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.
Friday, October 5, 2012
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. |
Sunday, September 30, 2012
Ouch! That Hurts: From Symptoms to Diagnogis (part 2)
LOCKING
There are two types of locking, true locking and pseudo-locking. More precisely, there’s what your doctor would call locking and what you would describe as locking.
True Locking
For the orthopedist, true locking doesn’t mean that the knee can’t be moved, but rather that something is preventing it from fully straightening out. It’s like trying to close a door that’s wedged open. Whatever it is that’s wedged in there may slide out of the way (only to remind you of its presence by sliding back again when you least expect it) or it may be a source of continuing trauma.
The key to locking is often a torn cartilage or a loose body (such as a bone chip) that has finally been caught and it has grabbed your attention. The locking of a meniscus, at least on the first occasion, generally occurs while doing something active, like playing football. A loose body lock is more likely to occur during an everyday activity, such as walking downstairs.
“How come l have this torn cartilage and it locked on me and I've never had a major injury?” I hear patients complain. If pressed, some do recall some sort of injury, maybe twenty years ago, but it was “no big deal.” That loose body in your knee may have been off to the side, with everything functioning fine, until that one additional maneuver gave it just enough freedom to ‘get caught. Or perhaps there truly was no one traumatic incident that initiated the whole process. Imagine a carpenter who is constantly squatting. For whatever reason, every time this carpenter squats there is a tear of his cartilage, microscopic at first, then after two years it’s a millimeter wide, another two years and another millimeter of tear, and finally one day it rips completely.
If the problem is a loose body sailing around the synovial sea, it probably started off as a small bone chip that broke loose during a moment of trauma. They range from sand size to as large as a quarter. Of course the body doesn’t like UFO’s (Unidentified Floating Objects), so it tries to break them down and reabsorb them. If that doesn’t work, it tries to wall the intruder off by laying down scar tissue, or it may start laying calcium over it. In either case the end result is felt as a locking sensation or a “giving way” of the knee.
To alleviate true locking, the fragment must be removed, whether it’s a bone chip or a torn meniscus. Otherwise there will be subsequent damage as the fragment continues to wedge itself into the bones of the knee. Fortunately, bothersome pieces of cartilage can easily be removed by a surgical technique called arthroscopy.
Some people have tried rest, elevation, and anti-inflammatories in an attempt to lesson the swelling that sometimes accompanies locking. Occasionally this allows the fragment to slide back into place. Others have also tried twisting or manipulating the leg. However, the best answer is still a surgical one.
Pseudo-locking
The second type, which I call pseudo-locking, is what a lot of people call locking when certain movements simply hurt too much to do. The knee may not be incapable of complete movement, but there is an area of exposed surface within the knee. When that surface bumps up against another surface there is pain and discomfort, which discourages you from extending your knee all the way.
So you tell your doctor your knee is locked and you can’t straighten your leg out all the way. You say, “My knee locked while going down a flight of stairs. There was this sharp pain and then I couldn’t move it.” I say, “But can you move it if you try?” “Yes,” you say, “but it hurts.” What is actually happening is that when your knee hits a particular angle or feels a certain pressure, it hits the panic button, triggering protective muscle function and a string of internal expletives.
The most common cause is damage to the knee surface, generally chondromalacia patella or osteoarthritis. You will likely have a history of grating within the knee if you develop pseudo-locking. You’re also a likely victim of a subluxating or dislocating patella. Swelling, however, is not common.
For pseudo-locking the best treatment is rest, which allows the area of irritation to heal and then regain its movement and strength. So if you suffer from an episode of pseudo-locking, relax. Get off your feet for a few minutes. Usually you’ll be able to move again- gently—after a few minutes. A cold pack while you’re resting may also help.
