or speed work, or a major event such as a marathon.
 Dosage: One Arnica 30c.
 Rhus Toxicodendron
 Use Rhus Tox. 30c if the pain is worse on first movement but relieved by continued movement, and the patient is restless, anxious and even more depressed.
 Dosage: One Rhus Tox. 30c daily for three days.
 Ruta Graveolens
 If gentle motion ameliorates the pain and the legs give out when rising from a chair, and if the patient is depressed and dissatisfied.
 Dosage: One Ruta 30c, three times a day for three days.
 Sticta Pulmonaria
 Sticta 30c may be useful if the pain is in the hip and due to bursitis.
 See the details in Chapter 10 and below under ‘Bursae and Bursitis’ (page 00).
 Dosage: One Sticta 30c daily for three days.

Torn Meniscus
 The most common meniscus tear is in the medial meniscus, and is usually the result of twisting force on the weight-bearing leg that causes a femoral condyle to shear the fibrocartilage of the meniscus. It may be associated with a tear of the collateral ligament. In footballers and dancers there can also be cruciate ligament damage. These are shocking and devastating injuries to a professional that can destroy a career.
 There is typically a locking of the knee due to the presence of loose material getting trapped between joint surfaces. The knee is commonly  locked in a flexed position. The onset is sudden, and pain is deep within the knee. The patient may describe a feeling of ‘giving way’. Effusion may be extensive and haemarthrosis may result if there is ligament damage. This can give rise to serious muscle atrophy.
 Immediate basic first aid and referral for medical attention are essential.
 Arnica
 This remedy will limit the effusion and haemarthrosis, and the subsequent swelling. It will reduce the pain, prevent shock and limit the subsequent atrophy.
 Dosage: One tablet of Arnica, any potency, immediately and three times daily for three days after injury. For bruising, swelling and pain use Ruta, Bryonia, Ledum and Bellis according to the symptoms outlined above.
 The following remedies may also help:
 Guaiacum
 The knee remains flexed and there is tearing pain when attempting extension. The least movement of the leg will be very painful, and there is a reluctance to move. Heat and touch makes it worse. Worse when sitting, and in the morning. Look out for yawning and stretching, some obstinacy and fixed ideas.
 Dosage: One Guaiacum 30c.
 Lycopodium
 Locked knee that has tearing pain preventing extension. The person describes the knee as giving way suddenly. It is relieved by heat, and he is not so reluctant to move. He feels better generally from heat but dislikes a warm room. Pressure hurts. Wakes feeling bad, and may be angry about the injury. This remedy is useful, especially for injuries to the right knee.
 Dosage: One Lycopodium 30c.

Torn Cruciate Ligament 
 The anterior cruciate ligament may be injured in sport and dance. The performer has usually participated in running, jumping or skiing and has stopped suddenly and fallen with a twisting movement. He may have attempted a ‘cutting’ tackle in football. The combination of abduction and rotation is similar to that which causes meniscus and medial ligament damage, and the three injuries often form what is known as the ‘unhappy triad’.
 Swelling is often immediate as the result of haemarthrosis. Within twenty-four hours a minor tear of the cruciate ligament can produce a tense swelling. Arnica in any potency, given immediately and followed by several doses, will help to keep the swelling and effusion to the minimum and reduce shock and swelling.
 Homoeopathic treatment for all three of the ‘unhappy triad’ should be according to the manifested symptoms. Please refer to the previous sections on collateral ligaments and meniscus for details of the most commonly recommended remedies. Give Ruta, Rhus Tox. and Bryonia as necessary, plus Symphytum to help the tendons, ligaments and cartilage to repair. There are two remedies that are almost specific to the unusual symptoms of this condition:
 Calcarea Fluorica
 This remedy can promote the recovery of damaged fibrous tissue.
 Dosage: Take one Calc. Fluor. 6x three times daily for as long as necessary, but for not more than a month.
 Phosphorus
 If during recovery there is a feeling of looseness in the knee so that it feels as if it would dislocate, burning pain or soreness in a small spot, extreme stiffness and weakness, all of which are worse from exertion, this remedy will help. The knee will be much worse if he lies on it, and from cold, and the pain will come on after he has been at work. This person is very sensitive, anxious, and seeks sympathy.
 Dosage: One Phosphorus 30c.

