Of all the possible traumatic injuries, there is one that is a four star pain in the knee. A player whose foot is planted receives a blow to the outside of the joint, forcing the large bones inward. This puts an extraordinary amount of pressure on internal structures and may stretch or tear the meniscus when it is crushed between the bones; the anterior cruciate ligament may also give way, and the medical collateral ligament also stretches or tears. This orthopedic nightmare is called “the tenible triad.”
Treatment
Due to the magnitude of the injury, 90 percent of the time this means surgery, and generally not a simple arthroscopic procedure but a combination of open and arthroscopic surgery. Recovery for ligamentous injuries in general ranges from nine to eighteen months and in the case mentioned above we’re probably talking about the high end of that range. Someone who has suffered the terrible triad has actually suffered two traumas: an injury trauma and a surgical trauma. It is big surgery to put it all back together. A lot of tissue must be cut through to work on the areas affected. All of that has to heal while the person undergoes all types of muscular rehabilitation.
The prognosis is pretty good, however. ln my experience 85 percent of all patients report good or excellent results postoperaiively. Only 5 percent report fair results, and 10 percent say their condition is unsatisfactory.
FRACTURES
There are two types of fractures affecting athletes: traumatic and stress. Major trauma, such as a fall down a flight of stairs or a car accident, often causes a fracture. One traumatic blow in sports, which could be the indelicate landing of a 250-pound tackle or a knee dive into the floor, is all it takes to cause a fracture.
A sheer force crashing into the kneecap can knock a piece of bone off of the patella or the patella track. A direct blow can crack or damage the kneecap’s surface or it can force the patella back into its groove and fracture the backside of the patella.
The other type of fracture, a stress fracture, may comprise as much as 10 percent of all sports injuries and up to 16 percent of all injuries to runners. A stress fracture is the result of repeated stress from excessive motion or impact shock. The result is a series of microscopic cracks that, over time, become larger and larger until eventually symptoms develop. Because the symptoms are similar to a number of other conditions, the first diagnosis is often wrong. The most common misdiagnosis is probably tendinitis, with bursitis and “runner’s knee” also getting a share of blame. If your knee doesn’t respond to therapy within a couple of weeks, a physician will usually become suspicious and order further tests, hoping to find evidence of a stress fracture. Thus, stress fractures are often a diagnosis of exclusion, which means the examining physician first figures out what is not causing the pain and then proceeds toward a diagnosis of stress fracture.
Don’t be too hard on your doctor if he or she first misses a stress fracture. Besides the fact that the symptoms echo a number of other complaints, another confounder is that symptoms may pre-L cede X-ray evidence by up to three months and, in a significant number of stress fractures, there may never be positive X-ray evidence at all. Fortunately, conventional X rays may be supplemented by a bone scan (radionuclide bone scintigraphy) if there is a high suspicion of stress fracture. This has shown to be a very sensitive diagnostic tool, capable of detecting stress fractures within seventy-two hours of onset of pain. A few facilities are also beginning to use magnetic resonance imaging for stress fracture detection.
Symptoms
Bone pain is the primary symptom of fractures. The pain begins mildly and gradually worsens. The longer the stress fracture continues to be stressed and goes untreated, the more severe the pain becomes. Localized tenderness and swelling, as well as pain related to activity, are also common, but again these are hardly specific complaints.
Treatment
For traumatic fractures, the first step of all treatment is to recognize the fracture. lt’s important that fractures be treated within the first week in order to avoid further injury and to guide healing. Sometimes treatment is limited to immobilization (usually a brace or a cast), rest, and protection. For complicated fractures, surgery may be necessary to do internal repair with pins, wires, screws, and plates in order to hold everything in place during healing. The patient often retums quickly to day-to-day activities, but recreational activities are severely limited during recovery. Cycling, swimming, and running in water are sometimes permitted as alter-
native activities to maintain fitness. Stretching and flexibility exercises are emphasized, as well as local muscle strengthening, stretching, and retraining.
Once an individual has been pain-free for ten to fourteen days, there is a gradual reintroduction to sports.
Perhaps the single most important factor in avoiding stress fracture reinjury is a schedule of alternate-day activity. ln other words, if you’ re a runner, your best bet for avoiding stress fractures might be to alternate running with bicycling, or just take a day off between runs. One study reported in Military Medicine (147:285-87, 1982), found that such a recovery period during training cut the stress fracture rate in military recruits by one third. , The average time to recovery for traumatic fractures is ten to thirteen weeks. For stress fractures, four to ten weeks is generally required.