GIVING WAY
Sometimes a knee doesn’t lock, but it does give way for a moment, giving the owner a bit of a stop. When I was growing up in the Midwest l had an electric train. If it went over an imperfect junction it would bounce off the edge and bump right back onto the track. Like my Lionel train, the knee has three tracks. One holds
the kneecap (or patella). lf, for some reason, the kneecap doesn’t stay in its track and subluxates (slips out) for a moment, your thigh‘ muscles lose control. That’s instability. If one of my Lincoln logs fell across my train track, it would derail. A loose body along the general track of your knee probably won’t derail you, but you’ll know you’ve hit a bump. And the third track is made up of your ligaments. Perhaps they’ve been damaged by injury or become stretched out. The forces of movement may be too much for them to handle and they give way. All of these would come under the general diagnosis of patella subluxation or dislocation.
Another possibility is that the muscles that control the knee are weak and unstable; perhaps there was a previous injury and they have not been properly rehabilitated. If the muscles lose control for a moment, you feel them give way and you instinctively reach for support or prepare for a fall.
Giving way due to an old ligament injury, muscle instability, or the locking of a loose body frequently occurs while descending stairs or jumping from a height. If the problem is a torn cartilage, the triggering event is often a rotary movement, such as turning round suddenly, stepping on a small stone, or walking on uneven
ground.
SNAP, CRACKLE, POP
Perhaps the most common concern expressed about the knee comes from people who worry about the snap, crackle, and pop that comes with activity. They fear that their knees are deteriorating right before their very ears. For the most part, as long as there is no accompanying pain, an occasional grumble from the knee should not be of major concern. In fact, considering what the joint is forced to put up with over the course of daily living, it’s not all that surprising that most people over the age of twenty manage to hear at least some knee noise.
Generally, such sounds can be traced to tiny bits of cartilage that have chipped away from bone and gone floating off into the synovial sea. When the joint moves, the chip passes between the intact cartilage and makes a popping sound. Usually, this is not painful and does not damage the joint. It just makes it tricky to
sneak up on people.
When large pieces of cartilage have broken off, however, they may actually chip away more protective cartilage as they go popping around the knee. And if a large piece wedges itself between the bones, the knee may suddenly lock.
How can you tell if the sounds you hear are just normal Rice Krispies or something more serious? Sometimes it’s difficult. lf you’re concemed about it, see your orthopedic specialist. However, the rule of thumb (or knee) is that you’re safe as long as there is no accompanying pain, swelling, or loss of function. For example, if you can’t sit for a normal length of time without pain, that would indicate a loss of function. (That’s what the British call “the theater sign.”) If you have poorly localized knee pain, which is exacerbated
by going down stairs and hills, that also could indicate a more serious problem. Again, when in doubt, ask a specialist.
Most commonly heard is an occasional click, which is fairly universal and represents nothing very significant. Too many clicks, however, equal a creak, and you don’t want to be up a creek without a diagnosis. So if you’re worried, check in for a checkup.
The most common cause of all this noise is chondromalacia patella, which results from trauma. A subluxating or dislocating patella is also a possibility, with traumatic and degenerative arthritis a less likely competitor in the snap, crackle, pop diagnostic derby.
A snap or pop (which is not accompanied by a traumatic event) could represent something sliding over the joint, such as a torn cartilage or a loose fragment. It could also be the kneecap snapping or popping along (or out of) its track.
Crackling, grating, or grinding is most worrisome. That is called crepitation, and it means that there is a roughness to a surface and you’re hearing bone rubbing against bone or roughened cartilage. That’s a much more ominous sign of degeneration of a joint surface.
PAIN AND TENDERNESS
Pain may be caused by swelling, nerve fibers that have become torn or irritated, or degenerative changes, most often associated with arthritis. If you can accurately locate the site of the pain, it will greatly assist the doctor in making the diagnosis. Of course if you happen to be a procrastinator, it’s best to remember where the pain was felt first. '
The location of the pain, the severity of the pain, and what makes the pain occur all offer clues to the underlying problem. For example, a low-grade aching pain on the front of the knee occurring during hill climbing most likely represents chondromalacia patella. The same pain may also appear in the middle of physical activity and the same patella problem is probably at fault. (For more information concerning this and other specific complaints.)
