How do they get heat in an ointment? Generally by making wintergreen a primary ingredient. This aromatic plant is a mild irritant and it causes the sensation of warmth. Some of the rubs also have Xylocaine in them, which is a superficial numbing medicine.
Analgesic creams are not in my trainer’s bag at least not any more. In England I saw a soccer team once and all they had on the sidelines was a bucket of ice water and a sponge. When an athlete went down he would scream, “I need the sponge.” At that the trainer would race across the field and slap the “magic” sponge on the player’s sore spot. That sponge and water were as effective as everything I had in my trainer’s bag! I could hand out Band-Aids and splints and analgesics,,I could immobilize a shoulder or brace a knee, and I watched that soccer team in England and I brought back a sponge. I wanted to remind myself to check my motives at all times. Am I working to help the athlete or to impress the coaches? Or am I acting just to look good?
If creams or ointments make you feel better, then use them. Sometimes I suspect it’s less the actual lotion than it is the act of rubbing the sore spot that really helps, especially if someone else applies it for you. Massage makes anyone feel more comfortable and relaxed, and it may even improve flexibility and help the body metabolize some of the waste products of the athletic event.
Which of these is best for you? Only you can tell, and in fact, even between two medications that are absolutely the same you may find that one works for you while the other doesn’t. Why? Some people might say it’s your imagination, but it’s more complicated than that. Research on the placebo effect, which is how the body responds to chemically inert substances such as sugar pills, suggests that up to one third the benefit of certain medications could be attributable to a familiar size, shape, color, or name on a tablet. This is not imaginary, nor should it be denigrated. Such effects can encourage the body’s own pain-relieving efforts, and anything that can boost the potency of analgesic medication is a real boon to people in pain.
Don’t, however, bombard your body with a little of everything in hopes of overwhelming the pain. What you really may be doing is overwhelming your body and doing significant damage. Don’t even mix aspirin with one of the aspirin alternatives. There is a growing fear that combining more than one analgesic may increase the risk of kidney damage, for example. A number of countries have banned multi-ingredient painkillers. The United States, however, is not one of them. Read the package before you buy a painkiller and check that you’re not getting a mixed bag of medication.
Perhaps the biggest problem associated with all this self-medicafing is a major new risk of ulcers. Over-the-counter analgesics, such as aspirin, are a fraction of the total market for non-steroidal anti inflammatory drugs, or NSAIDS. Over 270 million prescriptions for NSAIDS are written each year. But whether prescription or over-the counter, NSAIDS may be causing ulcers in an estimated 20 percent of the 40 million Americans who regularly use these drugs.
These ulcers associated with NSAIDS are often symptomless, providing no warning to the patient or physician. Again, we’ve been so bombarded with advertising touting these products that we have become almost anesthetized to the fact that these are all powerful drugs. And in sports medicine we have already mentioned the risks involved with burying pain and steam rolling ahead with activity. Use of these drugs is certainly no substitute for the more permanent forms of rehabilitation we’ll be discussing.
There is, of course, a time and place for pain relief in sports medicine. Sometimes you overdo it and need some relief from your complaining muscles; at other times, medication can ease recovery. And if you’re in rehabilitation, pain relievers may reduce your discomfort and increase your chances of completing your therapy program. If you find a drug that works for you, fine, but if you find that you’re relying more and more on medication, it’s time to see a doctor before you suffer a mid-sports crisis.
Friday, October 12, 2012
Thursday, October 11, 2012
Pain Pills and Potions
No two people suffer pain alike. Some do it stoically, some do it sympathetically, and some do it loudly, but almost all of us do it with a pill. Pain relief medication is a $1.7 billion-dollar-a-year business, but that doesn’t begin_to suggest the size of the entire pain market. According to data circulated by the makers of analgesics, nearly one third of all Americans have persistent or recurrent chronic pain. Each year such pain costs an estimated $80 to $90 billion in doctors’ fees, drugs, compensation, and litigation and is responsible for the loss of 700 million workdays.
Pain is perhaps the most personal of all experiences. lts impact is intimately intertwined with an individual’s emotions, moods, upbringing, and general outlook on life. My trying to tell you about my pain is an approximation at best, an exercise in futility at worst. For this reason alone, discussing pain and its management is a complicated task. Throw in the fact that most of our information about pain comes to us from today’s multibillion-dollar corporate pill peddlers and one begins to appreciate the benefits of arguing something a little more cut and dried—like politics or religion. As it relates to sports medicine in general and knee pain in particular, however, pain relief does become a slightly more manageable discussion topic. But only slightly.
The first problem is the psychological component. People who are athletically active—not just athletes, but also people who participate in recreational sports and activities—often believe that an admission of pain is tantamount to failure. Less extreme views, which consider pain an admission of imperfection or the price for
play, are equally unhealthy. Pain is the body’s alarm system. Shutting off the alarm, without finding out what triggered the alert in the first place, is both foolish and dangerous. By tuming off the pain which is your body’s way of saying “Hey, there’s something wrong down here!”-—you can take a minor knee problem and turn it into an activity-stopping, life-altering injury.
Another, more complicated problem is determining what’s causing the pain. In the case of the knee, we’ve discussed at length in this book the dozens of factors that play a role in the problems and symptoms associated with knee pain. The best rule of thumb for pill poppers is, if pain persists beyond three days of self-medication, get a medical examination.
Of course if you are self-medicating, you need something to medicate yourself with, and manufacturers have certainly stepped in to ‘offer you relief: There are more than 100 different products vying to relieve your pain. Such variety! Such selection! Such a smoke screen! Your choices are basically three: aspirin, acetaminophen, and ibuprofen.
ASPIRIN
It has been called the “prince of panaceas” and “the miracle in your medicine cabinet.” lt’s the little white pill you take for granted and for almost everything else from colds to cramps, from hangovers to headaches, from rheumatoid arthritis to rheumatic fever.
Americans consume more than 80 million aspirin tablets a day, 16,000 tons a year, or roughly 175 tablets per person per year. lt’s one of the earliest painkillers known to man. Two thousand years ago, Hippocrates, the “father of medicine,” told women of ancient Greece to chew the bitter leaves of the willow tree to decrease the pains of labor. Today the active ingredient in those leaves, salicin, has been refined, and now acetylsalicylic acid, or aspirin, is the most popular drug in the world.
Although its chemical structure is simple, we haven’t come close to fully understanding just how aspirin works. Prostaglandins are chemical messengers that are involved, one way or another, in virtually every biological function, but when produced in excess they can trigger pain, fever, inflammation, and more. Apparently, aspirin blocks the manufacture of prostaglandins. Whatever it does, aspirin has enjoyed almost a century of popularity because it works.
Aspirin is the active ingredient in Anacin, Excedrin, and Bayer. Buffered aspirin is also available and promoted as “faster” and “gentler” than plain aspirin. Actual clinical trials, however, have shown no difference in the speed at which plain or buffered aspirin works. As for the claim that buffering protects the stomach, aspirin can indeed attack the stomach lining and cause irritation, especially at the high dosages that are required for an anti-inflammatory effect. But here again researchers studying the claim have found no difference in damage. If a tablet has a special coating that prevents it from dissolving until it reaches the small intestine, then there is protection from stomach upset. Enteric coating, however, is not the same as buffering.
Most people have heard that alcohol and aspirin don’t mix; their combined initating effects may be especially hazardous to one’s gastrointestinal tract. Less well known is the fact that aspirin and vitamin C may have a similar synergistic effect. Vitamin C is ascorbic acid and it is in and of itself a bit of an irritant to the stomach. When combined with aspirin, these two substances may be any thing but healthy. lf you’re taking vitamin C, give the aspirin three hours to clear out of your stomach. And always take any analgesic with a full glass of water or other liquid in order to minimize any stomach upset.
Another side effect of aspirin is of special interest to anyone about to undergo a surgical procedure such as arthroscopy. Aspirin causes platelets, the disc-shaped clotting factors in blood, to become “slippery.” These slippery platelets don’t form clots, which can be beneficial as a protection against stroke but hazardous to
surgical patients, who need their blood to clot in order to halt the bleeding caused by surgery. Thus you should refrain from taking aspirin or other anti-inflammatory agents during the week prior to surgery. If this presents a problem, it should be discussed with your physician.
Aspirin is so commonly used by athletes, I think some people get the idea that aspirin is sports medicine. A few years ago some researchers were actually suggesting that we increase our use of aspirin insports. The theory was that aspirin might prevent cartilage damage by inhibiting certain destructive enzymes. Further study, however, has failed to confirm those initial findings. At the other extreme, some sports medicine specialists are now trying to get aspirin out of the locker room. Many athletes take aspirin to relieve the pain of injuries both big and small and they end up taking ten to twenty tablets a day. One football player who took up to fifteen tablets a day for more than a week ended up with small skin hemorrhages all over his body. This was a result of aspirin’s ability to thin the blood. Does this mean we shouldfget rid of aspirin in
favor of some other pain medication? No. Anything—and especially any drug—taken to excess is bound to be harmful. This argues in favor of medical supervision, not against the use of aspirin.
ACETAMINOPHEN
The most popular aspirin substitute is acetaminophen (Tylenol, Anacin-3, Panadol, Datril), which does not cause as many gastrointestinal problems as aspirin but it also doesn’t offer aspirin’s anti inflammatory effect. Still, it has taken 45 percent of the painkiller market, one percentage point behind aspirin, which had a fifty-five-year head start. That market share, however, is more a testament to advertising success than clinical success. Because of the massive amount of advertising being done, it’s best to remember who’s paying for these ad campaigns. According to Consumer Reports (February 1987), all acetaminophen is created equal. If your brand is more expensive, you’re paying for a massive ad campaign, not for more effective pain relief.
Coming up with powerful descriptors such as “extra-strength” is also a marketing ploy and should not be confused with reality.‘ Most extra-strength pain relievers are just larger doses of the regular-strength drugs. For instance, two extra-strength Tylenol tablets equal three regular-strength tablets. And they offer little, if any, additional pain relief compared to the regular dose. The smallest effective dose of any drug is the dose that should be taken. Such marketing ploys only serve to sell a product and overdose the consumer.
One group of people should avoid acetaminophen—active alcoholics. A Veterans Administration study recently found that acetaminophen can cause serious liver damage in alcoholics, even with moderate doses of the drug. The study leads me to believe that long-term use could even be hazardous to the livers of nonalcoholic patients taking as few as six extra-strength acetominophen tablets a day.
IBUPROFEN
The new kid in town does reduce inflammation as wellas provide pain and fever relief, and apparently accomplishes its task with a stomach-upset profile that is better than aspirin but not quite as good as acetaminophen. Ibuprofen (Advil, Nuprin, Medipren, Ibuprin) has quickly garnered 9 percent of the nonprescription pain-relief market, although it is considerably more expensive than aspirin.
Are you getting anything more for your money? Maybe. Studies suggestthat you may be getting some pain-relief advantages with ibuprofen. Research suggests that one 200-milligram tablet may bring slightly more pain relief than 650 milligrams (two regular strength tablets) of aspirin or acetaminophen. Although ibuprofen manufacturers suggest two tablets should be taken if one doesn’t work, there’s no benefit to taking‘ more than two tablets for normal aches and pains. Studies suggest that dosages above 400 milligrams
don’t increase the level or duration of pain relief except for arthritis, where up to 800 milligrams are used at a time.
For sports medicine use, ibuprofen may hold some slight edge over the competition. Studies suggest it may be better for treating soft-tissue injuries such as sprains and strains. However, as one specialist put it in an overview of these and other non-steroidal anti-flammatory drugs (Sports Medicine, 1986, 32242-46), much of the pertinent world literature on the value and usefulness of these agents in the treatment of sports injuries is “conflictual, vague, and uninstructive."
It’s still too early to tell, but one of the original concerns about ibuprofen was its deleterious effects on the kidneys. Large doses or continued use over time can reduce blood flow to the kidneys, creating a serious situation for people who already suffer kidney impainnent. Those who should take ibuprofen only under a doctor’s supervision include individuals on diuretics or patients with kidney disease, heart disease, severe hypertension, or cirrhosis of the liver. Elderly people, with or without these problems, could also face a risk since kidney function declines with age. Anyone who notices fluid buildup (edema), back pain, increased urination, or a change of color to their urine must contact a doctor immediately. These symptoms could be a sign of kidney damage.
Pain is perhaps the most personal of all experiences. lts impact is intimately intertwined with an individual’s emotions, moods, upbringing, and general outlook on life. My trying to tell you about my pain is an approximation at best, an exercise in futility at worst. For this reason alone, discussing pain and its management is a complicated task. Throw in the fact that most of our information about pain comes to us from today’s multibillion-dollar corporate pill peddlers and one begins to appreciate the benefits of arguing something a little more cut and dried—like politics or religion. As it relates to sports medicine in general and knee pain in particular, however, pain relief does become a slightly more manageable discussion topic. But only slightly.
The first problem is the psychological component. People who are athletically active—not just athletes, but also people who participate in recreational sports and activities—often believe that an admission of pain is tantamount to failure. Less extreme views, which consider pain an admission of imperfection or the price for
play, are equally unhealthy. Pain is the body’s alarm system. Shutting off the alarm, without finding out what triggered the alert in the first place, is both foolish and dangerous. By tuming off the pain which is your body’s way of saying “Hey, there’s something wrong down here!”-—you can take a minor knee problem and turn it into an activity-stopping, life-altering injury.
Another, more complicated problem is determining what’s causing the pain. In the case of the knee, we’ve discussed at length in this book the dozens of factors that play a role in the problems and symptoms associated with knee pain. The best rule of thumb for pill poppers is, if pain persists beyond three days of self-medication, get a medical examination.
Of course if you are self-medicating, you need something to medicate yourself with, and manufacturers have certainly stepped in to ‘offer you relief: There are more than 100 different products vying to relieve your pain. Such variety! Such selection! Such a smoke screen! Your choices are basically three: aspirin, acetaminophen, and ibuprofen.
ASPIRIN
It has been called the “prince of panaceas” and “the miracle in your medicine cabinet.” lt’s the little white pill you take for granted and for almost everything else from colds to cramps, from hangovers to headaches, from rheumatoid arthritis to rheumatic fever.
Americans consume more than 80 million aspirin tablets a day, 16,000 tons a year, or roughly 175 tablets per person per year. lt’s one of the earliest painkillers known to man. Two thousand years ago, Hippocrates, the “father of medicine,” told women of ancient Greece to chew the bitter leaves of the willow tree to decrease the pains of labor. Today the active ingredient in those leaves, salicin, has been refined, and now acetylsalicylic acid, or aspirin, is the most popular drug in the world.
Although its chemical structure is simple, we haven’t come close to fully understanding just how aspirin works. Prostaglandins are chemical messengers that are involved, one way or another, in virtually every biological function, but when produced in excess they can trigger pain, fever, inflammation, and more. Apparently, aspirin blocks the manufacture of prostaglandins. Whatever it does, aspirin has enjoyed almost a century of popularity because it works.