Sunday, October 7, 2012
Saturday, October 6, 2012
DEGENBRATIVE MENISCAL TEARS
The meniscal tear most often associated with aging is called a cleavage-type tear. This may sound sexy, but the pain and swelling associated with the horizontal separation is hardly alluring. (To get an idea of this separation, picture the venetian-blind eflect that occurs when a favorite pair of blue jeans wears out at the knee.)
Often the problem can be brought under control with exercises that build power and endurance in the quadriceps and hamstrings. (See Appendix A.) That assumes, however, that you avoid the repetitive squatting or kneeling that most likely caused the problem. Otherwise, arthroscopy can be performed and the torn portion of the meniscus can be removed.
LIGAMENT TEARS (“Sprained Knee”)
We’ve discussed how the ligaments act as the scaffolding for the bones of the knee. The collateral ligaments run up the inside and outside of the knee, while the anterior cruciate ligament and the posterior cruciate ligament cross within the joint. A sprain occurs when any of these ligaments are stretched excessively or tom.
The inner or medial collaterial ligament (MCL) is the most common site of knee sprains. Indeed, the MCL is probably 50 times more likely to be injured than the ACL. (Fortunately, most MCL injuries are of such a minor nature that they are never even called to a doctor’s attention.) The ACL is often tom in contact sports. To give you an idea of the scope of knee sprains, by conservative estimate at least 50,000 occur each year in the United States just among skiers. Fortunately, less than 15 percent require surgery.
Symptoms
The Standard Nomenclature of Athletic Injuries, published by the American Medical Association (impressive, huh), defines three categories of ligamentous injury:
1. Grade 1 “mild” sprains are those with mild tendemess, minimal hemorrhage and swelling, no abnormal motion, and minimal disability. There are minor tears of ligament fibers. There is minimal loss of strength, no lengthening, and no loss of function.
2. Grade 2 “moderate” sprains are those with moderate loss of function, more joint reaction (i.e., swelling and tendemess), slight to moderate abnormal motion, and partial tearing of ligamentous tissues. There is stretching of some ligament fibers and tearing of some.
3. Grade 3 “severe” sprains are those with marked abnormal motion, indicating a complete tear of the ligament. This causes a total loss of strength and functional capacity and may require surgical repair.
Treatment
Back in the 1950s, casting was the primary treatment for an MCL injury. (Back then ACL injuries were basically ignored!) Then we went through a phase when surgery was the “treatment” of choice. As a matter of fact, during the seventies MCL repair was the most common knee ligament surgery. However, during the last few years there has been an astronomical drop in the incidence of MCL surgical repairs. What we leamed is that Grade 1 and Grade 2 MCL sprains will heal just as well with conservative treatment as they will with surgical intervention. So surgery is now generally reserved for only the most serious, Grade 3, MCL injuries.
In general the treatment for sprains depends on the severity of the injury. For a mild sprain, RICE is advised: rest, ice, compression, and elevation. Usually there is a relatively quick return to activity. Two to three weeks is not uncommon, although we’ll soon explain why the recovery period may be even longer.
If it is a second-degree sprain, the treatment will vary depending on the functional requirements of the individual, the pain and discomfort being experienced, and how badly other knee structures, such as cartilage or muscles, have been damaged. Also, one ligament may have a second-degree injury while another might have suffered a more severe third-degree injury, so strains are often far from cut-and-dried phenomenon.
The knee will need protection for one to six weeks in the form of a removable splint and an intermittent range of motion exercises or a brace that allows for limited movement.
For the most severe (Grade 3) sprains, surgical repair is often considered, with prolonged (three to eight weeks) splint or brace protection generally recommended. Some continued protection may even be appropriate beyond eight weeks. It should be noted that the bracing is not meant to simply provide stability; the surgical repair should do that. Instead, it is to protect and prevent reinjury while allowing for the healing of the ligament.
Perhaps the biggest problem in treating sprains is undertreating mild ones and overtreating the moderate and severe ones. Many mild sprains are functioning again within two to three weeks, yet by definition a Grade 1 sprain has damaged tissue and is weakened for a longer period of time, perhaps several months. The real hazard with Grade 1 sprains is that you will not fully appreciate your injury and you will return to activity too soon and find yourself reinjured. Unfortunately, when this happens the resulting sprain may be much more serious than the original.
While it may take only a few weeks to return to action following a sprain, actual healing may take up to two years. During the first year you will reach a significant plateau of healing and then slow healing will likely continue for another year.