Such low-grade pain often begins after activity, but if you persist in these activities, the pain becomes sharper and more persistent. lf left untreated, the pain may eventually force you to severely restrict your activity. Besides chondromalacia patella, this type of pain is symptomatic with tendinitis, patellar tendinitis, or stress fractures on the front of the knee and iliotibial band friction syndrome on the outer side of the knee or bursitis on the inner side.
Another classic pain is often quite sharp and associated with a tearing sensation, swelling, and instability, all brought about thanks to a fall or twisting maneuver deep within the knee. Such moves can cause either ligament or meniscal damage. The mode of injury is often an athlete attempting to change direction quickly. lf there is an audible “Pop!” upon injury, the problem is likely to be a torn anterior cruciate ligament. lf the pain occurs on either side of the knee, then the injury is suggestive of a medial (inner) or lateral (outer) ligament or meniscus tear.
PUTTING IT ALL TOGETHER
Let’s take an example and look at what happens to a knee, and to add some drama to the script, let’s say your first response is to ignore the problem. (Sound at all familiar?) Your foot is planted and you make a sudden turn. No big deal, a little swelling perhaps. But a part of your meniscus has tom and it’s caught there between the inner edge of your femur and tibia. You continue to walk on it, trying to force the knee closed with every step. Your knee says,
“This is stupid. If that’s the way you’re going to be, all I can do is pour out more lubricant and at least try to minimize the damage,” and the swelling increases. You’ve still got that fragment wedged in there, and now the meniscus is starting to atrophy because you keep grinding away at it. At the same time the fragment is starting
to wear a groove in the bone surface, setting the stage for an arthritic condition, an inflammation, or effusion of the joint.
Pain is now more diffuse and you can’t put your finger on the source. (Of course by now it’s so tender you probably don’t want to touch it anyway.) The muscles controlling the knee attempt to protect the injury by going into spasm and preventing the normal arc of movement. Unable to move through their natural range, the muscles start to atrophy. So now you’ve got muscle weakness, a locked knee that probably gives way with increasing frequency, swelling of the knee, more pain than you care to think about, you’re startingto scratch and damage the surface of the joint, and somewhere, from deep inside, comes an inclination to call a doctor.
Perhaps half of the pain of a traumatic injury is due to accompanying muscle spasms. In a spasm the muscles surrounding the injured part vigorously contract and hold that position——sometimes for days. While such spasms are intensely painful, they’re actually the body’s way of protecting itself from further injury. Think of it as a built-in splint, immobilizing the damaged part much like a cast
immobilizes a broken leg.
Too often, pain is ignored or blunted with medication. This is an Invitation to reinjury or even greater injury. When it comes to pain, the individual who self-medicates has a fool for a doctor. If pain persists after two days of self-medication, see your doctor.
There are two types of locking, true locking and pseudo-locking. More precisely, there’s what your doctor would call locking and what you would describe as locking.
True Locking
For the orthopedist, true locking doesn’t mean that the knee can’t be moved, but rather that something is preventing it from fully straightening out. It’s like trying to close a door that’s wedged open. Whatever it is that’s wedged in there may slide out of the way (only to remind you of its presence by sliding back again when you least expect it) or it may be a source of continuing trauma.
The key to locking is often a torn cartilage or a loose body (such as a bone chip) that has finally been caught and it has grabbed your attention. The locking of a meniscus, at least on the first occasion, generally occurs while doing something active, like playing football. A loose body lock is more likely to occur during an everyday activity, such as walking downstairs.
“How come l have this torn cartilage and it locked on me and I've never had a major injury?” I hear patients complain. If pressed, some do recall some sort of injury, maybe twenty years ago, but it was “no big deal.” That loose body in your knee may have been off to the side, with everything functioning fine, until that one additional maneuver gave it just enough freedom to ‘get caught. Or perhaps there truly was no one traumatic incident that initiated the whole process. Imagine a carpenter who is constantly squatting. For whatever reason, every time this carpenter squats there is a tear of his cartilage, microscopic at first, then after two years it’s a millimeter wide, another two years and another millimeter of tear, and finally one day it rips completely.