Aspirin is the active ingredient in Anacin, Excedrin, and Bayer. Buffered aspirin is also available and promoted as “faster” and “gentler” than plain aspirin. Actual clinical trials, however, have shown no difference in the speed at which plain or buffered aspirin works. As for the claim that buffering protects the stomach, aspirin can indeed attack the stomach lining and cause irritation, especially at the high dosages that are required for an anti-inflammatory effect. But here again researchers studying the claim have found no difference in damage. If a tablet has a special coating that prevents it from dissolving until it reaches the small intestine, then there is protection from stomach upset. Enteric coating, however, is not the same as buffering.
Most people have heard that alcohol and aspirin don’t mix; their combined initating effects may be especially hazardous to one’s gastrointestinal tract. Less well known is the fact that aspirin and vitamin C may have a similar synergistic effect. Vitamin C is ascorbic acid and it is in and of itself a bit of an irritant to the stomach. When combined with aspirin, these two substances may be any thing but healthy. lf you’re taking vitamin C, give the aspirin three hours to clear out of your stomach. And always take any analgesic with a full glass of water or other liquid in order to minimize any stomach upset.
Another side effect of aspirin is of special interest to anyone about to undergo a surgical procedure such as arthroscopy. Aspirin causes platelets, the disc-shaped clotting factors in blood, to become “slippery.” These slippery platelets don’t form clots, which can be beneficial as a protection against stroke but hazardous to
surgical patients, who need their blood to clot in order to halt the bleeding caused by surgery. Thus you should refrain from taking aspirin or other anti-inflammatory agents during the week prior to surgery. If this presents a problem, it should be discussed with your physician.
Aspirin is so commonly used by athletes, I think some people get the idea that aspirin is sports medicine. A few years ago some researchers were actually suggesting that we increase our use of aspirin insports. The theory was that aspirin might prevent cartilage damage by inhibiting certain destructive enzymes. Further study, however, has failed to confirm those initial findings. At the other extreme, some sports medicine specialists are now trying to get aspirin out of the locker room. Many athletes take aspirin to relieve the pain of injuries both big and small and they end up taking ten to twenty tablets a day. One football player who took up to fifteen tablets a day for more than a week ended up with small skin hemorrhages all over his body. This was a result of aspirin’s ability to thin the blood. Does this mean we shouldfget rid of aspirin in
favor of some other pain medication? No. Anything—and especially any drug—taken to excess is bound to be harmful. This argues in favor of medical supervision, not against the use of aspirin.
ACETAMINOPHEN
The most popular aspirin substitute is acetaminophen (Tylenol, Anacin-3, Panadol, Datril), which does not cause as many gastrointestinal problems as aspirin but it also doesn’t offer aspirin’s anti inflammatory effect. Still, it has taken 45 percent of the painkiller market, one percentage point behind aspirin, which had a fifty-five-year head start. That market share, however, is more a testament to advertising success than clinical success. Because of the massive amount of advertising being done, it’s best to remember who’s paying for these ad campaigns. According to Consumer Reports (February 1987), all acetaminophen is created equal. If your brand is more expensive, you’re paying for a massive ad campaign, not for more effective pain relief.
Coming up with powerful descriptors such as “extra-strength” is also a marketing ploy and should not be confused with reality.‘ Most extra-strength pain relievers are just larger doses of the regular-strength drugs. For instance, two extra-strength Tylenol tablets equal three regular-strength tablets. And they offer little, if any, additional pain relief compared to the regular dose. The smallest effective dose of any drug is the dose that should be taken. Such marketing ploys only serve to sell a product and overdose the consumer.
One group of people should avoid acetaminophen—active alcoholics. A Veterans Administration study recently found that acetaminophen can cause serious liver damage in alcoholics, even with moderate doses of the drug. The study leads me to believe that long-term use could even be hazardous to the livers of nonalcoholic patients taking as few as six extra-strength acetominophen tablets a day.
IBUPROFEN
The new kid in town does reduce inflammation as wellas provide pain and fever relief, and apparently accomplishes its task with a stomach-upset profile that is better than aspirin but not quite as good as acetaminophen. Ibuprofen (Advil, Nuprin, Medipren, Ibuprin) has quickly garnered 9 percent of the nonprescription pain-relief market, although it is considerably more expensive than aspirin.
Are you getting anything more for your money? Maybe. Studies suggestthat you may be getting some pain-relief advantages with ibuprofen. Research suggests that one 200-milligram tablet may bring slightly more pain relief than 650 milligrams (two regular strength tablets) of aspirin or acetaminophen. Although ibuprofen manufacturers suggest two tablets should be taken if one doesn’t work, there’s no benefit to taking‘ more than two tablets for normal aches and pains. Studies suggest that dosages above 400 milligrams
don’t increase the level or duration of pain relief except for arthritis, where up to 800 milligrams are used at a time.
For sports medicine use, ibuprofen may hold some slight edge over the competition. Studies suggest it may be better for treating soft-tissue injuries such as sprains and strains. However, as one specialist put it in an overview of these and other non-steroidal anti-flammatory drugs (Sports Medicine, 1986, 32242-46), much of the pertinent world literature on the value and usefulness of these agents in the treatment of sports injuries is “conflictual, vague, and uninstructive."
It’s still too early to tell, but one of the original concerns about ibuprofen was its deleterious effects on the kidneys. Large doses or continued use over time can reduce blood flow to the kidneys, creating a serious situation for people who already suffer kidney impainnent. Those who should take ibuprofen only under a doctor’s supervision include individuals on diuretics or patients with kidney disease, heart disease, severe hypertension, or cirrhosis of the liver. Elderly people, with or without these problems, could also face a risk since kidney function declines with age. Anyone who notices fluid buildup (edema), back pain, increased urination, or a change of color to their urine must contact a doctor immediately. These symptoms could be a sign of kidney damage.
Wednesday, October 10, 2012
Questions to Ask Your Doctor
The most common complication in medicine is poor doctor/patient communication. lt’s especially problematic for knee patients because few have had much exposure at all to orthopedics. What do you ask? What do you say? And more fundamental yet: Who should you go to see?
ARE YOU THE RIGHT DOCTOR FOR ME? FIND OUT!
When you decide to see a doctor you may first visit your family practitioner. This approach has some advantages: lt's probably cost effective, you have good access, the doctor knows your medical history, and probably has some important insights into you as a person as well as a patient. However, if your doctor feels the need to inject you with cortisone, immobilize you in a cast or brace, or recommends physical therapy, you may wish to consult an orthopedist. The first two approaches may simply cover up the symptoms, while the last one could actually compound the problem in the absence of a complete and clear diagnosis. In any event, if after a few days you show no distinct signs of improvement, it’s definitely time to get a second opinion.
This is not so much a reflection on your own doctor’s capabilities as it is an indication of the complexities surrounding‘ this medical specialty. Simply put, the doctor who is best at treating life-threatening problems may not be the one to get your bum knee back to work. The examination of an acutely injured knee can be very difficult and misleading, even to an experienced clinician. So you need to find a doctor who has managed to keep up with the changes and whose knowledge is based on experience, not just a review of the
literature.
If you suspect you’re going to need a specialist, instead of asking your doctor for a generic referral, ask a specific question: “Who would you send a member of your family to if they had a knee problem?” Take your doctor’s advice and contact the person suggested. But at the same time tell your doctor that you would like to ask friends and associates for recommendations. Then ask if your doctor would be willing to review the list of suggestions and help you make a choice.
Ask your sources how they found their doctor. Are they satisfied with the treatment they received? What problems have they experienced? And, most important, ask, “How’s your knee?” Have they recovered or simply decided to live with a serious knee deficiency? A lack of pain is one thing, a complete recovery and return to active participation is quite another. Find out what their particular knee problem happened to be, then look it up in these pages. Was it a truly serious injury that would explain their lack of performance, did
they neglect their rehabilitation program, or did their doctor simply go on to other patients, leaving this one to hobble into the ranks of the seriously impaired?
A good health club, a well-designed and -managed aerobics class, friends or associates who are deeply involved in sports, a sports specialty store—any of these sources could provide you with referrals to competent sports medicine experts. But again, check the names with your family doctor. The runner’s store may merely suggest a favorite doc who happens to do a great 10K run or the ski shop may give you the name of a physician who recently ran up a $500 tab on a major shopping spree.
Once you come up with a name or two, the best approach is a face-to-face meeting. You’re entering into a relationship with another human being and a lot can be learned from the rapport that can come only from personal contact.
First, of course, you need to phone the doctor’s office. Before you even make an appointment you might want to ask about office hours and insurance acceptability. You can also quickly ask if the physician is board-certified, the percentage of his or her practice that is knees, and if he or she is a member of any special societies, such as the American Orthopedic Sports Medicine Society or the North American Arthroscopy Association.
While you wait for your meeting you’ll be surrounded by people who can give you inside information. Start a conversation by saying that you’re new and would appreciate any information they might offer regarding this physician or this office, in the case of a group practice. Besides questions about the surgeon, find out if they’ve ever had problems getting an appointment. Ask if they’ve ever called the office after hours. Was there a prompt response? Most people will be flattered that you asked and the ensuing discussion will undoubtedly be more educational than the dog—eared magazines you could be reading. If you have a general reluctance to enter into conversations in doctors’ offices, remember that this is the ideal setting: Bum knees are not considered a communicable disease.
Once inside the hallowed halls of orthopedia, don’t hesitate to ask questions. Here’s a starter list:
Where did you go to medical school?
Where did you do your orthopedic training and was it an accredited program? (The American Board of Orthopedic Surgery evaluates various residency programs to make sure that they fit their criteria of exposure to all aspects of orthopedics, including trauma, reconstructive surgery, pediatric surgery, hand surgery, etc., and in order to become qualified for a certification in orthopedic surgery, the surgeon must be a graduate of an approved program.)
Are you specially trained in sports medicine or have you gone through any fellowship programs?
Approximately how many knee surgeries do you do in a year? If surgery is one of your options: What is your success rate with this particular surgery? (lf the answer is 100 percent, you’ve probably got the wrong surgeon. There is no 100 percent in medicine—no guarantees, no warranties. If you can’t trust a surgeon to answer a simple question honestly, do you really want to put your life in his or her hands?)
If the surgeon is in a group practice: Do your partners cover you in the event of an absence?
If it's a solo practice: Who's on call whwn you're unavaiblable? Again, you want to know the background of these people if they're likely ever to care for you.
you will most likely be charged for an office consultation. However, if you use this approach to find a good doctor or to avoid one you're not gong to be happy with, this will be a good investment of both time and money.
ARE YOU THE RIGHT DOCTOR FOR ME? FIND OUT!
When you decide to see a doctor you may first visit your family practitioner. This approach has some advantages: lt's probably cost effective, you have good access, the doctor knows your medical history, and probably has some important insights into you as a person as well as a patient. However, if your doctor feels the need to inject you with cortisone, immobilize you in a cast or brace, or recommends physical therapy, you may wish to consult an orthopedist. The first two approaches may simply cover up the symptoms, while the last one could actually compound the problem in the absence of a complete and clear diagnosis. In any event, if after a few days you show no distinct signs of improvement, it’s definitely time to get a second opinion.
This is not so much a reflection on your own doctor’s capabilities as it is an indication of the complexities surrounding‘ this medical specialty. Simply put, the doctor who is best at treating life-threatening problems may not be the one to get your bum knee back to work. The examination of an acutely injured knee can be very difficult and misleading, even to an experienced clinician. So you need to find a doctor who has managed to keep up with the changes and whose knowledge is based on experience, not just a review of the
literature.
If you suspect you’re going to need a specialist, instead of asking your doctor for a generic referral, ask a specific question: “Who would you send a member of your family to if they had a knee problem?” Take your doctor’s advice and contact the person suggested. But at the same time tell your doctor that you would like to ask friends and associates for recommendations. Then ask if your doctor would be willing to review the list of suggestions and help you make a choice.
Ask your sources how they found their doctor. Are they satisfied with the treatment they received? What problems have they experienced? And, most important, ask, “How’s your knee?” Have they recovered or simply decided to live with a serious knee deficiency? A lack of pain is one thing, a complete recovery and return to active participation is quite another. Find out what their particular knee problem happened to be, then look it up in these pages. Was it a truly serious injury that would explain their lack of performance, did
they neglect their rehabilitation program, or did their doctor simply go on to other patients, leaving this one to hobble into the ranks of the seriously impaired?
A good health club, a well-designed and -managed aerobics class, friends or associates who are deeply involved in sports, a sports specialty store—any of these sources could provide you with referrals to competent sports medicine experts. But again, check the names with your family doctor. The runner’s store may merely suggest a favorite doc who happens to do a great 10K run or the ski shop may give you the name of a physician who recently ran up a $500 tab on a major shopping spree.
Once you come up with a name or two, the best approach is a face-to-face meeting. You’re entering into a relationship with another human being and a lot can be learned from the rapport that can come only from personal contact.
First, of course, you need to phone the doctor’s office. Before you even make an appointment you might want to ask about office hours and insurance acceptability. You can also quickly ask if the physician is board-certified, the percentage of his or her practice that is knees, and if he or she is a member of any special societies, such as the American Orthopedic Sports Medicine Society or the North American Arthroscopy Association.
While you wait for your meeting you’ll be surrounded by people who can give you inside information. Start a conversation by saying that you’re new and would appreciate any information they might offer regarding this physician or this office, in the case of a group practice. Besides questions about the surgeon, find out if they’ve ever had problems getting an appointment. Ask if they’ve ever called the office after hours. Was there a prompt response? Most people will be flattered that you asked and the ensuing discussion will undoubtedly be more educational than the dog—eared magazines you could be reading. If you have a general reluctance to enter into conversations in doctors’ offices, remember that this is the ideal setting: Bum knees are not considered a communicable disease.
Once inside the hallowed halls of orthopedia, don’t hesitate to ask questions. Here’s a starter list:
Where did you go to medical school?
Where did you do your orthopedic training and was it an accredited program? (The American Board of Orthopedic Surgery evaluates various residency programs to make sure that they fit their criteria of exposure to all aspects of orthopedics, including trauma, reconstructive surgery, pediatric surgery, hand surgery, etc., and in order to become qualified for a certification in orthopedic surgery, the surgeon must be a graduate of an approved program.)
Are you specially trained in sports medicine or have you gone through any fellowship programs?
Approximately how many knee surgeries do you do in a year? If surgery is one of your options: What is your success rate with this particular surgery? (lf the answer is 100 percent, you’ve probably got the wrong surgeon. There is no 100 percent in medicine—no guarantees, no warranties. If you can’t trust a surgeon to answer a simple question honestly, do you really want to put your life in his or her hands?)
If the surgeon is in a group practice: Do your partners cover you in the event of an absence?
If it's a solo practice: Who's on call whwn you're unavaiblable? Again, you want to know the background of these people if they're likely ever to care for you.
you will most likely be charged for an office consultation. However, if you use this approach to find a good doctor or to avoid one you're not gong to be happy with, this will be a good investment of both time and money.