Surgical Repair
Since ligaments do not have a rich blood supply, it should be remembered that they do not heal well. They should be evaluated for possible repair. Well, they can be ignored, but that does engender a certain amount of risk and a definite degree of suspense: When will your trick knee go into its next act?
If you and your doctor decide that surgical repair is necessary, the particular approach will depend on your precise injury. For a severe MCL injury, there needs to be some open surgery since the ligament is not accessible to our arthroscopes. (You’ll read more about arthroscopy later when we detail the advantages of this technology.)
Although the ACL is accessible to our microscopic surgical tools, this ligament is much more difficult to repair. The greatest likelihood for a successful repair occurs when a piece of either the femur or tibia actually breaks off with the ACL attached. That happens when the bone gives way before all of the forces can be transmitted to the ligament. It’s easier to repair a bone than it is a torn ligament, unfortunately.
Most surgeons believe that when the ACL is tom from the bone at either end, it should be reattached, since the chances of normal function after repair are good. Toward this end, orthopedists have developed a number of suturing and stapling techniques. Sadly, despite the initial enthusiasm, we’re finding that many patients undergoing this type of ACL repair really aren’t healing well. When we have had an opportunity to look at some of these patients later, what we find is pretty worthlex scar tissue instead of good resilient
tissue surrounding all that fancy medical handiwork.
Still, even this limited success is better than what we see if the anterior cruciate ligament has been torn interstitially, that is, along the ligament itself as opposed to a break at the point it connects to bone. Although a tear occurs at only one point along the ligament, there is failure all along the ligament before it ruptures. To the eye it appears to be intact, but microscopically there is noticeable damage up and down the ligament. It’s comparable to what you might have experienced if you’ve ever broken a rubber band, tied it back together with a knot, only to have it snap apart again an inch away from the original break. It looked fine, but what you couldn’t see was that in the constant stretching of the rubber band it lost its normal elasticity, its continuity, and even though only one small part broke, the rest of it was severely weakened. That’s what
happens in most ACL tears.
ACL Reconstruction
For these and other reasons, reconstruction is becoming more popular than repair: Other tissue or synthetic material is used to graft or reconstruct the ligament. If possible, someone’s own tissue is preferable to any of the artificial ligaments that are available at this time. (This technology is discussed in great detail in the epilogue.) Rather than repair the torn ACL, a tendon alongside the knee is moved over and down as a replacement. The process may include looping the tendon to actually provide more strength than the original. Some of the patients who have had this surgery were professional or college athletes who had been sidelined by continuing instability following previous surgery. Many were restored to their former levels of performance.
Several popular operations use the patellar tendon to replace the ACL because it’s one of the strongest grafts available. A potential problem with this approach is that the patellar tendon is a vital structure and taking one third to one half of it to do the reconstruction strikes me as robbing Peter to pay Paul. The penalty is often extra wear of the kneecap and difficulty in regaining flexion at the knee.
Non-Surgical Management of the Tom ACL
All of this assumes that you and your doctor decided on a surgical approach. Within the last few years we have come to realize that, contrary to earlier belief, a torn ACL is not necessarily the beginning of the end. Although a complete solution to the torn anterior cruciate ligament has yet to be devised, numerous options are available. And, indeed, one of those options is to learn how to live with it. Probably at least 60 percent or more of all patients can tolerate loss of this ligament. It depends on the amount of laxity present and the desired level of activity.
Age is also a factor. Ninety percent of the people undergoing ACL repairs or reconstruction are between nineteen and twenty-seven years old. The older person probably is not going to place the demand on their knee that someone younger will. And a tom ACL usually implies modification of life-style, including both athletic and vocational endeavors.
For example, living with a tom anterior cruciate ligament probably means living without running-and-cutting sports such as basketball and racquetball. Any activity involving sudden stops and tums would simply be harder to take and much more hazardous. Climbing or working on rough terrain or slippery surfaces would also be ill-advised. Remember, the cruciate ligaments prevent the bones from slipping backward or forward out of joint. Without an ACL for added support, going down hills or stepping in a hole can be a lot more treacherous because you just don’t have the resiliency and protection you once had. This means you can still run after your bus if you have a clear path, but stepping off the curb could send you to the ground.
In our office we’re currently studying the natural histories of patients who had untreated but documented anterior cruciate ligament tears. About 80 percent of them are satisfied, but we are going to find out what they had to change in order to accommodate their knee condition.
Often the problem can be brought under control with exercises that build power and endurance in the quadriceps and hamstrings. (See Appendix A.) That assumes, however, that you avoid the repetitive squatting or kneeling that most likely caused the problem. Otherwise, arthroscopy can be performed and the torn portion of the meniscus can be removed.