CASE 20
 This patient is an older woman who is very fit. She runs, weight-trains, and practises Tai Chi. During one stretching session she decided to increase the flexibility of her knees and sat back on her heels forcefully for two sets of two minutes each. She experienced some stiffness in her right knee on standing.
 The following day she had some pain in the medial posterior aspect of the right knee that was noticeable on rising from a seat. She felt her knee give way when she dismounted from her bicycle. In her next Tai Chi session certain twisting movements gave her pain and she felt again that the knee would give way. She described the pain as being like a splinter inside her knee.
 It was a minor condition. She thought it did not merit a sports medicine consultation. She mentioned it to me during a homoeopathic consultation for another matter.
 I suspected a strain of the posterior cruciate ligament due to the unusual forced flexion of the knee, and prescribed Ruta for the acute condition. She telephoned soon after to report that there was little change.
 Comment
 I looked at her case again. As she was a long-standing patient I already knew a lot about Janet; that she disliked milk and dairy products, and cold air, that she took up Tai Chi later in life because it gave her exercise without jarring and that she enjoyed the smooth, gliding nature of the exercise. She belonged to a type of person who seems driven to work and exercise as if afraid that once they stop they will give up altogether. I decided to prescribe Nitric Acid 200c three times daily for two days or until the pain eased. This was one of the remedies under consideration for her constitutionally.
 After one day of Nitric Acid 200c she reported that the pain had gone, and she later went on to improve in other aspects of her health.
 The only matching knee symptom for Nitric Acid in this patient’s condition was a splinter-like pain in the hollow of the knee, but the remedy cured her acute condition. Janet’s case is a good example of a remedy prescribed according to mental and general symptoms. It is not normally associated with weakness and giving way on standing and after exercise, or with pain in the hollow of the knee. Successful homoeopathic prescribing takes patience, a knowledge of the remedies, an ability to observe and listen to the patient and an open mind.
 Before Surgery to the Knee
 The patient should take one Arnica 30c before the operation. If he is very apprehensive about the operation, has great anxiety about it and is even very frightened, one Aconite 200c or 1M will help to calm the nerves.

After Surgery to the Knee 
 Arnica
 Dosage: One 30c tablet as soon as possible after surgery.
 Bryonia
 If the patient is reluctant to move, and to ease the first movements after surgery. This should be given routinely postoperatively for surgery to the knee.
 Dosage: One Bryonia 30c.
 Ruta Graveolens
 To help healing of the ligament.
 Dosage: One Ruta 30c, three times daily for two weeks.
 Staphysagria
 This remedy has a reputation for healing cuts from sharp instruments and for healing lacerated fibrous tissue. The knee feels beaten and painful.
 Dosage: One Staphysagria 30c, three times following the operation.
 If swelling returns some time after the operation, Rhus Tox., Calc. Carb., Chelidonium, Pulsatilla or other remedies as indicated by the symptoms may be necessary. For details see the section above on recurring swelling (page 00).

Bursae and Bursitis 
 Falls where the patella hits a hard surface can cause traumatic effusion or haemorrhage in the pre-patellar bursa. A kick to the knee, or frequent kneeling such as performed by Aikido players and carpet layers can also cause the condition that is still sometimes called ‘housemaid’s knee’.
 Haemorrhage can cause inflammation and swelling, and septic bursitis may result from secondary infection if the skin over the bursa is broken by laceration or a puncture wound. I experienced this before I knew about homoeopathy. Jumping down from a ledge during a climbing trip on limestone, my knee hit the rock and a sharp needle of limestone pierced the bursa. Within minutes the knee was swollen and very painful. I could walk only with difficulty, and felt shocked. In two or three hours I was becoming septicaemic. It resulted in a short stay in hospital and my climbing was curtailed for several weeks.
 I am sure, now, that if I had known about Arnica and used it immediately, followed by Sticta, I could have avoided these serious sequelae.
 When choosing a homoeopathic remedy it is best to consider the location and the type of pain and modalities, such as ‘worse kneeling’, ‘worse from first movement’, etc., and to choose one of the remedies already discussed above. There are a few remedies which are specific for bursitis. Remember too that if there is a history of trauma the treatment should always start with Arnica.