Tuesday, October 9, 2012
DIAGNOSING ARTHRITIS
lt’s important to distinguish everyday aches and pains from the onset of arthritis because early detection can prevent permanent damage. Warning signs include:
— persistent pain and stiffness upon awakening or at the end of the day
— pain, tenderness, or swelling in one or more joints
— inability to move a joint normally
— recurrent or persistent pain and stiffness in joints
— symptoms such as these that last for more than six weeks.
Making an accurate arthritis diagnosis, however, is not always easy. Prompt medical attention may prevent irreversible damage, but it may take a couple of weeks to several months to achieve a detailed diagnosis. If your personal physician is unable to arrive at an accurate diagnosis, you should be referred to a rheumatologist (a physician who specializes in the diagnosis and treatment of all forms of arthritis).
ln addifion to physical examinations, physicians use tests to assist in the diagnosis of arthritis, including X rays, blood tests, joint fluid analysis, and examination of small samples of muscle or joint tissue. X rays can show revealing changes in the joints and blood tests can ' indicate whether a complex protein called rheumatoid factor or elevated levels of uric acid are circulating in your bloodstream. Joint aspiration and tissue biopsies are not the most comfortable tests you’ll ever find in a doctor’s office, but they can be critically important in establishing the definitive diagnosis.
There may soon be additional means of diagnosing arthritis. We’ve discussed the growing role of magnetic resonance imaging (MRI) in the diagnosis of knee problems. Eventually MRI may replace arthrography and arthroscopy, which are also occasionally used in the diagnosis of OA and RA. MRI may offer a great advantage in the diagnosis of arthritis patients who report pain but do not yet have clinically recognizable signs of disease. This is a particularly frustrating phenomenon early in the course of the disease. Just when medical intervention may be most successful, arthritis is most difficult to diagnose.
Another new technology may soon let doctors hear your body talk. By tuning in to the vibrations a joint makes when it moves, by listening for that nearly inaudible crackle like crumpled plastic that reveals early arthritis, doctors may be able to detect arthritis in a noninvasive manner even before some of the current invasive approaches can be successfully utilized. Many of us are unnerved by the snap, crackle, pop of our joints, but that’s not really related to arthritic changes. To the human ear the sounds of arthritis really are the sounds of silence. It takes an inexpensive ($200) device called a rectifying-demodulating phonopneumograph (mercifully shortened to RDP) to listen in on your joint complaints. The microphone picks up inaudible sounds and produces a graph that displays a normal knee with both sharp peaks and smooth curves of sound or an arthritic knee, which graphs out with only sharp multipointed peaks.
While we still have no known cure for the major rheumatic diseases, the significance of what we have learned is substantial. If arthritis is not inevitable or a necessary consequence of activity, then there must be ways to interrupt the process, manage the disease, and possibly reverse it. We’ll take up the rest of this story later in our section on reliefand rehabilitation.
— persistent pain and stiffness upon awakening or at the end of the day
— pain, tenderness, or swelling in one or more joints
— inability to move a joint normally
— recurrent or persistent pain and stiffness in joints
— symptoms such as these that last for more than six weeks.
Making an accurate arthritis diagnosis, however, is not always easy. Prompt medical attention may prevent irreversible damage, but it may take a couple of weeks to several months to achieve a detailed diagnosis. If your personal physician is unable to arrive at an accurate diagnosis, you should be referred to a rheumatologist (a physician who specializes in the diagnosis and treatment of all forms of arthritis).
ln addifion to physical examinations, physicians use tests to assist in the diagnosis of arthritis, including X rays, blood tests, joint fluid analysis, and examination of small samples of muscle or joint tissue. X rays can show revealing changes in the joints and blood tests can ' indicate whether a complex protein called rheumatoid factor or elevated levels of uric acid are circulating in your bloodstream. Joint aspiration and tissue biopsies are not the most comfortable tests you’ll ever find in a doctor’s office, but they can be critically important in establishing the definitive diagnosis.
There may soon be additional means of diagnosing arthritis. We’ve discussed the growing role of magnetic resonance imaging (MRI) in the diagnosis of knee problems. Eventually MRI may replace arthrography and arthroscopy, which are also occasionally used in the diagnosis of OA and RA. MRI may offer a great advantage in the diagnosis of arthritis patients who report pain but do not yet have clinically recognizable signs of disease. This is a particularly frustrating phenomenon early in the course of the disease. Just when medical intervention may be most successful, arthritis is most difficult to diagnose.
Another new technology may soon let doctors hear your body talk. By tuning in to the vibrations a joint makes when it moves, by listening for that nearly inaudible crackle like crumpled plastic that reveals early arthritis, doctors may be able to detect arthritis in a noninvasive manner even before some of the current invasive approaches can be successfully utilized. Many of us are unnerved by the snap, crackle, pop of our joints, but that’s not really related to arthritic changes. To the human ear the sounds of arthritis really are the sounds of silence. It takes an inexpensive ($200) device called a rectifying-demodulating phonopneumograph (mercifully shortened to RDP) to listen in on your joint complaints. The microphone picks up inaudible sounds and produces a graph that displays a normal knee with both sharp peaks and smooth curves of sound or an arthritic knee, which graphs out with only sharp multipointed peaks.
While we still have no known cure for the major rheumatic diseases, the significance of what we have learned is substantial. If arthritis is not inevitable or a necessary consequence of activity, then there must be ways to interrupt the process, manage the disease, and possibly reverse it. We’ll take up the rest of this story later in our section on reliefand rehabilitation.
Monday, October 8, 2012
Arthritis - Is It or Isn't It?
Arthritis is the nation’s number one chronic disease, affecting over one in seven Americans, or nearly 41 million people. The most common form of arthritis, osteoarthritis, can be identified in the knees of one third of all persons by the age of thirty and affects nearly everyone by the age of sixty. Although often considered an ailment of the elderly, experts who know better call arthritis everybody’s disease. It haunts the athletically active regardless of age and is av real problem for a quarter of a million children under the age of sixteen.
Many individuals have “silent” arthritis, that is, they do not suffer the pain, limitation of motion, joint instability, and deformity that are the hallmarks of this disease. Still, about one third to one half of all people with arthritis have a condition serious enough to consult a doctor about their symptoms. The good news is that only a small percentage of this group have severe pain and disability. The bad news is that many people ignore early symptoms or delay effective countermeasures, thus aggravating the problem and sometimes causing permanent crippling. It may seem ludicrous, but it is true: The average individual with arthritis waits four years after symptoms develop before seeking medical help! By then a lot of damage has already taken place.
WHAT IS ARTHRITIS?
Although the pain of arthritis may be new to you, it’s one of the oldest identifiable diseases on earth. While Adam’s bones probably began creaking shortly after he took up residence outside of Eden, he was not the disease’s first victim. A giant dinosaur named Diplodocus Longus holds that honor. Today man’s aching joints are joined by those of birds, amphibians, reptiles, and mammals. The animals that are spared tend to have cartilaginous skeletons instead of bony skeletons, which means sharks have never experienced arthritis but porpoises have. So it appears that arthritis developed at the same time that bone did during the course ‘of evolution. One might expect, with this kind of long-term experience, that we should by now have a clear understanding of this disease, but in fact arthritis is still poorly understood and the source of many misconceptions. Part of the problem is that arthritis is a word that is used to label about 100 conditions that involve aches and pains in joints and connective tissue. The “big three” are osteoarthritis, rheumatoid arthritis, and gout.
Osteoarthritis (OA)
We discussed cartilage earlier and explained how it is a tough, elastic tissue that acts as a shock absorber and keeps the bones from rubbing against each other. In osteoarthritis (OA) there is a gradual wearing away of this cartilage, which leads to discomfort, pain, stiffness, grating, and, sometimes, deformity. The pain is often localized to only one or a few joints. Classically, the pain of OA occurs with movement and is relieved by rest; however, many OA patients will experience some degree of achy pain when they resume activity following a period of rest. Pain may also be worse at the end of the day.
Factors contributing to OA include repetitive stress and injury, heredity, and too much weight. An estimated 30 million Americans nuller from osteoarthritis, with the greatest incidence among the older population.
The list of specific causes is long: an improperly repaired meniscal tear or the removal of a meniscus, a fracture, bowlegs or knock knees, any abnormal development of the hip, prolonged immobililallon, overuse of a joint that is not entirely normal, chronic inflammation or infection, and most rheumatic diseases, which means that osteoarthritis may actually be caused by rheumatoid arthritis. Certain diseases may also predispose one to OA, including diabetes and hypothyroidism.
One of the most important lessons we’ve leamed in recent years regarding OA is that it is not a natural process of aging, nor is it necessarily a consequence of wear and tear. Consider, for example, that a whale, which spends its life supported in water in a total non-weight-bearing state, may have extensive OA while landlocked humans show no correlation between lifelong, weight-bearing physical activity and joint deterioration--even jogging does not lead to OA.
Rheumatoid Arthritis (RA)
Rheumatoid arthritis is a puzzle to researchers. RA is an inflammatory disease that is characterized by attacks on healthy tissue. The disease begins when the synovium (the thin membranes lining the body’s joints) become inflamed. This inflammation may spread and destroy cartilage or weaken ligaments. RA is the most destructive form of arthritis. Whereas most forms of arthritis affect only a few joints, RA can cause damage throughout the body. It may even invade other body tissue, such as the heart or lungs. RA tends to be symmetrical, that is, joints on both sides of the body will often be involved. (However, one knee may be more severely diseased than the other.)
The effects of RA differ from person to person, but they often begin as mild symptoms that come and go before becoming chronic. Early in the disease process people feel tired, sore, achy, and stiff. The joints stiffen, then swell, and later become tender, making full motion difficult and painful. The knees, hands, and feet are the most commonly involved joints. Symptoms are generally most noticeable after long periods of inactivity, such as in the morning.
The most crippling effects of RA are seen in about one of very six RA patients. These people will experience severe aches, pains, and badly damaged joints. If the hands are severely affected, the fingers may become crooked and deformed so that movement is difficult. Rheumatoid arthritis (RA), often occurs in younger individuals and even children. Unlike OA, which tends to be seen more often in men, women have the leading edge for rheumatoid arthritis. Of the six million Americans suffering from RA, three out of four are
women between the ages of twenty and fifty.
Gout
Gout is the result of inflammation of the joints produced by an excess of uric acid. Usually, uric acid circulates in the blood as a by-product of normal metabolism and gets whisked away through the kidneys. Gout patients, however, either produce too much uric acid or the kidneys can’t process and remove it properly. Either way, the end result is a uric acid buildup in the form of needlesharp crystals of monosodium urate in the joints.
The damaging mechanism of gout is a combination of erosion and inflammation. Those crystals are deposited in the cartilage and synovium, which we just defined as the starting spot of RA. This causes acute and chronic inflammation and, over time, an erosion of the cartilage and the underlying bone.
Gout is far more common than most people think. Nearly two million people in the United States suffer from it, 95 percent of whom are men. Acute gouty arthritis usually appears without warning, often at night, and may follow overindulgence in food or alcohol, fatigue, and emotional distress. The pain is not easily ignored and is often described as throbbing, crushing, or excruciating. lt may be so severe that even the pressure of a thin bed sheet can not be tolerated. The inflammation often resembles an acute infection: there is swelling, warmth, redness, and extreme tenderness. Although the classic location for gout is generally considered to be the big toe, it also commonly affects the knee, instep, ankle, wrist, and elbow.
The first attack of gout may last only a few days, but if left untreated, subsequent attacks may last for weeks. While gout is generally asymmetrical, that is, limited to one foot and not the other or one knee and not the other, the onset is rapid compared to osteoarthritis. lt’s even easier to distinguish gout from rheumatoid arthritis since RA is more likely to be symmetrical, more gradual in onset, and more likely to last longer for each acute attack.
Systemic Lupus Erythematosus (Lupus)
We’ll briefly mention one other common rheumatoid disorder that may affect the knees, systemic lupus erythematosus. Called SLE or lupus for short, this is another rheumatic disease that affects many more women than men. It is mild for many patients but it can lead to serious problems, including damage to the skin, joints, and intemal organs.
There is no known cure for lupus, but the treatment program can help reduce pain and inflammation and prevent serious joint damage from occurring. The treatment includes medication, heat or cold treatments, exercises, rest, joint protection, and, because of a sensitivity to sunlight, which often accompanies this disease, avoiding sun exposure.
Many individuals have “silent” arthritis, that is, they do not suffer the pain, limitation of motion, joint instability, and deformity that are the hallmarks of this disease. Still, about one third to one half of all people with arthritis have a condition serious enough to consult a doctor about their symptoms. The good news is that only a small percentage of this group have severe pain and disability. The bad news is that many people ignore early symptoms or delay effective countermeasures, thus aggravating the problem and sometimes causing permanent crippling. It may seem ludicrous, but it is true: The average individual with arthritis waits four years after symptoms develop before seeking medical help! By then a lot of damage has already taken place.
WHAT IS ARTHRITIS?
Although the pain of arthritis may be new to you, it’s one of the oldest identifiable diseases on earth. While Adam’s bones probably began creaking shortly after he took up residence outside of Eden, he was not the disease’s first victim. A giant dinosaur named Diplodocus Longus holds that honor. Today man’s aching joints are joined by those of birds, amphibians, reptiles, and mammals. The animals that are spared tend to have cartilaginous skeletons instead of bony skeletons, which means sharks have never experienced arthritis but porpoises have. So it appears that arthritis developed at the same time that bone did during the course ‘of evolution. One might expect, with this kind of long-term experience, that we should by now have a clear understanding of this disease, but in fact arthritis is still poorly understood and the source of many misconceptions. Part of the problem is that arthritis is a word that is used to label about 100 conditions that involve aches and pains in joints and connective tissue. The “big three” are osteoarthritis, rheumatoid arthritis, and gout.
Osteoarthritis (OA)
We discussed cartilage earlier and explained how it is a tough, elastic tissue that acts as a shock absorber and keeps the bones from rubbing against each other. In osteoarthritis (OA) there is a gradual wearing away of this cartilage, which leads to discomfort, pain, stiffness, grating, and, sometimes, deformity. The pain is often localized to only one or a few joints. Classically, the pain of OA occurs with movement and is relieved by rest; however, many OA patients will experience some degree of achy pain when they resume activity following a period of rest. Pain may also be worse at the end of the day.
Factors contributing to OA include repetitive stress and injury, heredity, and too much weight. An estimated 30 million Americans nuller from osteoarthritis, with the greatest incidence among the older population.
The list of specific causes is long: an improperly repaired meniscal tear or the removal of a meniscus, a fracture, bowlegs or knock knees, any abnormal development of the hip, prolonged immobililallon, overuse of a joint that is not entirely normal, chronic inflammation or infection, and most rheumatic diseases, which means that osteoarthritis may actually be caused by rheumatoid arthritis. Certain diseases may also predispose one to OA, including diabetes and hypothyroidism.
One of the most important lessons we’ve leamed in recent years regarding OA is that it is not a natural process of aging, nor is it necessarily a consequence of wear and tear. Consider, for example, that a whale, which spends its life supported in water in a total non-weight-bearing state, may have extensive OA while landlocked humans show no correlation between lifelong, weight-bearing physical activity and joint deterioration--even jogging does not lead to OA.