LIGAMENT TEARS (“Sprained Knee”)
We’ve discussed how the ligaments act as the scaffolding for the bones of the knee. The collateral ligaments run up the inside and outside of the knee, while the anterior cruciate ligament and the posterior cruciate ligament cross within the joint. A sprain occurs when any of these ligaments are stretched excessively or tom.
The inner or medial collaterial ligament (MCL) is the most common site of knee sprains. Indeed, the MCL is probably 50 times more likely to be injured than the ACL. (Fortunately, most MCL injuries are of such a minor nature that they are never even called to a doctor’s attention.) The ACL is often tom in contact sports. To give you an idea of the scope of knee sprains, by conservative estimate at least 50,000 occur each year in the United States just among skiers. Fortunately, less than 15 percent require surgery.
Symptoms
The Standard Nomenclature of Athletic Injuries, published by the American Medical Association (impressive, huh), defines three categories of ligamentous injury:
1. Grade 1 “mild” sprains are those with mild tendemess, minimal hemorrhage and swelling, no abnormal motion, and minimal disability. There are minor tears of ligament fibers. There is minimal loss of strength, no lengthening, and no loss of function.
2. Grade 2 “moderate” sprains are those with moderate loss of function, more joint reaction (i.e., swelling and tendemess), slight to moderate abnormal motion, and partial tearing of ligamentous tissues. There is stretching of some ligament fibers and tearing of some.
3. Grade 3 “severe” sprains are those with marked abnormal motion, indicating a complete tear of the ligament. This causes a total loss of strength and functional capacity and may require surgical repair.
Treatment
Back in the 1950s, casting was the primary treatment for an MCL injury. (Back then ACL injuries were basically ignored!) Then we went through a phase when surgery was the “treatment” of choice. As a matter of fact, during the seventies MCL repair was the most common knee ligament surgery. However, during the last few years there has been an astronomical drop in the incidence of MCL surgical repairs. What we leamed is that Grade 1 and Grade 2 MCL sprains will heal just as well with conservative treatment as they will with surgical intervention. So surgery is now generally reserved for only the most serious, Grade 3, MCL injuries.
In general the treatment for sprains depends on the severity of the injury. For a mild sprain, RICE is advised: rest, ice, compression, and elevation. Usually there is a relatively quick return to activity. Two to three weeks is not uncommon, although we’ll soon explain why the recovery period may be even longer.
If it is a second-degree sprain, the treatment will vary depending on the functional requirements of the individual, the pain and discomfort being experienced, and how badly other knee structures, such as cartilage or muscles, have been damaged. Also, one ligament may have a second-degree injury while another might have suffered a more severe third-degree injury, so strains are often far from cut-and-dried phenomenon.
The knee will need protection for one to six weeks in the form of a removable splint and an intermittent range of motion exercises or a brace that allows for limited movement.
For the most severe (Grade 3) sprains, surgical repair is often considered, with prolonged (three to eight weeks) splint or brace protection generally recommended. Some continued protection may even be appropriate beyond eight weeks. It should be noted that the bracing is not meant to simply provide stability; the surgical repair should do that. Instead, it is to protect and prevent reinjury while allowing for the healing of the ligament.
Perhaps the biggest problem in treating sprains is undertreating mild ones and overtreating the moderate and severe ones. Many mild sprains are functioning again within two to three weeks, yet by definition a Grade 1 sprain has damaged tissue and is weakened for a longer period of time, perhaps several months. The real hazard with Grade 1 sprains is that you will not fully appreciate your injury and you will return to activity too soon and find yourself reinjured. Unfortunately, when this happens the resulting sprain may be much more serious than the original.
While it may take only a few weeks to return to action following a sprain, actual healing may take up to two years. During the first year you will reach a significant plateau of healing and then slow healing will likely continue for another year.
Surgical Repair
Since ligaments do not have a rich blood supply, it should be remembered that they do not heal well. They should be evaluated for possible repair. Well, they can be ignored, but that does engender a certain amount of risk and a definite degree of suspense: When will your trick knee go into its next act?
If you and your doctor decide that surgical repair is necessary, the particular approach will depend on your precise injury. For a severe MCL injury, there needs to be some open surgery since the ligament is not accessible to our arthroscopes. (You’ll read more about arthroscopy later when we detail the advantages of this technology.)
Although the ACL is accessible to our microscopic surgical tools, this ligament is much more difficult to repair. The greatest likelihood for a successful repair occurs when a piece of either the femur or tibia actually breaks off with the ACL attached. That happens when the bone gives way before all of the forces can be transmitted to the ligament. It’s easier to repair a bone than it is a torn ligament, unfortunately.