Remedies for Bursitis 
 Baryta Carbonica
 If someone complains of pain in the knee when kneeling, and you suspect that bursitis in its early stages, it is possible to prevent its development with a few doses of Baryta Carb.
 Dosage: One Baryta Carb. 30c, three times daily for one week.
 Natrum Muriaticum
 This is almost specific for ‘housemaid’s knee’. Any pressure on the knee is painful. There is trembling, tingling and numbness. The condition comes on periodically, every day at a certain time, probably 9 to 11 a.m.  every other day, or even every week. It is made worse by heat, and is better in the open air. This person is very reserved and detests fuss or consolation.
 Dosage: One Nat. Mur. 30c, three times daily for one week.
 Silica
 Silica is specific for enlargement of the pre-patellar bursa and any inflammatory knee conditions. It will work better if other Silica symptoms are also present. You should look out for very sweaty and smelly feet, a feeling of paralysis in the legs when walking, a tendency towards cramps in the calves in the evening after training, and slow healing of cuts. The person dislikes cold, fresh air, and draughts, and, of course, pressure on his knee makes it worse. He can seem to lack confidence in his own ability, but at other times can be quite determined and even obstinate.
 Dosage: One Silica 30c, three times daily for one week.
 Warning: Do not give Silica above the 6c potency if the patient has synthetic tissue of any sort in his body. A replacement hip, or a polytetrafluoroethylene (PTFE) repair to a cruciate ligament may be rejected following Silica in high potency.
 Sticta Pulmonaria
 Sticta is usually necessary when the swelling feels especially spongy after a fall or blow. The swollen joint has red spots. The pain is stabbing and cutting. Sticta is another specific remedy for ‘housemaid’s knee’. The knee is better from pressure, whereas Nat. Mur. and Silica are worse from pressure. Sticta is worse from touch and motion and gets worse as the day goes on. Sponginess is the best indication for this remedy.
 Dosage: One Sticta 30c, repeated as necessary.

 Posterior Knee Pain 
 Pain and swelling behind the knee may result from a tendon strain, tendinitis or a Baker’s cyst. Pain may be caused by a strain to the hamstrings, popliteal or gastrocnemius muscles. If the cause is an obvious overuse or trauma, Arnica should be taken first. One of the following remedies will help healing.
 Causticum
 Stiffness in the hollow of the knee with cracking and a feeling of tension. The pain is tearing and rheumatic with burning. Worse when sitting and starting to walk. The tendons feel contracted with cracking and tension in the knee, especially when descending. The pain is much worse in the morning in bed. The pain is much worse from getting cold, or having ice treatment.
 Dosage: One Causticum 30c three times daily for a maximum of one month.
 Magnesia Carbonica
 This is a specific remedy for Baker’s cyst when there is swelling in the popliteal, and especially for the left knee. Cannot put the left foot to the ground. Feels better walking about in the open air despite the pain. The pain seems to be worse every other day, and is better from motion.
 Dosage: Three Mag. Carb. 30c daily for two or three days.
 Rhus Toxicodendron
 This is the first choice remedy for the condition if there is pain and swelling behind the knee when bending, extending and walking, especially on first movement but relieved by continued motion. Pain in the back of the thigh causing limping. The cause is likely to be over-use, and increased exertion. The pain will be worse at night and during rest. Rest is almost impossible because he has to keep moving to relieve the pain.
 Dosage: One Rhus Tox. 30c three times daily for one week.