Rheumatoid Arthritis (RA)
Rheumatoid arthritis is a puzzle to researchers. RA is an inflammatory disease that is characterized by attacks on healthy tissue. The disease begins when the synovium (the thin membranes lining the body’s joints) become inflamed. This inflammation may spread and destroy cartilage or weaken ligaments. RA is the most destructive form of arthritis. Whereas most forms of arthritis affect only a few joints, RA can cause damage throughout the body. It may even invade other body tissue, such as the heart or lungs. RA tends to be symmetrical, that is, joints on both sides of the body will often be involved. (However, one knee may be more severely diseased than the other.)
The effects of RA differ from person to person, but they often begin as mild symptoms that come and go before becoming chronic. Early in the disease process people feel tired, sore, achy, and stiff. The joints stiffen, then swell, and later become tender, making full motion difficult and painful. The knees, hands, and feet are the most commonly involved joints. Symptoms are generally most noticeable after long periods of inactivity, such as in the morning.
The most crippling effects of RA are seen in about one of very six RA patients. These people will experience severe aches, pains, and badly damaged joints. If the hands are severely affected, the fingers may become crooked and deformed so that movement is difficult. Rheumatoid arthritis (RA), often occurs in younger individuals and even children. Unlike OA, which tends to be seen more often in men, women have the leading edge for rheumatoid arthritis. Of the six million Americans suffering from RA, three out of four are
women between the ages of twenty and fifty.
Gout
Gout is the result of inflammation of the joints produced by an excess of uric acid. Usually, uric acid circulates in the blood as a by-product of normal metabolism and gets whisked away through the kidneys. Gout patients, however, either produce too much uric acid or the kidneys can’t process and remove it properly. Either way, the end result is a uric acid buildup in the form of needlesharp crystals of monosodium urate in the joints.
The damaging mechanism of gout is a combination of erosion and inflammation. Those crystals are deposited in the cartilage and synovium, which we just defined as the starting spot of RA. This causes acute and chronic inflammation and, over time, an erosion of the cartilage and the underlying bone.
Gout is far more common than most people think. Nearly two million people in the United States suffer from it, 95 percent of whom are men. Acute gouty arthritis usually appears without warning, often at night, and may follow overindulgence in food or alcohol, fatigue, and emotional distress. The pain is not easily ignored and is often described as throbbing, crushing, or excruciating. lt may be so severe that even the pressure of a thin bed sheet can not be tolerated. The inflammation often resembles an acute infection: there is swelling, warmth, redness, and extreme tenderness. Although the classic location for gout is generally considered to be the big toe, it also commonly affects the knee, instep, ankle, wrist, and elbow.
The first attack of gout may last only a few days, but if left untreated, subsequent attacks may last for weeks. While gout is generally asymmetrical, that is, limited to one foot and not the other or one knee and not the other, the onset is rapid compared to osteoarthritis. lt’s even easier to distinguish gout from rheumatoid arthritis since RA is more likely to be symmetrical, more gradual in onset, and more likely to last longer for each acute attack.
Systemic Lupus Erythematosus (Lupus)
We’ll briefly mention one other common rheumatoid disorder that may affect the knees, systemic lupus erythematosus. Called SLE or lupus for short, this is another rheumatic disease that affects many more women than men. It is mild for many patients but it can lead to serious problems, including damage to the skin, joints, and intemal organs.
There is no known cure for lupus, but the treatment program can help reduce pain and inflammation and prevent serious joint damage from occurring. The treatment includes medication, heat or cold treatments, exercises, rest, joint protection, and, because of a sensitivity to sunlight, which often accompanies this disease, avoiding sun exposure.
Sunday, October 7, 2012
THE TERRIBLE TRIAD
Of all the possible traumatic injuries, there is one that is a four star pain in the knee. A player whose foot is planted receives a blow to the outside of the joint, forcing the large bones inward. This puts an extraordinary amount of pressure on internal structures and may stretch or tear the meniscus when it is crushed between the bones; the anterior cruciate ligament may also give way, and the medical collateral ligament also stretches or tears. This orthopedic nightmare is called “the tenible triad.”
Treatment
Due to the magnitude of the injury, 90 percent of the time this means surgery, and generally not a simple arthroscopic procedure but a combination of open and arthroscopic surgery. Recovery for ligamentous injuries in general ranges from nine to eighteen months and in the case mentioned above we’re probably talking about the high end of that range. Someone who has suffered the terrible triad has actually suffered two traumas: an injury trauma and a surgical trauma. It is big surgery to put it all back together. A lot of tissue must be cut through to work on the areas affected. All of that has to heal while the person undergoes all types of muscular rehabilitation.
The prognosis is pretty good, however. ln my experience 85 percent of all patients report good or excellent results postoperaiively. Only 5 percent report fair results, and 10 percent say their condition is unsatisfactory.
FRACTURES
There are two types of fractures affecting athletes: traumatic and stress. Major trauma, such as a fall down a flight of stairs or a car accident, often causes a fracture. One traumatic blow in sports, which could be the indelicate landing of a 250-pound tackle or a knee dive into the floor, is all it takes to cause a fracture.
A sheer force crashing into the kneecap can knock a piece of bone off of the patella or the patella track. A direct blow can crack or damage the kneecap’s surface or it can force the patella back into its groove and fracture the backside of the patella.
The other type of fracture, a stress fracture, may comprise as much as 10 percent of all sports injuries and up to 16 percent of all injuries to runners. A stress fracture is the result of repeated stress from excessive motion or impact shock. The result is a series of microscopic cracks that, over time, become larger and larger until eventually symptoms develop. Because the symptoms are similar to a number of other conditions, the first diagnosis is often wrong. The most common misdiagnosis is probably tendinitis, with bursitis and “runner’s knee” also getting a share of blame. If your knee doesn’t respond to therapy within a couple of weeks, a physician will usually become suspicious and order further tests, hoping to find evidence of a stress fracture. Thus, stress fractures are often a diagnosis of exclusion, which means the examining physician first figures out what is not causing the pain and then proceeds toward a diagnosis of stress fracture.
Don’t be too hard on your doctor if he or she first misses a stress fracture. Besides the fact that the symptoms echo a number of other complaints, another confounder is that symptoms may pre-L cede X-ray evidence by up to three months and, in a significant number of stress fractures, there may never be positive X-ray evidence at all. Fortunately, conventional X rays may be supplemented by a bone scan (radionuclide bone scintigraphy) if there is a high suspicion of stress fracture. This has shown to be a very sensitive diagnostic tool, capable of detecting stress fractures within seventy-two hours of onset of pain. A few facilities are also beginning to use magnetic resonance imaging for stress fracture detection.
Symptoms
Bone pain is the primary symptom of fractures. The pain begins mildly and gradually worsens. The longer the stress fracture continues to be stressed and goes untreated, the more severe the pain becomes. Localized tenderness and swelling, as well as pain related to activity, are also common, but again these are hardly specific complaints.
Treatment
For traumatic fractures, the first step of all treatment is to recognize the fracture. lt’s important that fractures be treated within the first week in order to avoid further injury and to guide healing. Sometimes treatment is limited to immobilization (usually a brace or a cast), rest, and protection. For complicated fractures, surgery may be necessary to do internal repair with pins, wires, screws, and plates in order to hold everything in place during healing. The patient often retums quickly to day-to-day activities, but recreational activities are severely limited during recovery. Cycling, swimming, and running in water are sometimes permitted as alter-
native activities to maintain fitness. Stretching and flexibility exercises are emphasized, as well as local muscle strengthening, stretching, and retraining.
Once an individual has been pain-free for ten to fourteen days, there is a gradual reintroduction to sports.
Perhaps the single most important factor in avoiding stress fracture reinjury is a schedule of alternate-day activity. ln other words, if you’ re a runner, your best bet for avoiding stress fractures might be to alternate running with bicycling, or just take a day off between runs. One study reported in Military Medicine (147:285-87, 1982), found that such a recovery period during training cut the stress fracture rate in military recruits by one third. , The average time to recovery for traumatic fractures is ten to thirteen weeks. For stress fractures, four to ten weeks is generally required.
Treatment
Due to the magnitude of the injury, 90 percent of the time this means surgery, and generally not a simple arthroscopic procedure but a combination of open and arthroscopic surgery. Recovery for ligamentous injuries in general ranges from nine to eighteen months and in the case mentioned above we’re probably talking about the high end of that range. Someone who has suffered the terrible triad has actually suffered two traumas: an injury trauma and a surgical trauma. It is big surgery to put it all back together. A lot of tissue must be cut through to work on the areas affected. All of that has to heal while the person undergoes all types of muscular rehabilitation.
The prognosis is pretty good, however. ln my experience 85 percent of all patients report good or excellent results postoperaiively. Only 5 percent report fair results, and 10 percent say their condition is unsatisfactory.
FRACTURES
There are two types of fractures affecting athletes: traumatic and stress. Major trauma, such as a fall down a flight of stairs or a car accident, often causes a fracture. One traumatic blow in sports, which could be the indelicate landing of a 250-pound tackle or a knee dive into the floor, is all it takes to cause a fracture.
A sheer force crashing into the kneecap can knock a piece of bone off of the patella or the patella track. A direct blow can crack or damage the kneecap’s surface or it can force the patella back into its groove and fracture the backside of the patella.
The other type of fracture, a stress fracture, may comprise as much as 10 percent of all sports injuries and up to 16 percent of all injuries to runners. A stress fracture is the result of repeated stress from excessive motion or impact shock. The result is a series of microscopic cracks that, over time, become larger and larger until eventually symptoms develop. Because the symptoms are similar to a number of other conditions, the first diagnosis is often wrong. The most common misdiagnosis is probably tendinitis, with bursitis and “runner’s knee” also getting a share of blame. If your knee doesn’t respond to therapy within a couple of weeks, a physician will usually become suspicious and order further tests, hoping to find evidence of a stress fracture. Thus, stress fractures are often a diagnosis of exclusion, which means the examining physician first figures out what is not causing the pain and then proceeds toward a diagnosis of stress fracture.
Don’t be too hard on your doctor if he or she first misses a stress fracture. Besides the fact that the symptoms echo a number of other complaints, another confounder is that symptoms may pre-L cede X-ray evidence by up to three months and, in a significant number of stress fractures, there may never be positive X-ray evidence at all. Fortunately, conventional X rays may be supplemented by a bone scan (radionuclide bone scintigraphy) if there is a high suspicion of stress fracture. This has shown to be a very sensitive diagnostic tool, capable of detecting stress fractures within seventy-two hours of onset of pain. A few facilities are also beginning to use magnetic resonance imaging for stress fracture detection.
Symptoms
Bone pain is the primary symptom of fractures. The pain begins mildly and gradually worsens. The longer the stress fracture continues to be stressed and goes untreated, the more severe the pain becomes. Localized tenderness and swelling, as well as pain related to activity, are also common, but again these are hardly specific complaints.
Treatment
For traumatic fractures, the first step of all treatment is to recognize the fracture. lt’s important that fractures be treated within the first week in order to avoid further injury and to guide healing. Sometimes treatment is limited to immobilization (usually a brace or a cast), rest, and protection. For complicated fractures, surgery may be necessary to do internal repair with pins, wires, screws, and plates in order to hold everything in place during healing. The patient often retums quickly to day-to-day activities, but recreational activities are severely limited during recovery. Cycling, swimming, and running in water are sometimes permitted as alter-
native activities to maintain fitness. Stretching and flexibility exercises are emphasized, as well as local muscle strengthening, stretching, and retraining.
Once an individual has been pain-free for ten to fourteen days, there is a gradual reintroduction to sports.
Perhaps the single most important factor in avoiding stress fracture reinjury is a schedule of alternate-day activity. ln other words, if you’ re a runner, your best bet for avoiding stress fractures might be to alternate running with bicycling, or just take a day off between runs. One study reported in Military Medicine (147:285-87, 1982), found that such a recovery period during training cut the stress fracture rate in military recruits by one third. , The average time to recovery for traumatic fractures is ten to thirteen weeks. For stress fractures, four to ten weeks is generally required.
Saturday, October 6, 2012
DEGENBRATIVE MENISCAL TEARS
The meniscal tear most often associated with aging is called a cleavage-type tear. This may sound sexy, but the pain and swelling associated with the horizontal separation is hardly alluring. (To get an idea of this separation, picture the venetian-blind eflect that occurs when a favorite pair of blue jeans wears out at the knee.)
Often the problem can be brought under control with exercises that build power and endurance in the quadriceps and hamstrings. (See Appendix A.) That assumes, however, that you avoid the repetitive squatting or kneeling that most likely caused the problem. Otherwise, arthroscopy can be performed and the torn portion of the meniscus can be removed.
LIGAMENT TEARS (“Sprained Knee”)
We’ve discussed how the ligaments act as the scaffolding for the bones of the knee. The collateral ligaments run up the inside and outside of the knee, while the anterior cruciate ligament and the posterior cruciate ligament cross within the joint. A sprain occurs when any of these ligaments are stretched excessively or tom.
The inner or medial collaterial ligament (MCL) is the most common site of knee sprains. Indeed, the MCL is probably 50 times more likely to be injured than the ACL. (Fortunately, most MCL injuries are of such a minor nature that they are never even called to a doctor’s attention.) The ACL is often tom in contact sports. To give you an idea of the scope of knee sprains, by conservative estimate at least 50,000 occur each year in the United States just among skiers. Fortunately, less than 15 percent require surgery.
Symptoms
The Standard Nomenclature of Athletic Injuries, published by the American Medical Association (impressive, huh), defines three categories of ligamentous injury:
1. Grade 1 “mild” sprains are those with mild tendemess, minimal hemorrhage and swelling, no abnormal motion, and minimal disability. There are minor tears of ligament fibers. There is minimal loss of strength, no lengthening, and no loss of function.
2. Grade 2 “moderate” sprains are those with moderate loss of function, more joint reaction (i.e., swelling and tendemess), slight to moderate abnormal motion, and partial tearing of ligamentous tissues. There is stretching of some ligament fibers and tearing of some.
3. Grade 3 “severe” sprains are those with marked abnormal motion, indicating a complete tear of the ligament. This causes a total loss of strength and functional capacity and may require surgical repair.
Treatment
Back in the 1950s, casting was the primary treatment for an MCL injury. (Back then ACL injuries were basically ignored!) Then we went through a phase when surgery was the “treatment” of choice. As a matter of fact, during the seventies MCL repair was the most common knee ligament surgery. However, during the last few years there has been an astronomical drop in the incidence of MCL surgical repairs. What we leamed is that Grade 1 and Grade 2 MCL sprains will heal just as well with conservative treatment as they will with surgical intervention. So surgery is now generally reserved for only the most serious, Grade 3, MCL injuries.
In general the treatment for sprains depends on the severity of the injury. For a mild sprain, RICE is advised: rest, ice, compression, and elevation. Usually there is a relatively quick return to activity. Two to three weeks is not uncommon, although we’ll soon explain why the recovery period may be even longer.