Most surgeons believe that when the ACL is tom from the bone at either end, it should be reattached, since the chances of normal function after repair are good. Toward this end, orthopedists have developed a number of suturing and stapling techniques. Sadly, despite the initial enthusiasm, we’re finding that many patients undergoing this type of ACL repair really aren’t healing well. When we have had an opportunity to look at some of these patients later, what we find is pretty worthlex scar tissue instead of good resilient
tissue surrounding all that fancy medical handiwork.
Still, even this limited success is better than what we see if the anterior cruciate ligament has been torn interstitially, that is, along the ligament itself as opposed to a break at the point it connects to bone. Although a tear occurs at only one point along the ligament, there is failure all along the ligament before it ruptures. To the eye it appears to be intact, but microscopically there is noticeable damage up and down the ligament. It’s comparable to what you might have experienced if you’ve ever broken a rubber band, tied it back together with a knot, only to have it snap apart again an inch away from the original break. It looked fine, but what you couldn’t see was that in the constant stretching of the rubber band it lost its normal elasticity, its continuity, and even though only one small part broke, the rest of it was severely weakened. That’s what
happens in most ACL tears.
ACL Reconstruction
For these and other reasons, reconstruction is becoming more popular than repair: Other tissue or synthetic material is used to graft or reconstruct the ligament. If possible, someone’s own tissue is preferable to any of the artificial ligaments that are available at this time. (This technology is discussed in great detail in the epilogue.) Rather than repair the torn ACL, a tendon alongside the knee is moved over and down as a replacement. The process may include looping the tendon to actually provide more strength than the original. Some of the patients who have had this surgery were professional or college athletes who had been sidelined by continuing instability following previous surgery. Many were restored to their former levels of performance.
Several popular operations use the patellar tendon to replace the ACL because it’s one of the strongest grafts available. A potential problem with this approach is that the patellar tendon is a vital structure and taking one third to one half of it to do the reconstruction strikes me as robbing Peter to pay Paul. The penalty is often extra wear of the kneecap and difficulty in regaining flexion at the knee.
Non-Surgical Management of the Tom ACL
All of this assumes that you and your doctor decided on a surgical approach. Within the last few years we have come to realize that, contrary to earlier belief, a torn ACL is not necessarily the beginning of the end. Although a complete solution to the torn anterior cruciate ligament has yet to be devised, numerous options are available. And, indeed, one of those options is to learn how to live with it. Probably at least 60 percent or more of all patients can tolerate loss of this ligament. It depends on the amount of laxity present and the desired level of activity.
Age is also a factor. Ninety percent of the people undergoing ACL repairs or reconstruction are between nineteen and twenty-seven years old. The older person probably is not going to place the demand on their knee that someone younger will. And a tom ACL usually implies modification of life-style, including both athletic and vocational endeavors.
For example, living with a tom anterior cruciate ligament probably means living without running-and-cutting sports such as basketball and racquetball. Any activity involving sudden stops and tums would simply be harder to take and much more hazardous. Climbing or working on rough terrain or slippery surfaces would also be ill-advised. Remember, the cruciate ligaments prevent the bones from slipping backward or forward out of joint. Without an ACL for added support, going down hills or stepping in a hole can be a lot more treacherous because you just don’t have the resiliency and protection you once had. This means you can still run after your bus if you have a clear path, but stepping off the curb could send you to the ground.
In our office we’re currently studying the natural histories of patients who had untreated but documented anterior cruciate ligament tears. About 80 percent of them are satisfied, but we are going to find out what they had to change in order to accommodate their knee condition.
Friday, October 5, 2012
Acute Knee Problems
So you’ve finally found time to go out and shoot some baskets first exercise in a week and what happens but your knee gives way just when you plant and pivot, about to drive in with your killer slam dunk. What’s wrong? If it’s acute, you should find an answer in this chapter.
ACUTE MENISCAL TEARS (see also “Sprains,” this chapter)
We’ve already talked a little about the knee’s shock absorbers, the menisci. When you talk of a tornncartilage it’s the meniscus that has been folded, spindled, and . . . well, you know.
Acute tears most commonly occur from a twisting action while putting weight on the knee; you may feel a tearing sensation at the time of injury. Repetitive squatting or kneeling as well as natural aging processes can weaken the menisci and set the stage for an acute meniscal injury. In fact, it’s amazing how little force is necessary to damage even a healthy meniscus: simply squatting to pick up something from the floor or getting out of a car can be the last straw that completes the tear. Of course not all cartilage is created equal. God gave some people top-of-the-line cushioning while others got brand X.