If the problem is a loose body sailing around the synovial sea, it probably started off as a small bone chip that broke loose during a moment of trauma. They range from sand size to as large as a quarter. Of course the body doesn’t like UFO’s (Unidentified Floating Objects), so it tries to break them down and reabsorb them. If that doesn’t work, it tries to wall the intruder off by laying down scar tissue, or it may start laying calcium over it. In either case the end result is felt as a locking sensation or a “giving way” of the knee.
To alleviate true locking, the fragment must be removed, whether it’s a bone chip or a torn meniscus. Otherwise there will be subsequent damage as the fragment continues to wedge itself into the bones of the knee. Fortunately, bothersome pieces of cartilage can easily be removed by a surgical technique called arthroscopy.
Some people have tried rest, elevation, and anti-inflammatories in an attempt to lesson the swelling that sometimes accompanies locking. Occasionally this allows the fragment to slide back into place. Others have also tried twisting or manipulating the leg. However, the best answer is still a surgical one.
Pseudo-locking
The second type, which I call pseudo-locking, is what a lot of people call locking when certain movements simply hurt too much to do. The knee may not be incapable of complete movement, but there is an area of exposed surface within the knee. When that surface bumps up against another surface there is pain and discomfort, which discourages you from extending your knee all the way.
So you tell your doctor your knee is locked and you can’t straighten your leg out all the way. You say, “My knee locked while going down a flight of stairs. There was this sharp pain and then I couldn’t move it.” I say, “But can you move it if you try?” “Yes,” you say, “but it hurts.” What is actually happening is that when your knee hits a particular angle or feels a certain pressure, it hits the panic button, triggering protective muscle function and a string of internal expletives.
The most common cause is damage to the knee surface, generally chondromalacia patella or osteoarthritis. You will likely have a history of grating within the knee if you develop pseudo-locking. You’re also a likely victim of a subluxating or dislocating patella. Swelling, however, is not common.
For pseudo-locking the best treatment is rest, which allows the area of irritation to heal and then regain its movement and strength. So if you suffer from an episode of pseudo-locking, relax. Get off your feet for a few minutes. Usually you’ll be able to move again- gently—after a few minutes. A cold pack while you’re resting may also help.
GIVING WAY
Sometimes a knee doesn’t lock, but it does give way for a moment, giving the owner a bit of a stop. When I was growing up in the Midwest l had an electric train. If it went over an imperfect junction it would bounce off the edge and bump right back onto the track. Like my Lionel train, the knee has three tracks. One holds
the kneecap (or patella). lf, for some reason, the kneecap doesn’t stay in its track and subluxates (slips out) for a moment, your thigh‘ muscles lose control. That’s instability. If one of my Lincoln logs fell across my train track, it would derail. A loose body along the general track of your knee probably won’t derail you, but you’ll know you’ve hit a bump. And the third track is made up of your ligaments. Perhaps they’ve been damaged by injury or become stretched out. The forces of movement may be too much for them to handle and they give way. All of these would come under the general diagnosis of patella subluxation or dislocation.
Another possibility is that the muscles that control the knee are weak and unstable; perhaps there was a previous injury and they have not been properly rehabilitated. If the muscles lose control for a moment, you feel them give way and you instinctively reach for support or prepare for a fall.
Giving way due to an old ligament injury, muscle instability, or the locking of a loose body frequently occurs while descending stairs or jumping from a height. If the problem is a torn cartilage, the triggering event is often a rotary movement, such as turning round suddenly, stepping on a small stone, or walking on uneven
ground.
SNAP, CRACKLE, POP
Perhaps the most common concern expressed about the knee comes from people who worry about the snap, crackle, and pop that comes with activity. They fear that their knees are deteriorating right before their very ears. For the most part, as long as there is no accompanying pain, an occasional grumble from the knee should not be of major concern. In fact, considering what the joint is forced to put up with over the course of daily living, it’s not all that surprising that most people over the age of twenty manage to hear at least some knee noise.
Generally, such sounds can be traced to tiny bits of cartilage that have chipped away from bone and gone floating off into the synovial sea. When the joint moves, the chip passes between the intact cartilage and makes a popping sound. Usually, this is not painful and does not damage the joint. It just makes it tricky to
sneak up on people.