If it is a second-degree sprain, the treatment will vary depending on the functional requirements of the individual, the pain and discomfort being experienced, and how badly other knee structures, such as cartilage or muscles, have been damaged. Also, one ligament may have a second-degree injury while another might have suffered a more severe third-degree injury, so strains are often far from cut-and-dried phenomenon.
The knee will need protection for one to six weeks in the form of a removable splint and an intermittent range of motion exercises or a brace that allows for limited movement.
For the most severe (Grade 3) sprains, surgical repair is often considered, with prolonged (three to eight weeks) splint or brace protection generally recommended. Some continued protection may even be appropriate beyond eight weeks. It should be noted that the bracing is not meant to simply provide stability; the surgical repair should do that. Instead, it is to protect and prevent reinjury while allowing for the healing of the ligament.
Perhaps the biggest problem in treating sprains is undertreating mild ones and overtreating the moderate and severe ones. Many mild sprains are functioning again within two to three weeks, yet by definition a Grade 1 sprain has damaged tissue and is weakened for a longer period of time, perhaps several months. The real hazard with Grade 1 sprains is that you will not fully appreciate your injury and you will return to activity too soon and find yourself reinjured. Unfortunately, when this happens the resulting sprain may be much more serious than the original.
While it may take only a few weeks to return to action following a sprain, actual healing may take up to two years. During the first year you will reach a significant plateau of healing and then slow healing will likely continue for another year.
Surgical Repair
Since ligaments do not have a rich blood supply, it should be remembered that they do not heal well. They should be evaluated for possible repair. Well, they can be ignored, but that does engender a certain amount of risk and a definite degree of suspense: When will your trick knee go into its next act?
If you and your doctor decide that surgical repair is necessary, the particular approach will depend on your precise injury. For a severe MCL injury, there needs to be some open surgery since the ligament is not accessible to our arthroscopes. (You’ll read more about arthroscopy later when we detail the advantages of this technology.)
Although the ACL is accessible to our microscopic surgical tools, this ligament is much more difficult to repair. The greatest likelihood for a successful repair occurs when a piece of either the femur or tibia actually breaks off with the ACL attached. That happens when the bone gives way before all of the forces can be transmitted to the ligament. It’s easier to repair a bone than it is a torn ligament, unfortunately.
Most surgeons believe that when the ACL is tom from the bone at either end, it should be reattached, since the chances of normal function after repair are good. Toward this end, orthopedists have developed a number of suturing and stapling techniques. Sadly, despite the initial enthusiasm, we’re finding that many patients undergoing this type of ACL repair really aren’t healing well. When we have had an opportunity to look at some of these patients later, what we find is pretty worthlex scar tissue instead of good resilient
tissue surrounding all that fancy medical handiwork.
Still, even this limited success is better than what we see if the anterior cruciate ligament has been torn interstitially, that is, along the ligament itself as opposed to a break at the point it connects to bone. Although a tear occurs at only one point along the ligament, there is failure all along the ligament before it ruptures. To the eye it appears to be intact, but microscopically there is noticeable damage up and down the ligament. It’s comparable to what you might have experienced if you’ve ever broken a rubber band, tied it back together with a knot, only to have it snap apart again an inch away from the original break. It looked fine, but what you couldn’t see was that in the constant stretching of the rubber band it lost its normal elasticity, its continuity, and even though only one small part broke, the rest of it was severely weakened. That’s what
happens in most ACL tears.
ACL Reconstruction
For these and other reasons, reconstruction is becoming more popular than repair: Other tissue or synthetic material is used to graft or reconstruct the ligament. If possible, someone’s own tissue is preferable to any of the artificial ligaments that are available at this time. (This technology is discussed in great detail in the epilogue.) Rather than repair the torn ACL, a tendon alongside the knee is moved over and down as a replacement. The process may include looping the tendon to actually provide more strength than the original. Some of the patients who have had this surgery were professional or college athletes who had been sidelined by continuing instability following previous surgery. Many were restored to their former levels of performance.
Several popular operations use the patellar tendon to replace the ACL because it’s one of the strongest grafts available. A potential problem with this approach is that the patellar tendon is a vital structure and taking one third to one half of it to do the reconstruction strikes me as robbing Peter to pay Paul. The penalty is often extra wear of the kneecap and difficulty in regaining flexion at the knee.
Non-Surgical Management of the Tom ACL
All of this assumes that you and your doctor decided on a surgical approach. Within the last few years we have come to realize that, contrary to earlier belief, a torn ACL is not necessarily the beginning of the end. Although a complete solution to the torn anterior cruciate ligament has yet to be devised, numerous options are available. And, indeed, one of those options is to learn how to live with it. Probably at least 60 percent or more of all patients can tolerate loss of this ligament. It depends on the amount of laxity present and the desired level of activity.
Age is also a factor. Ninety percent of the people undergoing ACL repairs or reconstruction are between nineteen and twenty-seven years old. The older person probably is not going to place the demand on their knee that someone younger will. And a tom ACL usually implies modification of life-style, including both athletic and vocational endeavors.
For example, living with a tom anterior cruciate ligament probably means living without running-and-cutting sports such as basketball and racquetball. Any activity involving sudden stops and tums would simply be harder to take and much more hazardous. Climbing or working on rough terrain or slippery surfaces would also be ill-advised. Remember, the cruciate ligaments prevent the bones from slipping backward or forward out of joint. Without an ACL for added support, going down hills or stepping in a hole can be a lot more treacherous because you just don’t have the resiliency and protection you once had. This means you can still run after your bus if you have a clear path, but stepping off the curb could send you to the ground.
In our office we’re currently studying the natural histories of patients who had untreated but documented anterior cruciate ligament tears. About 80 percent of them are satisfied, but we are going to find out what they had to change in order to accommodate their knee condition.
Often the problem can be brought under control with exercises that build power and endurance in the quadriceps and hamstrings. (See Appendix A.) That assumes, however, that you avoid the repetitive squatting or kneeling that most likely caused the problem. Otherwise, arthroscopy can be performed and the torn portion of the meniscus can be removed.
LIGAMENT TEARS (“Sprained Knee”)
We’ve discussed how the ligaments act as the scaffolding for the bones of the knee. The collateral ligaments run up the inside and outside of the knee, while the anterior cruciate ligament and the posterior cruciate ligament cross within the joint. A sprain occurs when any of these ligaments are stretched excessively or tom.
The inner or medial collaterial ligament (MCL) is the most common site of knee sprains. Indeed, the MCL is probably 50 times more likely to be injured than the ACL. (Fortunately, most MCL injuries are of such a minor nature that they are never even called to a doctor’s attention.) The ACL is often tom in contact sports. To give you an idea of the scope of knee sprains, by conservative estimate at least 50,000 occur each year in the United States just among skiers. Fortunately, less than 15 percent require surgery.
Symptoms
The Standard Nomenclature of Athletic Injuries, published by the American Medical Association (impressive, huh), defines three categories of ligamentous injury:
1. Grade 1 “mild” sprains are those with mild tendemess, minimal hemorrhage and swelling, no abnormal motion, and minimal disability. There are minor tears of ligament fibers. There is minimal loss of strength, no lengthening, and no loss of function.
2. Grade 2 “moderate” sprains are those with moderate loss of function, more joint reaction (i.e., swelling and tendemess), slight to moderate abnormal motion, and partial tearing of ligamentous tissues. There is stretching of some ligament fibers and tearing of some.
3. Grade 3 “severe” sprains are those with marked abnormal motion, indicating a complete tear of the ligament. This causes a total loss of strength and functional capacity and may require surgical repair.
Treatment
Back in the 1950s, casting was the primary treatment for an MCL injury. (Back then ACL injuries were basically ignored!) Then we went through a phase when surgery was the “treatment” of choice. As a matter of fact, during the seventies MCL repair was the most common knee ligament surgery. However, during the last few years there has been an astronomical drop in the incidence of MCL surgical repairs. What we leamed is that Grade 1 and Grade 2 MCL sprains will heal just as well with conservative treatment as they will with surgical intervention. So surgery is now generally reserved for only the most serious, Grade 3, MCL injuries.
In general the treatment for sprains depends on the severity of the injury. For a mild sprain, RICE is advised: rest, ice, compression, and elevation. Usually there is a relatively quick return to activity. Two to three weeks is not uncommon, although we’ll soon explain why the recovery period may be even longer.
If it is a second-degree sprain, the treatment will vary depending on the functional requirements of the individual, the pain and discomfort being experienced, and how badly other knee structures, such as cartilage or muscles, have been damaged. Also, one ligament may have a second-degree injury while another might have suffered a more severe third-degree injury, so strains are often far from cut-and-dried phenomenon.
The knee will need protection for one to six weeks in the form of a removable splint and an intermittent range of motion exercises or a brace that allows for limited movement.
For the most severe (Grade 3) sprains, surgical repair is often considered, with prolonged (three to eight weeks) splint or brace protection generally recommended. Some continued protection may even be appropriate beyond eight weeks. It should be noted that the bracing is not meant to simply provide stability; the surgical repair should do that. Instead, it is to protect and prevent reinjury while allowing for the healing of the ligament.
Perhaps the biggest problem in treating sprains is undertreating mild ones and overtreating the moderate and severe ones. Many mild sprains are functioning again within two to three weeks, yet by definition a Grade 1 sprain has damaged tissue and is weakened for a longer period of time, perhaps several months. The real hazard with Grade 1 sprains is that you will not fully appreciate your injury and you will return to activity too soon and find yourself reinjured. Unfortunately, when this happens the resulting sprain may be much more serious than the original.
While it may take only a few weeks to return to action following a sprain, actual healing may take up to two years. During the first year you will reach a significant plateau of healing and then slow healing will likely continue for another year.
Surgical Repair
Since ligaments do not have a rich blood supply, it should be remembered that they do not heal well. They should be evaluated for possible repair. Well, they can be ignored, but that does engender a certain amount of risk and a definite degree of suspense: When will your trick knee go into its next act?
If you and your doctor decide that surgical repair is necessary, the particular approach will depend on your precise injury. For a severe MCL injury, there needs to be some open surgery since the ligament is not accessible to our arthroscopes. (You’ll read more about arthroscopy later when we detail the advantages of this technology.)
Although the ACL is accessible to our microscopic surgical tools, this ligament is much more difficult to repair. The greatest likelihood for a successful repair occurs when a piece of either the femur or tibia actually breaks off with the ACL attached. That happens when the bone gives way before all of the forces can be transmitted to the ligament. It’s easier to repair a bone than it is a torn ligament, unfortunately.
Most surgeons believe that when the ACL is tom from the bone at either end, it should be reattached, since the chances of normal function after repair are good. Toward this end, orthopedists have developed a number of suturing and stapling techniques. Sadly, despite the initial enthusiasm, we’re finding that many patients undergoing this type of ACL repair really aren’t healing well. When we have had an opportunity to look at some of these patients later, what we find is pretty worthlex scar tissue instead of good resilient
tissue surrounding all that fancy medical handiwork.
Still, even this limited success is better than what we see if the anterior cruciate ligament has been torn interstitially, that is, along the ligament itself as opposed to a break at the point it connects to bone. Although a tear occurs at only one point along the ligament, there is failure all along the ligament before it ruptures. To the eye it appears to be intact, but microscopically there is noticeable damage up and down the ligament. It’s comparable to what you might have experienced if you’ve ever broken a rubber band, tied it back together with a knot, only to have it snap apart again an inch away from the original break. It looked fine, but what you couldn’t see was that in the constant stretching of the rubber band it lost its normal elasticity, its continuity, and even though only one small part broke, the rest of it was severely weakened. That’s what
happens in most ACL tears.
ACL Reconstruction
For these and other reasons, reconstruction is becoming more popular than repair: Other tissue or synthetic material is used to graft or reconstruct the ligament. If possible, someone’s own tissue is preferable to any of the artificial ligaments that are available at this time. (This technology is discussed in great detail in the epilogue.) Rather than repair the torn ACL, a tendon alongside the knee is moved over and down as a replacement. The process may include looping the tendon to actually provide more strength than the original. Some of the patients who have had this surgery were professional or college athletes who had been sidelined by continuing instability following previous surgery. Many were restored to their former levels of performance.
Several popular operations use the patellar tendon to replace the ACL because it’s one of the strongest grafts available. A potential problem with this approach is that the patellar tendon is a vital structure and taking one third to one half of it to do the reconstruction strikes me as robbing Peter to pay Paul. The penalty is often extra wear of the kneecap and difficulty in regaining flexion at the knee.
Non-Surgical Management of the Tom ACL
All of this assumes that you and your doctor decided on a surgical approach. Within the last few years we have come to realize that, contrary to earlier belief, a torn ACL is not necessarily the beginning of the end. Although a complete solution to the torn anterior cruciate ligament has yet to be devised, numerous options are available. And, indeed, one of those options is to learn how to live with it. Probably at least 60 percent or more of all patients can tolerate loss of this ligament. It depends on the amount of laxity present and the desired level of activity.
Age is also a factor. Ninety percent of the people undergoing ACL repairs or reconstruction are between nineteen and twenty-seven years old. The older person probably is not going to place the demand on their knee that someone younger will. And a tom ACL usually implies modification of life-style, including both athletic and vocational endeavors.
For example, living with a tom anterior cruciate ligament probably means living without running-and-cutting sports such as basketball and racquetball. Any activity involving sudden stops and tums would simply be harder to take and much more hazardous. Climbing or working on rough terrain or slippery surfaces would also be ill-advised. Remember, the cruciate ligaments prevent the bones from slipping backward or forward out of joint. Without an ACL for added support, going down hills or stepping in a hole can be a lot more treacherous because you just don’t have the resiliency and protection you once had. This means you can still run after your bus if you have a clear path, but stepping off the curb could send you to the ground.
In our office we’re currently studying the natural histories of patients who had untreated but documented anterior cruciate ligament tears. About 80 percent of them are satisfied, but we are going to find out what they had to change in order to accommodate their knee condition.
Friday, October 5, 2012
Acute Knee Problems
So you’ve finally found time to go out and shoot some baskets first exercise in a week and what happens but your knee gives way just when you plant and pivot, about to drive in with your killer slam dunk. What’s wrong? If it’s acute, you should find an answer in this chapter.
ACUTE MENISCAL TEARS (see also “Sprains,” this chapter)
We’ve already talked a little about the knee’s shock absorbers, the menisci. When you talk of a tornncartilage it’s the meniscus that has been folded, spindled, and . . . well, you know.
Acute tears most commonly occur from a twisting action while putting weight on the knee; you may feel a tearing sensation at the time of injury. Repetitive squatting or kneeling as well as natural aging processes can weaken the menisci and set the stage for an acute meniscal injury. In fact, it’s amazing how little force is necessary to damage even a healthy meniscus: simply squatting to pick up something from the floor or getting out of a car can be the last straw that completes the tear. Of course not all cartilage is created equal. God gave some people top-of-the-line cushioning while others got brand X.
Symptoms
When a meniscus is first tom, bleeding within the joint irritates the lining, or synovium, of the knee. ln an attempt to wash away the irritant, the knee increases its production of synovial fluid and
the knee swells.