Symptoms
When a meniscus is first tom, bleeding within the joint irritates the lining, or synovium, of the knee. ln an attempt to wash away the irritant, the knee increases its production of synovial fluid and
the knee swells.
One of the most common tears of the meniscus is the “buckethandle” tear. The meniscus develops a split and part of it becomes trapped within the joint. When this portion of meniscus is separated, yet still attached at either end, it appears to be the shape of a bucket, with the entrapped portion representing the handle. The knee is locked and prevents complete leg straightening. There’s also pain along the edge of the “bucket” and swelling, usually two to six hours post-injury.
Often you try to ignore a damaged meniscus and, for a time, your knee cooperates. Some movement retums and you begin to think that you’re going to recover. Of course your leg won’t straighten completely or bend as far as it used to, but between these extremes there is acceptable movement. However, some swelling simply refuses to go away, so you break down and make an appointment with your doctor.
Diagnosis is often one of exclusion, and unless your knee is locked by a bucket-handle tear, it may be weeks after your initial injury before you know exactly what’s wrong with your knee. The most revealing symptoms are tendemess, inability to squat, duck, walk, or bounce up and down while standing. There is also pain when you attempt to rotate with the feet planted.
Treatment
A tom meniscus means surgery most of the time. But today most physicians agree that unless the meniscus is definitely unstable -or symptomatic, it should be left in—or only part of it removed-to protect the knee from osteoarthritis. That’s why 90 percent of the nearly 100,000 meniscectomies done in the United States today are only partial meniscectomies.
Certain tears in the meniscus can be sutured. However, this is not always possible, and it does involve an extended period of disability and recovery. There are particular modifying factors that affect a decision to do a meniscal repair. First, what is the complexity of the tear? It is much harder to get multiple tears to heal than it is if there is one discreet tear. Second, where has the tear(s) occurred? The outer one third of the meniscus has an excellent blood supply, which means it has the greatest capacity for healing. There are individual variations, but in general the farther into the meniscus a tear occurs, the less chance there is of healing and recovery.
Other considerations include the age of the injured, and his or her individual healing potential and life-style. Usually the younger person is the most amenable technically and socially to the repair process. For a meniscectomy, you’re on crutches for a few days; for a meniscal repair, six to eight weeks. If a simple, partial meniscectomy is performed, recovery takes about six weeks. For a meniscal repair, recovery will take six to twelve months. That’s a big difference. I don’t think it makes sense to try a repair on a sixty-year-old construction worker who is moving, twisting, and squatting all day as a part of his job. Will he be willing, let alone able, to take a year off or a reassignment in order to recover from the more complicated surgery? On the other hand, a total meniscectomy on a patient under the age of sixteen can be a real catastrophe. Ten to fifteen years later that individual may face real arthritic problems. So if I tore my meniscus, I’d say just take it out arthroscopically. If my daughter tore hers, I would want it repaired if possible. If there were multiple tears, I’d need to see some statistics to indicate that the repair will heal and she will be better off after a year of recovery.
Exercise
A large meniscal tear that causes the knee to lock, block, or give way probably will not be affected by a strengthening program. Even so, a rehabilitation program is valuable; if surgery is performed, the strengthening program will help prevent further injury and facilitate postoperative recovery. Whenever a knee injury occurs, muscle strength, power, and endurance quickly weaken in the affected leg. A loss of just 15 to 20 percent of muscle strength significantly Increases the risk of reinjury. During the first two weeks most people will have at least 15 percent deficiency, and by the time I we most of my patients, one month after the onset of symptoms the vast majority have lost 30 to 40 percent of their muscle strength.
ACUTE MENISCAL TEARS (see also “Sprains,” this chapter)
We’ve already talked a little about the knee’s shock absorbers, the menisci. When you talk of a tornncartilage it’s the meniscus that has been folded, spindled, and . . . well, you know.
Acute tears most commonly occur from a twisting action while putting weight on the knee; you may feel a tearing sensation at the time of injury. Repetitive squatting or kneeling as well as natural aging processes can weaken the menisci and set the stage for an acute meniscal injury. In fact, it’s amazing how little force is necessary to damage even a healthy meniscus: simply squatting to pick up something from the floor or getting out of a car can be the last straw that completes the tear. Of course not all cartilage is created equal. God gave some people top-of-the-line cushioning while others got brand X.