When large pieces of cartilage have broken off, however, they may actually chip away more protective cartilage as they go popping around the knee. And if a large piece wedges itself between the bones, the knee may suddenly lock.
How can you tell if the sounds you hear are just normal Rice Krispies or something more serious? Sometimes it’s difficult. lf you’re concemed about it, see your orthopedic specialist. However, the rule of thumb (or knee) is that you’re safe as long as there is no accompanying pain, swelling, or loss of function. For example, if you can’t sit for a normal length of time without pain, that would indicate a loss of function. (That’s what the British call “the theater sign.”) If you have poorly localized knee pain, which is exacerbated
by going down stairs and hills, that also could indicate a more serious problem. Again, when in doubt, ask a specialist.
Most commonly heard is an occasional click, which is fairly universal and represents nothing very significant. Too many clicks, however, equal a creak, and you don’t want to be up a creek without a diagnosis. So if you’re worried, check in for a checkup.
The most common cause of all this noise is chondromalacia patella, which results from trauma. A subluxating or dislocating patella is also a possibility, with traumatic and degenerative arthritis a less likely competitor in the snap, crackle, pop diagnostic derby.
A snap or pop (which is not accompanied by a traumatic event) could represent something sliding over the joint, such as a torn cartilage or a loose fragment. It could also be the kneecap snapping or popping along (or out of) its track.
Crackling, grating, or grinding is most worrisome. That is called crepitation, and it means that there is a roughness to a surface and you’re hearing bone rubbing against bone or roughened cartilage. That’s a much more ominous sign of degeneration of a joint surface.
PAIN AND TENDERNESS
Pain may be caused by swelling, nerve fibers that have become torn or irritated, or degenerative changes, most often associated with arthritis. If you can accurately locate the site of the pain, it will greatly assist the doctor in making the diagnosis. Of course if you happen to be a procrastinator, it’s best to remember where the pain was felt first. '
The location of the pain, the severity of the pain, and what makes the pain occur all offer clues to the underlying problem. For example, a low-grade aching pain on the front of the knee occurring during hill climbing most likely represents chondromalacia patella. The same pain may also appear in the middle of physical activity and the same patella problem is probably at fault. (For more information concerning this and other specific complaints.)
Such low-grade pain often begins after activity, but if you persist in these activities, the pain becomes sharper and more persistent. lf left untreated, the pain may eventually force you to severely restrict your activity. Besides chondromalacia patella, this type of pain is symptomatic with tendinitis, patellar tendinitis, or stress fractures on the front of the knee and iliotibial band friction syndrome on the outer side of the knee or bursitis on the inner side.
Another classic pain is often quite sharp and associated with a tearing sensation, swelling, and instability, all brought about thanks to a fall or twisting maneuver deep within the knee. Such moves can cause either ligament or meniscal damage. The mode of injury is often an athlete attempting to change direction quickly. lf there is an audible “Pop!” upon injury, the problem is likely to be a torn anterior cruciate ligament. lf the pain occurs on either side of the knee, then the injury is suggestive of a medial (inner) or lateral (outer) ligament or meniscus tear.
PUTTING IT ALL TOGETHER
Let’s take an example and look at what happens to a knee, and to add some drama to the script, let’s say your first response is to ignore the problem. (Sound at all familiar?) Your foot is planted and you make a sudden turn. No big deal, a little swelling perhaps. But a part of your meniscus has tom and it’s caught there between the inner edge of your femur and tibia. You continue to walk on it, trying to force the knee closed with every step. Your knee says,
“This is stupid. If that’s the way you’re going to be, all I can do is pour out more lubricant and at least try to minimize the damage,” and the swelling increases. You’ve still got that fragment wedged in there, and now the meniscus is starting to atrophy because you keep grinding away at it. At the same time the fragment is starting
to wear a groove in the bone surface, setting the stage for an arthritic condition, an inflammation, or effusion of the joint.