One of the most common tears of the meniscus is the “buckethandle” tear. The meniscus develops a split and part of it becomes trapped within the joint. When this portion of meniscus is separated, yet still attached at either end, it appears to be the shape of a bucket, with the entrapped portion representing the handle. The knee is locked and prevents complete leg straightening. There’s also pain along the edge of the “bucket” and swelling, usually two to six hours post-injury.
Often you try to ignore a damaged meniscus and, for a time, your knee cooperates. Some movement retums and you begin to think that you’re going to recover. Of course your leg won’t straighten completely or bend as far as it used to, but between these extremes there is acceptable movement. However, some swelling simply refuses to go away, so you break down and make an appointment with your doctor.
Diagnosis is often one of exclusion, and unless your knee is locked by a bucket-handle tear, it may be weeks after your initial injury before you know exactly what’s wrong with your knee. The most revealing symptoms are tendemess, inability to squat, duck, walk, or bounce up and down while standing. There is also pain when you attempt to rotate with the feet planted.
Treatment
A tom meniscus means surgery most of the time. But today most physicians agree that unless the meniscus is definitely unstable -or symptomatic, it should be left in—or only part of it removed-to protect the knee from osteoarthritis. That’s why 90 percent of the nearly 100,000 meniscectomies done in the United States today are only partial meniscectomies.
Certain tears in the meniscus can be sutured. However, this is not always possible, and it does involve an extended period of disability and recovery. There are particular modifying factors that affect a decision to do a meniscal repair. First, what is the complexity of the tear? It is much harder to get multiple tears to heal than it is if there is one discreet tear. Second, where has the tear(s) occurred? The outer one third of the meniscus has an excellent blood supply, which means it has the greatest capacity for healing. There are individual variations, but in general the farther into the meniscus a tear occurs, the less chance there is of healing and recovery.
Other considerations include the age of the injured, and his or her individual healing potential and life-style. Usually the younger person is the most amenable technically and socially to the repair process. For a meniscectomy, you’re on crutches for a few days; for a meniscal repair, six to eight weeks. If a simple, partial meniscectomy is performed, recovery takes about six weeks. For a meniscal repair, recovery will take six to twelve months. That’s a big difference. I don’t think it makes sense to try a repair on a sixty-year-old construction worker who is moving, twisting, and squatting all day as a part of his job. Will he be willing, let alone able, to take a year off or a reassignment in order to recover from the more complicated surgery? On the other hand, a total meniscectomy on a patient under the age of sixteen can be a real catastrophe. Ten to fifteen years later that individual may face real arthritic problems. So if I tore my meniscus, I’d say just take it out arthroscopically. If my daughter tore hers, I would want it repaired if possible. If there were multiple tears, I’d need to see some statistics to indicate that the repair will heal and she will be better off after a year of recovery.
Exercise
A large meniscal tear that causes the knee to lock, block, or give way probably will not be affected by a strengthening program. Even so, a rehabilitation program is valuable; if surgery is performed, the strengthening program will help prevent further injury and facilitate postoperative recovery. Whenever a knee injury occurs, muscle strength, power, and endurance quickly weaken in the affected leg. A loss of just 15 to 20 percent of muscle strength significantly Increases the risk of reinjury. During the first two weeks most people will have at least 15 percent deficiency, and by the time I we most of my patients, one month after the onset of symptoms the vast majority have lost 30 to 40 percent of their muscle strength.
ACUTE MENISCAL TEARS (see also “Sprains,” this chapter)
We’ve already talked a little about the knee’s shock absorbers, the menisci. When you talk of a tornncartilage it’s the meniscus that has been folded, spindled, and . . . well, you know.
Acute tears most commonly occur from a twisting action while putting weight on the knee; you may feel a tearing sensation at the time of injury. Repetitive squatting or kneeling as well as natural aging processes can weaken the menisci and set the stage for an acute meniscal injury. In fact, it’s amazing how little force is necessary to damage even a healthy meniscus: simply squatting to pick up something from the floor or getting out of a car can be the last straw that completes the tear. Of course not all cartilage is created equal. God gave some people top-of-the-line cushioning while others got brand X.
Symptoms
When a meniscus is first tom, bleeding within the joint irritates the lining, or synovium, of the knee. ln an attempt to wash away the irritant, the knee increases its production of synovial fluid and
the knee swells.
One of the most common tears of the meniscus is the “buckethandle” tear. The meniscus develops a split and part of it becomes trapped within the joint. When this portion of meniscus is separated, yet still attached at either end, it appears to be the shape of a bucket, with the entrapped portion representing the handle. The knee is locked and prevents complete leg straightening. There’s also pain along the edge of the “bucket” and swelling, usually two to six hours post-injury.
Often you try to ignore a damaged meniscus and, for a time, your knee cooperates. Some movement retums and you begin to think that you’re going to recover. Of course your leg won’t straighten completely or bend as far as it used to, but between these extremes there is acceptable movement. However, some swelling simply refuses to go away, so you break down and make an appointment with your doctor.
Diagnosis is often one of exclusion, and unless your knee is locked by a bucket-handle tear, it may be weeks after your initial injury before you know exactly what’s wrong with your knee. The most revealing symptoms are tendemess, inability to squat, duck, walk, or bounce up and down while standing. There is also pain when you attempt to rotate with the feet planted.
Treatment
A tom meniscus means surgery most of the time. But today most physicians agree that unless the meniscus is definitely unstable -or symptomatic, it should be left in—or only part of it removed-to protect the knee from osteoarthritis. That’s why 90 percent of the nearly 100,000 meniscectomies done in the United States today are only partial meniscectomies.
Certain tears in the meniscus can be sutured. However, this is not always possible, and it does involve an extended period of disability and recovery. There are particular modifying factors that affect a decision to do a meniscal repair. First, what is the complexity of the tear? It is much harder to get multiple tears to heal than it is if there is one discreet tear. Second, where has the tear(s) occurred? The outer one third of the meniscus has an excellent blood supply, which means it has the greatest capacity for healing. There are individual variations, but in general the farther into the meniscus a tear occurs, the less chance there is of healing and recovery.
Other considerations include the age of the injured, and his or her individual healing potential and life-style. Usually the younger person is the most amenable technically and socially to the repair process. For a meniscectomy, you’re on crutches for a few days; for a meniscal repair, six to eight weeks. If a simple, partial meniscectomy is performed, recovery takes about six weeks. For a meniscal repair, recovery will take six to twelve months. That’s a big difference. I don’t think it makes sense to try a repair on a sixty-year-old construction worker who is moving, twisting, and squatting all day as a part of his job. Will he be willing, let alone able, to take a year off or a reassignment in order to recover from the more complicated surgery? On the other hand, a total meniscectomy on a patient under the age of sixteen can be a real catastrophe. Ten to fifteen years later that individual may face real arthritic problems. So if I tore my meniscus, I’d say just take it out arthroscopically. If my daughter tore hers, I would want it repaired if possible. If there were multiple tears, I’d need to see some statistics to indicate that the repair will heal and she will be better off after a year of recovery.
Exercise
A large meniscal tear that causes the knee to lock, block, or give way probably will not be affected by a strengthening program. Even so, a rehabilitation program is valuable; if surgery is performed, the strengthening program will help prevent further injury and facilitate postoperative recovery. Whenever a knee injury occurs, muscle strength, power, and endurance quickly weaken in the affected leg. A loss of just 15 to 20 percent of muscle strength significantly Increases the risk of reinjury. During the first two weeks most people will have at least 15 percent deficiency, and by the time I we most of my patients, one month after the onset of symptoms the vast majority have lost 30 to 40 percent of their muscle strength.
Thursday, October 4, 2012
SPONTANEOUS OSTEONECROSIS
In separate chapters we’ll discuss arthritis. Whereas arthritis is a gradual degenerative condition, which develops over months or years, spontaneous osteonecrosis has sometimes been described by patients as “instant arthritis.” It is a more common problem for older individuals, with the average patient about sixty-five years old, although the range is from forty to eighty-five. We really don’t know what causes this condition, but its typical presentation is a real attention-getter.
Symptoms
A sudden, severe pain, rarely associated with trauma of any sort, occurs spontaneously. If you’ve experienced this pain, you probably remember exactly what you were doing when the pain struck. The pain most often occurs on the inner side of the knee. It is not improved by rest, and weight-bearing activities, such as walking, may aggravate the pain. lt does not subside with time. During this early phase the knee appears “locked” because it’s prevented from complete extension or flexion due to pain, effusion, and muscle spasm. It’s not a true “locked” knee because there is no mechanical block, although a mechanical block does sometimes develop.
The future isn’t bright for those knees struck with spontaneous osteonecrosis. Although for a few lucky people the pain will subside in three to six months, others will continue to experience degenerative changes within their knee, causing pain and a limiting of function. This may occur rapidly, although the typical case develops slowly. The prognosis is sometimes dramatically poor and rarely good.
During the first four to eight weeks X rays are normal, then sometime between two and six months changes are often noted by X rays.
Treatment
If diagnosed early, pain medication is best, along with crutches or a cane and at least six months of isometric quadriceps exercises. Although the threat of continued arthritic-type changes is great, the majority of patients seem to respond to this conservative approach.
Unfortunately, S.O. victims sometimes show (in X rays) a lesion actually creating a growing crater along the inner ends of the femur and tibia. If major problems persist and there is increasing deformity one to three years following the onset of symptoms, surgery, ranging from arthroscopy to a total knee replacement, may be necessary. The best success, in chronic cases, is seen with a high tibial osteotomy. That may sound like a religious ceremony, but what it means is that by removing a wedge of bone on the lateral, or outer, side of the knee, the knee undergoes a realignment. This has the same effect as realigning a car’ s tires: lt corrects the alignment problem caused by the lesion and takes the load off of the injured bone by transferring it to another part of the knee.
Symptoms
A sudden, severe pain, rarely associated with trauma of any sort, occurs spontaneously. If you’ve experienced this pain, you probably remember exactly what you were doing when the pain struck. The pain most often occurs on the inner side of the knee. It is not improved by rest, and weight-bearing activities, such as walking, may aggravate the pain. lt does not subside with time. During this early phase the knee appears “locked” because it’s prevented from complete extension or flexion due to pain, effusion, and muscle spasm. It’s not a true “locked” knee because there is no mechanical block, although a mechanical block does sometimes develop.
The future isn’t bright for those knees struck with spontaneous osteonecrosis. Although for a few lucky people the pain will subside in three to six months, others will continue to experience degenerative changes within their knee, causing pain and a limiting of function. This may occur rapidly, although the typical case develops slowly. The prognosis is sometimes dramatically poor and rarely good.
During the first four to eight weeks X rays are normal, then sometime between two and six months changes are often noted by X rays.
Treatment
If diagnosed early, pain medication is best, along with crutches or a cane and at least six months of isometric quadriceps exercises. Although the threat of continued arthritic-type changes is great, the majority of patients seem to respond to this conservative approach.
Unfortunately, S.O. victims sometimes show (in X rays) a lesion actually creating a growing crater along the inner ends of the femur and tibia. If major problems persist and there is increasing deformity one to three years following the onset of symptoms, surgery, ranging from arthroscopy to a total knee replacement, may be necessary. The best success, in chronic cases, is seen with a high tibial osteotomy. That may sound like a religious ceremony, but what it means is that by removing a wedge of bone on the lateral, or outer, side of the knee, the knee undergoes a realignment. This has the same effect as realigning a car’ s tires: lt corrects the alignment problem caused by the lesion and takes the load off of the injured bone by transferring it to another part of the knee.
Wednesday, October 3, 2012
ILIOTIBIAL BAND FRICTION SYNDROME
The tendinitis associated with runners and dancers is called iliotibial band friction syndrome (IBFS); it involves a tendon that runs from the hip down to the outer (lateral) side of the knee. As the knee flexes and extends, the iliotibial band rubs against the end of the thighbone (femur), which ends in two elliptical notches called condyles. (Picture a dog’s bone. The rounded endpoints are condyles.) Excessive motion or tightness of the tendon can produce irritation when it rubs against the outer condyle. Because this is an especially common problem among runners.
Symptoms
The first indication of IBFS will likely be a post-aerobic burning pain. It is a very specific pain that occurs at the end of your thighbone at a point known as the lateral femoral condyle. Soon it occurs during your aerobic acfivity and eventually prevents or limits your activity or, at the very least, limits your time due to pain. For example, the pain may become so severe that it is impossible to run more than a short distance, which may be only a fraction of your usual mileage. Sports such as squash or tennis may also produce discomfort, as will repetitive flexion-extension movements such as cycling, skiing, or weight lifting.
With running, IBFS is often associated with a rapid increase in mileage, a course that involves hills, or a running surface that is at a slight angle.
Treatment
Initial treatment may include ice/friction massage and stretching of the iliotibial band. For specific stretching exercises see Appendix A. Anti-inflammatory medication, such as aspirin, speeds recovery, and if, after three weeks, the pain is still persistent, a hydrocortisone injection may be helpful while you continue to limit activity, perform stretching exercises, and change your individual activities to prevent recurrence. The latter may involve moving your activity to a softer surface, rerouting to avoid downhill or sidehill running, andnvarying mileage patterns (alternating short distances with long). A shoe insert or orthotic may also be beneficial if there is a mild malalignment of the knee or ankle.
PATHOLOGICAL SYNOVIAI PLICAE
The diagnosis of pathological synovial plicae is over-applied and over-discussed. Yes, it does exist, but it doesn’t deserve near the attention it has received.
Plicae were once considered a harmless developmental anomaly; today they are called by some authorities “the great imitators.” These are developmental leftovers that exist in anywhere from 18 to 60 percent of normal knees, depending on the medical authority who is reporting them and his or her care in detecting these folds of the knee lining. In order to understand this problem you must know a little about how the knee develops in a human body. By the eighth week of development the knee is formed of three synovial compartments, which are separated by thin, membranous walls. During the fourth fetal month these walls are usually reabsorbed back into the body, leaving the three compartments fused into one knee. However, sometimes these walls, or some portion of them, remain. These fetal remnants are called plicae.
Prior to the advent of the arthroscope, no one paid much attention to these remnants, which were considered incapable of causing any problems. They were an annoyance to the surgeon who sometimes had to get his equipment through toughened plica tissue, but for the most part they appeared to be a pretty insignificant knee structure. Then surgeons began reporting that in some painful knees the only internal problem they could find were the fibrous bands of tissue, and when these bands were divided the pain was relieved. Eventually physicians began to recognize these structures as capable of causing acute and chronic knee pain.
Trauma can injure the plicae, producing inflammation. This may be a simple stretch, tear, or contusion, but when the body repairs the injury the fold has lost some of its elasticity and becomes more fibrous and abrasive. Activity only increases the irritation and minor trauma increases the abnormal thickening of the once pliant tissue. Eventually pain may develop with activity or a single traumatic event may cause a knee-jerk response and plenty of pain.
Symptoms
Although the incidence of plicae in the general population may be quite high, only 15 to 20 percent are ever responsible for symptoms. The most common complaints include tendemess or aching pain, over the condyles or above the kneecap, that worsens with activity. There may also be swelling or a feeling of “tightness” In the knee, weakness or instability in the knee, and sound effects much as popping, snapping, or clicking. It is rare, however, to find a patient who is fully disabled by the symptoms and incapable of pursuing either work or school activities. Individuals with this condition generally do not have pain when standing still.