Symptoms
When a meniscus is first tom, bleeding within the joint irritates the lining, or synovium, of the knee. ln an attempt to wash away the irritant, the knee increases its production of synovial fluid and
the knee swells.
One of the most common tears of the meniscus is the “buckethandle” tear. The meniscus develops a split and part of it becomes trapped within the joint. When this portion of meniscus is separated, yet still attached at either end, it appears to be the shape of a bucket, with the entrapped portion representing the handle. The knee is locked and prevents complete leg straightening. There’s also pain along the edge of the “bucket” and swelling, usually two to six hours post-injury.
Often you try to ignore a damaged meniscus and, for a time, your knee cooperates. Some movement retums and you begin to think that you’re going to recover. Of course your leg won’t straighten completely or bend as far as it used to, but between these extremes there is acceptable movement. However, some swelling simply refuses to go away, so you break down and make an appointment with your doctor.
Diagnosis is often one of exclusion, and unless your knee is locked by a bucket-handle tear, it may be weeks after your initial injury before you know exactly what’s wrong with your knee. The most revealing symptoms are tendemess, inability to squat, duck, walk, or bounce up and down while standing. There is also pain when you attempt to rotate with the feet planted.
Treatment
A tom meniscus means surgery most of the time. But today most physicians agree that unless the meniscus is definitely unstable -or symptomatic, it should be left in—or only part of it removed-to protect the knee from osteoarthritis. That’s why 90 percent of the nearly 100,000 meniscectomies done in the United States today are only partial meniscectomies.
Certain tears in the meniscus can be sutured. However, this is not always possible, and it does involve an extended period of disability and recovery. There are particular modifying factors that affect a decision to do a meniscal repair. First, what is the complexity of the tear? It is much harder to get multiple tears to heal than it is if there is one discreet tear. Second, where has the tear(s) occurred? The outer one third of the meniscus has an excellent blood supply, which means it has the greatest capacity for healing. There are individual variations, but in general the farther into the meniscus a tear occurs, the less chance there is of healing and recovery.
Other considerations include the age of the injured, and his or her individual healing potential and life-style. Usually the younger person is the most amenable technically and socially to the repair process. For a meniscectomy, you’re on crutches for a few days; for a meniscal repair, six to eight weeks. If a simple, partial meniscectomy is performed, recovery takes about six weeks. For a meniscal repair, recovery will take six to twelve months. That’s a big difference. I don’t think it makes sense to try a repair on a sixty-year-old construction worker who is moving, twisting, and squatting all day as a part of his job. Will he be willing, let alone able, to take a year off or a reassignment in order to recover from the more complicated surgery? On the other hand, a total meniscectomy on a patient under the age of sixteen can be a real catastrophe. Ten to fifteen years later that individual may face real arthritic problems. So if I tore my meniscus, I’d say just take it out arthroscopically. If my daughter tore hers, I would want it repaired if possible. If there were multiple tears, I’d need to see some statistics to indicate that the repair will heal and she will be better off after a year of recovery.
Exercise
A large meniscal tear that causes the knee to lock, block, or give way probably will not be affected by a strengthening program. Even so, a rehabilitation program is valuable; if surgery is performed, the strengthening program will help prevent further injury and facilitate postoperative recovery. Whenever a knee injury occurs, muscle strength, power, and endurance quickly weaken in the affected leg. A loss of just 15 to 20 percent of muscle strength significantly Increases the risk of reinjury. During the first two weeks most people will have at least 15 percent deficiency, and by the time I we most of my patients, one month after the onset of symptoms the vast majority have lost 30 to 40 percent of their muscle strength.
Thursday, October 4, 2012
SPONTANEOUS OSTEONECROSIS
In separate chapters we’ll discuss arthritis. Whereas arthritis is a gradual degenerative condition, which develops over months or years, spontaneous osteonecrosis has sometimes been described by patients as “instant arthritis.” It is a more common problem for older individuals, with the average patient about sixty-five years old, although the range is from forty to eighty-five. We really don’t know what causes this condition, but its typical presentation is a real attention-getter.
Symptoms
A sudden, severe pain, rarely associated with trauma of any sort, occurs spontaneously. If you’ve experienced this pain, you probably remember exactly what you were doing when the pain struck. The pain most often occurs on the inner side of the knee. It is not improved by rest, and weight-bearing activities, such as walking, may aggravate the pain. lt does not subside with time. During this early phase the knee appears “locked” because it’s prevented from complete extension or flexion due to pain, effusion, and muscle spasm. It’s not a true “locked” knee because there is no mechanical block, although a mechanical block does sometimes develop.