Pain is now more diffuse and you can’t put your finger on the source. (Of course by now it’s so tender you probably don’t want to touch it anyway.) The muscles controlling the knee attempt to protect the injury by going into spasm and preventing the normal arc of movement. Unable to move through their natural range, the muscles start to atrophy. So now you’ve got muscle weakness, a locked knee that probably gives way with increasing frequency, swelling of the knee, more pain than you care to think about, you’re startingto scratch and damage the surface of the joint, and somewhere, from deep inside, comes an inclination to call a doctor.
Perhaps half of the pain of a traumatic injury is due to accompanying muscle spasms. In a spasm the muscles surrounding the injured part vigorously contract and hold that position——sometimes for days. While such spasms are intensely painful, they’re actually the body’s way of protecting itself from further injury. Think of it as a built-in splint, immobilizing the damaged part much like a cast
immobilizes a broken leg.
Too often, pain is ignored or blunted with medication. This is an Invitation to reinjury or even greater injury. When it comes to pain, the individual who self-medicates has a fool for a doctor. If pain persists after two days of self-medication, see your doctor.
Saturday, September 29, 2012
Ouch! That Hurts: From Symptoms to Diagnogis (part 1)
Of course the obvious question is how do you know if your injury requires medical attention or if it can be brought around with a little verbal exercise and some T.L.C.?
The key is understanding what your knee is trying to tell you. It’s hard to be a conscientious care-giver if you haven’t a clue as to what your charge is saying. With a better understanding of symptoms, you’ll be a much better guardian to your knee and a lot better patient for your doctor.
In 1985 over 650,000 patients underwent arthroscopy for diagnosis and repair of knee injuries, 84,000 patients had ligamentous repairs, and another 75,000 people were fitted with artificial knees. If these figures make you weak in the knees, the good news is that the vast majority of knee injuries do not require surgical intervention.
From the doctor’s perspective, this is good; any time you invade the body, even for a relatively benign procedure, there is the possibility of complications. Unfortunately, the high-tech advancements of the last few years have gotten a lot of attention, and as a result, particularly for the sports-minded, surgery has become the instant panacea for all known knee ills. That’s not a healthy attitude. There is no orthopedic condition that cannot be made worse by surgery. Yet, to most people, the knee is an absolute mystery. Well, we’ve gone through some of the cast of characters. Now it’s time to start reading your knee. The plot thickens.
EFFUSION, or SWELLING
The pressure of local swelling, or effusion, is one of the most common knee symptoms. This is nature’s way of limiting knee activity until healing occurs or the mechanical disability that is causing the swelling is corrected surgically.
To your doctor, swelling occurs when excess fluid accumulates outside of a joint. If the fluid gathers within a joint, the problem is said to be effusion. If you report swelling, 98 percent of the time the problem is caused by effusion. ln other words, “swelling” has both a technical meaning and a layman’s meaning. However, we give up. There’s no point in bucking that kind of a tide. So, in this book we’ll use the term swelling and not effusion.
There are two types of swelling: One is caused by an increase in the production of the knee’s own lubricant, synovial fluid, and the other by blood where it doesn’t belong (hemarthrosis). If the swelling occurs within the first hour of injury, there is probably bleeding into the joint. If it takes longer, the joint is frantically pumping out additional fluid into the synovial lining trying to lubricate an abnor- mality within the knee.
Sudden and Intermediate Swelling
Sudden swelling within an hour or so of the injury is very suggestive of bleeding into the joint and is probably a ligamentous tear (most often of the anterior cmciate ligament) or a fracture. Swelling that occurs anywhere from two to twenty-four hours after an injury is more likely to be a tear of the meniscus, most commonly medial meniscus. If the knee blows up suddenly and then decompresses, that’s no time to relax. lt could mean major ligamentous damage and injuries involving multiple ligaments around the knee. Indeed, you may have just managed to blow out all the major structures in the knee, including the surrounding envelope, which allows fluid to rush out and bleed into the fatty tissue beneath the skin. That’s why it swells and decompresses so fast. Normal swelling can be compared to a dam with a slow leak. But in the case of a pedestrian accident where the knee is struck by a car bumper, major skiing accident, or any high-velocity/high-force injury, it’s more like a dam that breaks and floods the countryside. The best home treatment for swelling is RICE—rest, ice, compression with a light wrap, and elevation. The immediate application of ice (not directly on skin but wrapped in a towel) can limit the extent of tissue damage and shorten healing time considerably. However, with swelling that occurs two to six hours later, ice is not as beneficial.