Pain is increased with repetitive activities, such as running and jumping, and is commonly aggravated by a quadriceps-strengthening program, but it will subside with rest.
Here, too, the diagnosis is typically one of exclusion. Frequently the symptoms suggest either chondromalacia patella, a meniscal tear, or a number of other internal derangements of the knee. These possibilities must be carefully ruled out before concluding that a plica is the sole cause of pain.
Treatment
If your screaming plicae have resulted from overuse, you have at least an 80 percent chance of responding well to conservative measures consisting of rest, ice initially and then heat, and keeping your legs extended while sitting. Medication, such as aspirin, may be beneficial, as are hamstring-s and quadriceps-stretching exercises. lf your symptoms followed blunt trauma, such as a fall or the striking of a solid object, or a twisting injury, the prospects are pretty much reversed: Your chance of relief by conservative measures is 20 percent or less. Fortunately, 90 percent of patients undergoing arthroscopic removal of these folds report good or excellent results. Complications are rare and recovery quick. So if, after three to four months, symptomatic plicae have failed to respond to conservative measures, it’s probably time to consider anthroscopy.
Symptoms
The first indication of IBFS will likely be a post-aerobic burning pain. It is a very specific pain that occurs at the end of your thighbone at a point known as the lateral femoral condyle. Soon it occurs during your aerobic acfivity and eventually prevents or limits your activity or, at the very least, limits your time due to pain. For example, the pain may become so severe that it is impossible to run more than a short distance, which may be only a fraction of your usual mileage. Sports such as squash or tennis may also produce discomfort, as will repetitive flexion-extension movements such as cycling, skiing, or weight lifting.
With running, IBFS is often associated with a rapid increase in mileage, a course that involves hills, or a running surface that is at a slight angle.
Treatment
Initial treatment may include ice/friction massage and stretching of the iliotibial band. For specific stretching exercises see Appendix A. Anti-inflammatory medication, such as aspirin, speeds recovery, and if, after three weeks, the pain is still persistent, a hydrocortisone injection may be helpful while you continue to limit activity, perform stretching exercises, and change your individual activities to prevent recurrence. The latter may involve moving your activity to a softer surface, rerouting to avoid downhill or sidehill running, andnvarying mileage patterns (alternating short distances with long). A shoe insert or orthotic may also be beneficial if there is a mild malalignment of the knee or ankle.
PATHOLOGICAL SYNOVIAI PLICAE
The diagnosis of pathological synovial plicae is over-applied and over-discussed. Yes, it does exist, but it doesn’t deserve near the attention it has received.
Plicae were once considered a harmless developmental anomaly; today they are called by some authorities “the great imitators.” These are developmental leftovers that exist in anywhere from 18 to 60 percent of normal knees, depending on the medical authority who is reporting them and his or her care in detecting these folds of the knee lining. In order to understand this problem you must know a little about how the knee develops in a human body. By the eighth week of development the knee is formed of three synovial compartments, which are separated by thin, membranous walls. During the fourth fetal month these walls are usually reabsorbed back into the body, leaving the three compartments fused into one knee. However, sometimes these walls, or some portion of them, remain. These fetal remnants are called plicae.
Prior to the advent of the arthroscope, no one paid much attention to these remnants, which were considered incapable of causing any problems. They were an annoyance to the surgeon who sometimes had to get his equipment through toughened plica tissue, but for the most part they appeared to be a pretty insignificant knee structure. Then surgeons began reporting that in some painful knees the only internal problem they could find were the fibrous bands of tissue, and when these bands were divided the pain was relieved. Eventually physicians began to recognize these structures as capable of causing acute and chronic knee pain.
Trauma can injure the plicae, producing inflammation. This may be a simple stretch, tear, or contusion, but when the body repairs the injury the fold has lost some of its elasticity and becomes more fibrous and abrasive. Activity only increases the irritation and minor trauma increases the abnormal thickening of the once pliant tissue. Eventually pain may develop with activity or a single traumatic event may cause a knee-jerk response and plenty of pain.
Symptoms
Although the incidence of plicae in the general population may be quite high, only 15 to 20 percent are ever responsible for symptoms. The most common complaints include tendemess or aching pain, over the condyles or above the kneecap, that worsens with activity. There may also be swelling or a feeling of “tightness” In the knee, weakness or instability in the knee, and sound effects much as popping, snapping, or clicking. It is rare, however, to find a patient who is fully disabled by the symptoms and incapable of pursuing either work or school activities. Individuals with this condition generally do not have pain when standing still.
Pain is increased with repetitive activities, such as running and jumping, and is commonly aggravated by a quadriceps-strengthening program, but it will subside with rest.
Here, too, the diagnosis is typically one of exclusion. Frequently the symptoms suggest either chondromalacia patella, a meniscal tear, or a number of other internal derangements of the knee. These possibilities must be carefully ruled out before concluding that a plica is the sole cause of pain.
Treatment
If your screaming plicae have resulted from overuse, you have at least an 80 percent chance of responding well to conservative measures consisting of rest, ice initially and then heat, and keeping your legs extended while sitting. Medication, such as aspirin, may be beneficial, as are hamstring-s and quadriceps-stretching exercises. lf your symptoms followed blunt trauma, such as a fall or the striking of a solid object, or a twisting injury, the prospects are pretty much reversed: Your chance of relief by conservative measures is 20 percent or less. Fortunately, 90 percent of patients undergoing arthroscopic removal of these folds report good or excellent results. Complications are rare and recovery quick. So if, after three to four months, symptomatic plicae have failed to respond to conservative measures, it’s probably time to consider anthroscopy.
Tuesday, October 2, 2012
PATELLA SUBLUXATION (Dislocated Kneecap)
The knee joint is created by the end of the thighbone (femur) sitting snugly on top of the shinbone (tibia). Near the end ofbthe femur there is a track that holds the kneecap as it protects thebjoint. At times the kneecap can be knocked completely off the bgroove; technically, this is a dislocated kneecap. At other times the bkneecap may be “riding” on the edge and not completely dislocated; this is when we say the patella has subluxated.
Sometimes individuals have a congenital defect and the kneecap tends to run off the track or “subluxate” in the face of a severe sudden twist or constant stress. Picture a sliding door with a tendency to run off the track momentarily because it wasn’t built right. For other people there may not be anything inherently wrong with the knee; a traumatic event, such as a fall, dislocates the kneecap and the next time it takes less trauma to cause a recurrence.
This is probably the second most common disorder of the kneecap. It is also one that has captured the imagination of many orthopedic specialists. For example, by 1959 there were at least 137 surgical methods designed to solve this problem. This is a sure sign that no one really knows what will consistently work.
Yet we have to keep trying because this problem comprises a significant segment of knee injuries and represents a major cause of intemal derangement. Each time a kneecap dislocates there will likely be cartilage or joint damage, a fracture of the undersurface of the kneecap, or even a fracture of the lateral femoral condyle, which is the bone end that the kneecap slides over as it dislocates. If that’s not bad enough, over time this condition can lead to the onset of arthritis and further degenerative damage.
Symptoms
Because the subluxation happens quickly, the patient rarely reports a completely dislocated kneecap. Instead, the complaint is generally of poorly localized knee pain and a history of vague complaints that the knee “gives way,” “pops,” “locks,” or “goes out of place.” In fact, what generally convinces someone to seek medical advice is not the pain of subluxation but rather the pain caused by the degenerative changes taking place inside the knee.
The pain is aggravated by both activity, especially stair climbing, and inactivity with the knee bent (such as in an automobile or theater). During sports participation, subluxation occurs when your knee gives way when you tum, cut back, or push oft during activity.
Typically, the first dislocation is recalled with great clarity: “I slid into second base, I hit the baseman, and ‘Pow!’—I thought my knee was coming off!” The next dislocation was almost as painful, but the third time not nearly so. After that the kneecap goes off its track and there’s a moment of instability and that’s about it. There’s little pain and hardly any swelling.
That first episode causes everything anchoring the kneecap to become stretched or torn. The muscles and tendons heal, but in a lengthened position, and after a while they become very stretched out. The longer the problem is ignored, the greater degenerative problem there will be to manage.
The complaints—locking, giving way, pain, and swelling-are the same symptoms associated with meniscal injuries, which means diagnosis can be difficult. I’ve seen people who have had their meniscus removed when in fact their problem was really a subluxating patella. This obviously didn’t solve the problem and often resulted in severe arthritic degeneration as the subluxation continued.
One of the key diagnostic features of this problem is something called the “apprehension sign.” People with subluxation often display marked apprehension when the doctor moves to push the patella laterally while testing for stability or increased mobility. This isn’t as sadistic as it sounds. A good examiner will note this apprehension and back off, hoping to avoid the “throat sign,” which is where the patient grabs the examiner if he goes one step further.
Treatment
The most notable feature of patella subluxation is a wasting of the vastus medialus muscles, which are part of the quadriceps. The quads hold the patella tightly against the femur, so retuming these muscles to peak condition is a primary goal of treatment. Nonpainful leg lifts and leg lifts with weights are important in getting the kneecap back on track. Support by bracing is also often recommended.
Studies suggest that with conservative treatment—that is, nonsurgical remedies-—dislocations become less frequent over time and there is little evidence of osteoarthritis. For people who have undergone surgery there is a higher recurrence rate, a risk that further surgery may be necessary, and a disturbingly high incidence of osteoarthritis. Therefore, surgery should be considered only after conservative rehabilitative techniques have failed.
BURSITIS (“I-Iousemaid’s Knee")
The letters -itis mean inflammation, so bursitis is inflammation of the bursa. The what? The bursa are little empty sacs around any joint that for the most part go unnoticed-—until they fill with fluid and swell. They’ re a little like air bags in cars, tucked away, out of sight and out of mind until—WHAMl-and they’re suddenly real hard to ignore.
There are fourteen bursas around the knee and any one of them can become inflamed. What generally happens is that something initates the knee, maybe the knee strikes a sharp object, or maybe the knee’s owner has been kneeling a bit too much, and the bursa decides the knee could do with some extra protection. So it fills with fluid or blood and tries to protect the knee from further injury. That’s great for the knee but, if it’s your knee, you will find there’s a cost for this added protection: intense pain.
The bursa in front of the knee is what gets irritated by too much kneeling and the result is a bursitis known as “housemaid’s knee.” Of course you don’t have to be anywhere near a kitchen floor to have angry bursa; carpenters, bricklayers, plumbers, and even ministers are often victims.
If you have gout, gouty crystals may form in the knee causing irritation and bursitis.
Symptoms
Localized pain, swelling, and tenderness are the hallmarks of bursitis.
Treatment
The first order of business is to eliminate the irritant. For example, either get a long-handled mop or pray standing up. Then oral anti-inflammatory drugs will help calm the bursa. In severe cases the bursa may have to be drained, the area injected with cortisone, and the fluid checked for special conditions like gout or infection. One to three injections of cortisone generally brings quick relief.
Bursitis is usually a very self-limiting phenomenon, unless it is also associated with gout, or arthritis, or some other condition that will cause continued irritation and continually angry bursa.
PATELLAR TENDINITIS (“Jumper’s Knee”)
The kneecap is connected to the front thigh muscle and shinbone by patellar and quadriceps tendons. A small tear here causes tendinitis, or “jumper’s knee.” This condition is usually sport-related, represents overuse of the involved tendon, and is common among basketball and volleyball players, hurdlers, and dancers. It may also be a complicating factor of Osgood-Schlatter disease in children.
Symptoms
A sharp pain in and around the patella is usually exacerbated by jumping. The knee may show swelling, redness, even warmth around the kneecap. Straight leg raising also causes pain. Various stages have been classically described: Stage 1——aching after participation; Stage 2-—aching during participation; Stage 3-aching and pain during participation, which is now affecting ability to participate; Stage 4—the catastrophic event that is caused by deterioration of the tendon to the point that it ruptures. Ouch!
Treatment
Jumping must be avoided for one to three weeks until the pain stops. Anti-inflammatory agents and massage can be helpful. In ice/friction massage, ice is rubbed on the skin for several minutes until numbness occurs. (lce is also used with cross-fiber friction massage, followed by the use of a dry washcloth to rewarm the skin. This. is repeated twice, ending with ice to stimulate the circulation. )
For some people, shoe orthotics, knee wraps, or a “jumper’s knee brace” may be beneficial.
As with chondromalacia patellae, quadriceps-strengthening and -stretching exercises can prevent recurrence.
My own experience suggests that about 70 percent of patients seem to be able to arrest their condition at the Stage 1 level with braces, an exercise program, use of minimal anti-inflammatory medication, and ice/friction massage. Of the remaining 30 percent, two out of three end up with more aggressive medical management, including perhaps a steroid injection, a more prolonged period of rest and recovery, and, in truly severe cases, perhaps surgery. And 10 percent will have to significantly modify their activities and go to a different sport. For example, basketball or volleyball will have to be replaced with a less knee-demanding activity. Strangely enough, this problem was much more common several years ago than it is now. Although there’s no concrete proof, I would like to ascribe this to better training habits, improved training
surfaces, better shoes, and better exercise regimens.
Sometimes individuals have a congenital defect and the kneecap tends to run off the track or “subluxate” in the face of a severe sudden twist or constant stress. Picture a sliding door with a tendency to run off the track momentarily because it wasn’t built right. For other people there may not be anything inherently wrong with the knee; a traumatic event, such as a fall, dislocates the kneecap and the next time it takes less trauma to cause a recurrence.
This is probably the second most common disorder of the kneecap. It is also one that has captured the imagination of many orthopedic specialists. For example, by 1959 there were at least 137 surgical methods designed to solve this problem. This is a sure sign that no one really knows what will consistently work.
Yet we have to keep trying because this problem comprises a significant segment of knee injuries and represents a major cause of intemal derangement. Each time a kneecap dislocates there will likely be cartilage or joint damage, a fracture of the undersurface of the kneecap, or even a fracture of the lateral femoral condyle, which is the bone end that the kneecap slides over as it dislocates. If that’s not bad enough, over time this condition can lead to the onset of arthritis and further degenerative damage.
 |
| The sites of major knee problems |
Symptoms
Because the subluxation happens quickly, the patient rarely reports a completely dislocated kneecap. Instead, the complaint is generally of poorly localized knee pain and a history of vague complaints that the knee “gives way,” “pops,” “locks,” or “goes out of place.” In fact, what generally convinces someone to seek medical advice is not the pain of subluxation but rather the pain caused by the degenerative changes taking place inside the knee.
The pain is aggravated by both activity, especially stair climbing, and inactivity with the knee bent (such as in an automobile or theater). During sports participation, subluxation occurs when your knee gives way when you tum, cut back, or push oft during activity.
Typically, the first dislocation is recalled with great clarity: “I slid into second base, I hit the baseman, and ‘Pow!’—I thought my knee was coming off!” The next dislocation was almost as painful, but the third time not nearly so. After that the kneecap goes off its track and there’s a moment of instability and that’s about it. There’s little pain and hardly any swelling.
