The key is understanding what your knee is trying to tell you. It’s hard to be a conscientious care-giver if you haven’t a clue as to what your charge is saying. With a better understanding of symptoms, you’ll be a much better guardian to your knee and a lot better patient for your doctor.
In 1985 over 650,000 patients underwent arthroscopy for diagnosis and repair of knee injuries, 84,000 patients had ligamentous repairs, and another 75,000 people were fitted with artificial knees. If these figures make you weak in the knees, the good news is that the vast majority of knee injuries do not require surgical intervention.
From the doctor’s perspective, this is good; any time you invade the body, even for a relatively benign procedure, there is the possibility of complications. Unfortunately, the high-tech advancements of the last few years have gotten a lot of attention, and as a result, particularly for the sports-minded, surgery has become the instant panacea for all known knee ills. That’s not a healthy attitude. There is no orthopedic condition that cannot be made worse by surgery. Yet, to most people, the knee is an absolute mystery. Well, we’ve gone through some of the cast of characters. Now it’s time to start reading your knee. The plot thickens.
EFFUSION, or SWELLING
The pressure of local swelling, or effusion, is one of the most common knee symptoms. This is nature’s way of limiting knee activity until healing occurs or the mechanical disability that is causing the swelling is corrected surgically.
To your doctor, swelling occurs when excess fluid accumulates outside of a joint. If the fluid gathers within a joint, the problem is said to be effusion. If you report swelling, 98 percent of the time the problem is caused by effusion. ln other words, “swelling” has both a technical meaning and a layman’s meaning. However, we give up. There’s no point in bucking that kind of a tide. So, in this book we’ll use the term swelling and not effusion.
There are two types of swelling: One is caused by an increase in the production of the knee’s own lubricant, synovial fluid, and the other by blood where it doesn’t belong (hemarthrosis). If the swelling occurs within the first hour of injury, there is probably bleeding into the joint. If it takes longer, the joint is frantically pumping out additional fluid into the synovial lining trying to lubricate an abnor- mality within the knee.
Sudden and Intermediate Swelling
Sudden swelling within an hour or so of the injury is very suggestive of bleeding into the joint and is probably a ligamentous tear (most often of the anterior cmciate ligament) or a fracture. Swelling that occurs anywhere from two to twenty-four hours after an injury is more likely to be a tear of the meniscus, most commonly medial meniscus. If the knee blows up suddenly and then decompresses, that’s no time to relax. lt could mean major ligamentous damage and injuries involving multiple ligaments around the knee. Indeed, you may have just managed to blow out all the major structures in the knee, including the surrounding envelope, which allows fluid to rush out and bleed into the fatty tissue beneath the skin. That’s why it swells and decompresses so fast. Normal swelling can be compared to a dam with a slow leak. But in the case of a pedestrian accident where the knee is struck by a car bumper, major skiing accident, or any high-velocity/high-force injury, it’s more like a dam that breaks and floods the countryside. The best home treatment for swelling is RICE—rest, ice, compression with a light wrap, and elevation. The immediate application of ice (not directly on skin but wrapped in a towel) can limit the extent of tissue damage and shorten healing time considerably. However, with swelling that occurs two to six hours later, ice is not as beneficial.
Chronic Swelling
If swelling is a problem of long-standing, the individual may describe his condition as water on the knee. The most likely cause is a mechanical or internal derangement caused by trauma, such as a meniscal tear, a knee sprain, or a ruptured ligament. (In children’s knees the causes of swelling are likely to be quite different.) Probably the single most important factor in determining the cause of swelling is a careful review of just what the knee was doing at the time in question. Swelling can sneak up on you, in which case it could be related to arthritis, loose bodies knocking around inside the knee, or infection. If the swelling is rapid, trauma, no matter how trivial, is likely to be the cause. Squatting and turning, or simply turning with the knee flexed and the foot planted, can be enough to tear a meniscus.
If ignored, swelling distends the knee, prohibits full range of motion, and muscles may atrophy from non-use. Furthermore, if the effusion is caused by internal bleeding, the blood acts as a destructive irritant. It may be hard to imagine blood inside the body as an irritant—it’s hard to think of air as an initant either until the dentist blows it on a cavity. Iron within the blood especially irritates the lining of the knee and can even become deposited on the joint surfaces.
Sometimes the only way to get rid of this excess fluid is to drain it off by needle aspiration. If the swelling is easily explained by the circumstances of the injury, a needle aspiration for diagnostic purposes may not be necessary. However, sometimes a sample of the fluid does need to be analyzed for infection, the presence of gout, pseudo-gout, or arthritis. If fat droplets are found suspended in the fluid, this suggests that a bone has fractured.
Sometimes anti-inflammatory agents, such as aspirin, are given to decrease the swelling, but it should be remembered that knees don’t just swell for the fun of it. A swollen knee has a serious problem and it’s telling you that it needs medical attention.
| Problem | Degree of Swelling (3 is most) | Speed of Onset | Other Symptoms | Method of Injury |
| Meniscal tear | 1-2 | 2-8 hrs. | Locked Knee Pain Tearing Sensation | Twisting or squatting |
| Sprains | ||||
| Grade 1 | 1 | Immediate | Severe pain | Falls |
| Grade 2 | 2-3 | Instability | Twisting | |
| Grade 3 | 3 | injuries | ||
| Chondromalacia patella | 1 | Slow and insidious | Aching on front of knee Pseudo-locking Instability Pain with flexion | Subluxated patella Repetitive squatting Overweight Blunt trauma |
| Osteochondritis dissecans | 1 | Slow and insidious | Pseudo-locking Low-grade aching Weakness Loose bodies | Unknown |
| Loose body | 2 | Intermittent | True locking Instability | Sheer fractures Osteochondrifis dissecans |
| Osteoarthritis | 1-2 | Slow and insidious | Stiffness Low-grade aching | Old trauma Aging process |
| Rheumatoid arthritis | 2-3 | Slow and insidious | Stiffness Loss of movement Low-grade aching | Unknown |
| Gout and pseudo-gout | 2 | 2-6 hours | Limited movement | Metabolic disease |
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