Chronic Swelling
If swelling is a problem of long-standing, the individual may describe his condition as water on the knee. The most likely cause is a mechanical or internal derangement caused by trauma, such as a meniscal tear, a knee sprain, or a ruptured ligament. (In children’s knees the causes of swelling are likely to be quite different.) Probably the single most important factor in determining the cause of swelling is a careful review of just what the knee was doing at the time in question. Swelling can sneak up on you, in which case it could be related to arthritis, loose bodies knocking around inside the knee, or infection. If the swelling is rapid, trauma, no matter how trivial, is likely to be the cause. Squatting and turning, or simply turning with the knee flexed and the foot planted, can be enough to tear a meniscus.
If ignored, swelling distends the knee, prohibits full range of motion, and muscles may atrophy from non-use. Furthermore, if the effusion is caused by internal bleeding, the blood acts as a destructive irritant. It may be hard to imagine blood inside the body as an irritant—it’s hard to think of air as an initant either until the dentist blows it on a cavity. Iron within the blood especially irritates the lining of the knee and can even become deposited on the joint surfaces.
Sometimes the only way to get rid of this excess fluid is to drain it off by needle aspiration. If the swelling is easily explained by the circumstances of the injury, a needle aspiration for diagnostic purposes may not be necessary. However, sometimes a sample of the fluid does need to be analyzed for infection, the presence of gout, pseudo-gout, or arthritis. If fat droplets are found suspended in the fluid, this suggests that a bone has fractured.
Sometimes anti-inflammatory agents, such as aspirin, are given to decrease the swelling, but it should be remembered that knees don’t just swell for the fun of it. A swollen knee has a serious problem and it’s telling you that it needs medical attention.
The key is understanding what your knee is trying to tell you. It’s hard to be a conscientious care-giver if you haven’t a clue as to what your charge is saying. With a better understanding of symptoms, you’ll be a much better guardian to your knee and a lot better patient for your doctor.
In 1985 over 650,000 patients underwent arthroscopy for diagnosis and repair of knee injuries, 84,000 patients had ligamentous repairs, and another 75,000 people were fitted with artificial knees. If these figures make you weak in the knees, the good news is that the vast majority of knee injuries do not require surgical intervention.
From the doctor’s perspective, this is good; any time you invade the body, even for a relatively benign procedure, there is the possibility of complications. Unfortunately, the high-tech advancements of the last few years have gotten a lot of attention, and as a result, particularly for the sports-minded, surgery has become the instant panacea for all known knee ills. That’s not a healthy attitude. There is no orthopedic condition that cannot be made worse by surgery. Yet, to most people, the knee is an absolute mystery. Well, we’ve gone through some of the cast of characters. Now it’s time to start reading your knee. The plot thickens.
EFFUSION, or SWELLING
The pressure of local swelling, or effusion, is one of the most common knee symptoms. This is nature’s way of limiting knee activity until healing occurs or the mechanical disability that is causing the swelling is corrected surgically.
To your doctor, swelling occurs when excess fluid accumulates outside of a joint. If the fluid gathers within a joint, the problem is said to be effusion. If you report swelling, 98 percent of the time the problem is caused by effusion. ln other words, “swelling” has both a technical meaning and a layman’s meaning. However, we give up. There’s no point in bucking that kind of a tide. So, in this book we’ll use the term swelling and not effusion.
There are two types of swelling: One is caused by an increase in the production of the knee’s own lubricant, synovial fluid, and the other by blood where it doesn’t belong (hemarthrosis). If the swelling occurs within the first hour of injury, there is probably bleeding into the joint. If it takes longer, the joint is frantically pumping out additional fluid into the synovial lining trying to lubricate an abnor- mality within the knee.