That first episode causes everything anchoring the kneecap to become stretched or torn. The muscles and tendons heal, but in a lengthened position, and after a while they become very stretched out. The longer the problem is ignored, the greater degenerative problem there will be to manage.
The complaints—locking, giving way, pain, and swelling-are the same symptoms associated with meniscal injuries, which means diagnosis can be difficult. I’ve seen people who have had their meniscus removed when in fact their problem was really a subluxating patella. This obviously didn’t solve the problem and often resulted in severe arthritic degeneration as the subluxation continued.
One of the key diagnostic features of this problem is something called the “apprehension sign.” People with subluxation often display marked apprehension when the doctor moves to push the patella laterally while testing for stability or increased mobility. This isn’t as sadistic as it sounds. A good examiner will note this apprehension and back off, hoping to avoid the “throat sign,” which is where the patient grabs the examiner if he goes one step further.
Treatment
The most notable feature of patella subluxation is a wasting of the vastus medialus muscles, which are part of the quadriceps. The quads hold the patella tightly against the femur, so retuming these muscles to peak condition is a primary goal of treatment. Nonpainful leg lifts and leg lifts with weights are important in getting the kneecap back on track. Support by bracing is also often recommended.
Studies suggest that with conservative treatment—that is, nonsurgical remedies-—dislocations become less frequent over time and there is little evidence of osteoarthritis. For people who have undergone surgery there is a higher recurrence rate, a risk that further surgery may be necessary, and a disturbingly high incidence of osteoarthritis. Therefore, surgery should be considered only after conservative rehabilitative techniques have failed.
BURSITIS (“I-Iousemaid’s Knee")
The letters -itis mean inflammation, so bursitis is inflammation of the bursa. The what? The bursa are little empty sacs around any joint that for the most part go unnoticed-—until they fill with fluid and swell. They’ re a little like air bags in cars, tucked away, out of sight and out of mind until—WHAMl-and they’re suddenly real hard to ignore.
There are fourteen bursas around the knee and any one of them can become inflamed. What generally happens is that something initates the knee, maybe the knee strikes a sharp object, or maybe the knee’s owner has been kneeling a bit too much, and the bursa decides the knee could do with some extra protection. So it fills with fluid or blood and tries to protect the knee from further injury. That’s great for the knee but, if it’s your knee, you will find there’s a cost for this added protection: intense pain.
The bursa in front of the knee is what gets irritated by too much kneeling and the result is a bursitis known as “housemaid’s knee.” Of course you don’t have to be anywhere near a kitchen floor to have angry bursa; carpenters, bricklayers, plumbers, and even ministers are often victims.
If you have gout, gouty crystals may form in the knee causing irritation and bursitis.
Symptoms
Localized pain, swelling, and tenderness are the hallmarks of bursitis.
Treatment
The first order of business is to eliminate the irritant. For example, either get a long-handled mop or pray standing up. Then oral anti-inflammatory drugs will help calm the bursa. In severe cases the bursa may have to be drained, the area injected with cortisone, and the fluid checked for special conditions like gout or infection. One to three injections of cortisone generally brings quick relief.
Bursitis is usually a very self-limiting phenomenon, unless it is also associated with gout, or arthritis, or some other condition that will cause continued irritation and continually angry bursa.
PATELLAR TENDINITIS (“Jumper’s Knee”)
The kneecap is connected to the front thigh muscle and shinbone by patellar and quadriceps tendons. A small tear here causes tendinitis, or “jumper’s knee.” This condition is usually sport-related, represents overuse of the involved tendon, and is common among basketball and volleyball players, hurdlers, and dancers. It may also be a complicating factor of Osgood-Schlatter disease in children.
Symptoms
A sharp pain in and around the patella is usually exacerbated by jumping. The knee may show swelling, redness, even warmth around the kneecap. Straight leg raising also causes pain. Various stages have been classically described: Stage 1——aching after participation; Stage 2-—aching during participation; Stage 3-aching and pain during participation, which is now affecting ability to participate; Stage 4—the catastrophic event that is caused by deterioration of the tendon to the point that it ruptures. Ouch!
Treatment
Jumping must be avoided for one to three weeks until the pain stops. Anti-inflammatory agents and massage can be helpful. In ice/friction massage, ice is rubbed on the skin for several minutes until numbness occurs. (lce is also used with cross-fiber friction massage, followed by the use of a dry washcloth to rewarm the skin. This. is repeated twice, ending with ice to stimulate the circulation. )
For some people, shoe orthotics, knee wraps, or a “jumper’s knee brace” may be beneficial.
As with chondromalacia patellae, quadriceps-strengthening and -stretching exercises can prevent recurrence.
My own experience suggests that about 70 percent of patients seem to be able to arrest their condition at the Stage 1 level with braces, an exercise program, use of minimal anti-inflammatory medication, and ice/friction massage. Of the remaining 30 percent, two out of three end up with more aggressive medical management, including perhaps a steroid injection, a more prolonged period of rest and recovery, and, in truly severe cases, perhaps surgery. And 10 percent will have to significantly modify their activities and go to a different sport. For example, basketball or volleyball will have to be replaced with a less knee-demanding activity. Strangely enough, this problem was much more common several years ago than it is now. Although there’s no concrete proof, I would like to ascribe this to better training habits, improved training
surfaces, better shoes, and better exercise regimens.
Monday, October 1, 2012
Chronic Knee Problems
The majority of people do not suffer from one inglorious moment, but rather develop problems over time and then wonder why their knee is so angry. This type of injury is called chronic—it takes a long time to develop, and once it’s around, it’s hard to get it to leave.
Here’s a collection of conditions, a summary of symptoms and treatment, and a look at the general prognosis.
CHONDROMALACIA PATELLA (“Runner's Knee”)
The most common knee complaint is kneecap pain and the most common cause is deterioration of the cartilage on the undersurface of the kneecap. The deterioration is called chondromalacia, the kneecap is the patella, hence the mouthful chondromalacia patella. According to the latest figures (1980), this condition is diagnosed twice as often in women as it is in men; however, in athletes in general, it appears to affect men and women equally. ‘
It is often associated with running and aerobics. Individuals whose feet pronate, or tend to roll toward the inside, are more susceptible to this condition. Dancers and weight lifters are at greater risk due to the number of deep knee bends they perform. Occasionally this condition is caused by some other problem, such as rheumatoid arthritis, recurrent bleeding into the knee, or infection. It may also be associated with long-forgotten knee injury. For example, a severe blow to the kneecap—or several over the course of time—may years later creep up on you as chondromalacia. And if you have ever sustained a knee injury requiring repeated cortisone injections or prolonged immobilization, this, too, may predispose you to this degenerative process.
The onset of chondromalacia patella is insidious, progressing slowly and often involving both knees. The exception, of course, is when it’s associated with injury to just one knee, such as in an automobile accident with the front of the knee striking the dashboard. If you find yourself victim to this disease, it is not to be ignored. Chondromalacia can lead to degenerative arthritis.
Symptoms
Typically this condition affects an otherwise healthy young person between the ages of twelve and thirty-five who complains of a poorly localized, dull aching pain on the front of the knee. The first pain is likely to result from activity such as running or hiking or after prolonged sitting, such as a long car or plane trip. The symptoms can be aggravated by climbing, walking inclines, or running hills. A crackling sound or grating feeling also often accompanies this problem, but itsshould be noted that to at least some degree this particular symptom is common in people over the age of twenty.
When your knee is straightened the kneecap is quite mobile, almost “floating.” However, when your leg is bent (flexed), the patella sits tightly in its groove. If the kneecap starts to soften around the edges, there are nerve endings that can’t take the pressure like they used to and eventually they let you know they are not pleased. So after sitting in one position for a while the classic “theater sign” occurs: Your legs take on a mind of their own and say, “Hey, dummy! Either stand up and stretch or at least grab an aisle seat.” Either way, you’ll take the pressure off your patella and it will feel better.
Treatment
If your complaints are mild, rest and avoidance of those activities that cause pain are best. This means no kneeling, extensive stair climbing, or prolonged sitting. When you do sit, stretch your legs or put your feet up and relax. Aspirin, or some other non-steroidal anti-inflammatory medication, three to four times a day for a couple of weeks may bring some relief. Warm soaks are also recommended.
Braces can be helpful when symptoms are related to specific activities. The best braces for chondromalacia consist of an elastic sleeve with a central opening for the kneecap and a pad that helps hold the patella in place. There are braces that have pads that totally surround the kneecap. These, however, should be avoided since they can actually hold the kneecap down in the flexed position even during activity. If symptoms are severe, crutches can be used until the pain subsides.
Isometric exercises for the quadriceps may also be started, but if they irritate the knee, back off. Don’t quit, just back off. Exercising improves quads strength, which will improve patellar tracking and reduce pain. Although you may worry about exercising while in pain, as long as your leg is straight during exercise, pain should be limited. However, exercises that have the knee going through its full range of motion (isotonic exercises) should be avoided, as should squatting. (You’ll find appropriate progressive resistance exercises
to help you overcome chondromalacia patella in Appendix A.)
If you have chondromalacia, the worst exercises are full deep squats, leg presses, “hack squats,” and lunges. Jumping activities, such as basketball and volleyball, are also not advised. Runners who suffer from chondromalacia need to take it easy during their recovery, but jogging (on flat land) is not considered as stressful as deep squatting or jumping.
If medical management has failed, you may have to consider surgical treatment. There are certain realignment measures that can be done arthroscopically; these will take pressure off of sensitive areas. Arthroscopic shaving is another alternative. In this procedure loose fibers of cartilage are removed, which decreases some of the breakdown products that may cause inflammation. Operative results in general, however, have really been too inconsistent to recommend surgery as an early approach.
So conservative management is preferred. If you can achieve your ideal weight range, avoid activities that involve repetitive squatting or kneeling, and rebuild thigh muscles to normal strength, probably 85 percent of symptoms can be brought under control. That does not mean complete freedom of symptoms, but it does mean results that are as good or even better than currently attainable by surgery.
Here’s a collection of conditions, a summary of symptoms and treatment, and a look at the general prognosis.
CHONDROMALACIA PATELLA (“Runner's Knee”)
The most common knee complaint is kneecap pain and the most common cause is deterioration of the cartilage on the undersurface of the kneecap. The deterioration is called chondromalacia, the kneecap is the patella, hence the mouthful chondromalacia patella. According to the latest figures (1980), this condition is diagnosed twice as often in women as it is in men; however, in athletes in general, it appears to affect men and women equally. ‘
It is often associated with running and aerobics. Individuals whose feet pronate, or tend to roll toward the inside, are more susceptible to this condition. Dancers and weight lifters are at greater risk due to the number of deep knee bends they perform. Occasionally this condition is caused by some other problem, such as rheumatoid arthritis, recurrent bleeding into the knee, or infection. It may also be associated with long-forgotten knee injury. For example, a severe blow to the kneecap—or several over the course of time—may years later creep up on you as chondromalacia. And if you have ever sustained a knee injury requiring repeated cortisone injections or prolonged immobilization, this, too, may predispose you to this degenerative process.
The onset of chondromalacia patella is insidious, progressing slowly and often involving both knees. The exception, of course, is when it’s associated with injury to just one knee, such as in an automobile accident with the front of the knee striking the dashboard. If you find yourself victim to this disease, it is not to be ignored. Chondromalacia can lead to degenerative arthritis.
Symptoms
Typically this condition affects an otherwise healthy young person between the ages of twelve and thirty-five who complains of a poorly localized, dull aching pain on the front of the knee. The first pain is likely to result from activity such as running or hiking or after prolonged sitting, such as a long car or plane trip. The symptoms can be aggravated by climbing, walking inclines, or running hills. A crackling sound or grating feeling also often accompanies this problem, but itsshould be noted that to at least some degree this particular symptom is common in people over the age of twenty.
When your knee is straightened the kneecap is quite mobile, almost “floating.” However, when your leg is bent (flexed), the patella sits tightly in its groove. If the kneecap starts to soften around the edges, there are nerve endings that can’t take the pressure like they used to and eventually they let you know they are not pleased. So after sitting in one position for a while the classic “theater sign” occurs: Your legs take on a mind of their own and say, “Hey, dummy! Either stand up and stretch or at least grab an aisle seat.” Either way, you’ll take the pressure off your patella and it will feel better.
Treatment
If your complaints are mild, rest and avoidance of those activities that cause pain are best. This means no kneeling, extensive stair climbing, or prolonged sitting. When you do sit, stretch your legs or put your feet up and relax. Aspirin, or some other non-steroidal anti-inflammatory medication, three to four times a day for a couple of weeks may bring some relief. Warm soaks are also recommended.
Braces can be helpful when symptoms are related to specific activities. The best braces for chondromalacia consist of an elastic sleeve with a central opening for the kneecap and a pad that helps hold the patella in place. There are braces that have pads that totally surround the kneecap. These, however, should be avoided since they can actually hold the kneecap down in the flexed position even during activity. If symptoms are severe, crutches can be used until the pain subsides.
Isometric exercises for the quadriceps may also be started, but if they irritate the knee, back off. Don’t quit, just back off. Exercising improves quads strength, which will improve patellar tracking and reduce pain. Although you may worry about exercising while in pain, as long as your leg is straight during exercise, pain should be limited. However, exercises that have the knee going through its full range of motion (isotonic exercises) should be avoided, as should squatting. (You’ll find appropriate progressive resistance exercises
to help you overcome chondromalacia patella in Appendix A.)
If you have chondromalacia, the worst exercises are full deep squats, leg presses, “hack squats,” and lunges. Jumping activities, such as basketball and volleyball, are also not advised. Runners who suffer from chondromalacia need to take it easy during their recovery, but jogging (on flat land) is not considered as stressful as deep squatting or jumping.
If medical management has failed, you may have to consider surgical treatment. There are certain realignment measures that can be done arthroscopically; these will take pressure off of sensitive areas. Arthroscopic shaving is another alternative. In this procedure loose fibers of cartilage are removed, which decreases some of the breakdown products that may cause inflammation. Operative results in general, however, have really been too inconsistent to recommend surgery as an early approach.
So conservative management is preferred. If you can achieve your ideal weight range, avoid activities that involve repetitive squatting or kneeling, and rebuild thigh muscles to normal strength, probably 85 percent of symptoms can be brought under control. That does not mean complete freedom of symptoms, but it does mean results that are as good or even better than currently attainable by surgery.
| CHONDROMALACIA PATELLA | - | |
| Common Name | Who Gets It | Where It Hurts |
| Runner’s Knee | Runners Aerobic dancers The overweight (may be secondary to subluating patella) May follow traumatic injury ("dasboard knee") | The kneecap |
| Other Symptoms | What to Do | Often Confused With |
| All bent-knee activities cause discomfort | Avoid bent-knee activities | Tear of the medial meniscus |
| Grinding, occasional swelling, sensation of locking | Strengthening leg muscles is critical | |
| Weakness Knee fatigues quickly | Orthotics may be beneficial. Use cold packs and anti-inflammatory medication. |
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