Sudden and Intermediate Swelling
Sudden swelling within an hour or so of the injury is very suggestive of bleeding into the joint and is probably a ligamentous tear (most often of the anterior cmciate ligament) or a fracture. Swelling that occurs anywhere from two to twenty-four hours after an injury is more likely to be a tear of the meniscus, most commonly medial meniscus. If the knee blows up suddenly and then decompresses, that’s no time to relax. lt could mean major ligamentous damage and injuries involving multiple ligaments around the knee. Indeed, you may have just managed to blow out all the major structures in the knee, including the surrounding envelope, which allows fluid to rush out and bleed into the fatty tissue beneath the skin. That’s why it swells and decompresses so fast. Normal swelling can be compared to a dam with a slow leak. But in the case of a pedestrian accident where the knee is struck by a car bumper, major skiing accident, or any high-velocity/high-force injury, it’s more like a dam that breaks and floods the countryside. The best home treatment for swelling is RICE—rest, ice, compression with a light wrap, and elevation. The immediate application of ice (not directly on skin but wrapped in a towel) can limit the extent of tissue damage and shorten healing time considerably. However, with swelling that occurs two to six hours later, ice is not as beneficial.
Chronic Swelling
If swelling is a problem of long-standing, the individual may describe his condition as water on the knee. The most likely cause is a mechanical or internal derangement caused by trauma, such as a meniscal tear, a knee sprain, or a ruptured ligament. (In children’s knees the causes of swelling are likely to be quite different.) Probably the single most important factor in determining the cause of swelling is a careful review of just what the knee was doing at the time in question. Swelling can sneak up on you, in which case it could be related to arthritis, loose bodies knocking around inside the knee, or infection. If the swelling is rapid, trauma, no matter how trivial, is likely to be the cause. Squatting and turning, or simply turning with the knee flexed and the foot planted, can be enough to tear a meniscus.
If ignored, swelling distends the knee, prohibits full range of motion, and muscles may atrophy from non-use. Furthermore, if the effusion is caused by internal bleeding, the blood acts as a destructive irritant. It may be hard to imagine blood inside the body as an irritant—it’s hard to think of air as an initant either until the dentist blows it on a cavity. Iron within the blood especially irritates the lining of the knee and can even become deposited on the joint surfaces.
Sometimes the only way to get rid of this excess fluid is to drain it off by needle aspiration. If the swelling is easily explained by the circumstances of the injury, a needle aspiration for diagnostic purposes may not be necessary. However, sometimes a sample of the fluid does need to be analyzed for infection, the presence of gout, pseudo-gout, or arthritis. If fat droplets are found suspended in the fluid, this suggests that a bone has fractured.
Sometimes anti-inflammatory agents, such as aspirin, are given to decrease the swelling, but it should be remembered that knees don’t just swell for the fun of it. A swollen knee has a serious problem and it’s telling you that it needs medical attention.
| Problem | Degree of Swelling (3 is most) | Speed of Onset | Other Symptoms | Method of Injury |
| Meniscal tear | 1-2 | 2-8 hrs. | Locked Knee Pain Tearing Sensation | Twisting or squatting |
| Sprains | ||||
| Grade 1 | 1 | Immediate | Severe pain | Falls |
| Grade 2 | 2-3 | Instability | Twisting | |
| Grade 3 | 3 | injuries | ||
| Chondromalacia patella | 1 | Slow and insidious | Aching on front of knee Pseudo-locking Instability Pain with flexion | Subluxated patella Repetitive squatting Overweight Blunt trauma |
| Osteochondritis dissecans | 1 | Slow and insidious | Pseudo-locking Low-grade aching Weakness Loose bodies | Unknown |
| Loose body | 2 | Intermittent | True locking Instability | Sheer fractures Osteochondrifis dissecans |
| Osteoarthritis | 1-2 | Slow and insidious | Stiffness Low-grade aching | Old trauma Aging process |
| Rheumatoid arthritis | 2-3 | Slow and insidious | Stiffness Loss of movement Low-grade aching | Unknown |
| Gout and pseudo-gout | 2 | 2-6 hours | Limited movement | Metabolic disease |
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