The future isn’t bright for those knees struck with spontaneous osteonecrosis. Although for a few lucky people the pain will subside in three to six months, others will continue to experience degenerative changes within their knee, causing pain and a limiting of function. This may occur rapidly, although the typical case develops slowly. The prognosis is sometimes dramatically poor and rarely good.
During the first four to eight weeks X rays are normal, then sometime between two and six months changes are often noted by X rays.
Treatment
If diagnosed early, pain medication is best, along with crutches or a cane and at least six months of isometric quadriceps exercises. Although the threat of continued arthritic-type changes is great, the majority of patients seem to respond to this conservative approach.
Unfortunately, S.O. victims sometimes show (in X rays) a lesion actually creating a growing crater along the inner ends of the femur and tibia. If major problems persist and there is increasing deformity one to three years following the onset of symptoms, surgery, ranging from arthroscopy to a total knee replacement, may be necessary. The best success, in chronic cases, is seen with a high tibial osteotomy. That may sound like a religious ceremony, but what it means is that by removing a wedge of bone on the lateral, or outer, side of the knee, the knee undergoes a realignment. This has the same effect as realigning a car’ s tires: lt corrects the alignment problem caused by the lesion and takes the load off of the injured bone by transferring it to another part of the knee.
Symptoms
A sudden, severe pain, rarely associated with trauma of any sort, occurs spontaneously. If you’ve experienced this pain, you probably remember exactly what you were doing when the pain struck. The pain most often occurs on the inner side of the knee. It is not improved by rest, and weight-bearing activities, such as walking, may aggravate the pain. lt does not subside with time. During this early phase the knee appears “locked” because it’s prevented from complete extension or flexion due to pain, effusion, and muscle spasm. It’s not a true “locked” knee because there is no mechanical block, although a mechanical block does sometimes develop.
The future isn’t bright for those knees struck with spontaneous osteonecrosis. Although for a few lucky people the pain will subside in three to six months, others will continue to experience degenerative changes within their knee, causing pain and a limiting of function. This may occur rapidly, although the typical case develops slowly. The prognosis is sometimes dramatically poor and rarely good.
During the first four to eight weeks X rays are normal, then sometime between two and six months changes are often noted by X rays.
Treatment
If diagnosed early, pain medication is best, along with crutches or a cane and at least six months of isometric quadriceps exercises. Although the threat of continued arthritic-type changes is great, the majority of patients seem to respond to this conservative approach.
Unfortunately, S.O. victims sometimes show (in X rays) a lesion actually creating a growing crater along the inner ends of the femur and tibia. If major problems persist and there is increasing deformity one to three years following the onset of symptoms, surgery, ranging from arthroscopy to a total knee replacement, may be necessary. The best success, in chronic cases, is seen with a high tibial osteotomy. That may sound like a religious ceremony, but what it means is that by removing a wedge of bone on the lateral, or outer, side of the knee, the knee undergoes a realignment. This has the same effect as realigning a car’ s tires: lt corrects the alignment problem caused by the lesion and takes the load off of the injured bone by transferring it to another part of the knee.
Wednesday, October 3, 2012
ILIOTIBIAL BAND FRICTION SYNDROME
The tendinitis associated with runners and dancers is called iliotibial band friction syndrome (IBFS); it involves a tendon that runs from the hip down to the outer (lateral) side of the knee. As the knee flexes and extends, the iliotibial band rubs against the end of the thighbone (femur), which ends in two elliptical notches called condyles. (Picture a dog’s bone. The rounded endpoints are condyles.) Excessive motion or tightness of the tendon can produce irritation when it rubs against the outer condyle. Because this is an especially common problem among runners.
Symptoms
The first indication of IBFS will likely be a post-aerobic burning pain. It is a very specific pain that occurs at the end of your thighbone at a point known as the lateral femoral condyle. Soon it occurs during your aerobic acfivity and eventually prevents or limits your activity or, at the very least, limits your time due to pain. For example, the pain may become so severe that it is impossible to run more than a short distance, which may be only a fraction of your usual mileage. Sports such as squash or tennis may also produce discomfort, as will repetitive flexion-extension movements such as cycling, skiing, or weight lifting.
With running, IBFS is often associated with a rapid increase in mileage, a course that involves hills, or a running surface that is at a slight angle.
Treatment
Initial treatment may include ice/friction massage and stretching of the iliotibial band. For specific stretching exercises see Appendix A. Anti-inflammatory medication, such as aspirin, speeds recovery, and if, after three weeks, the pain is still persistent, a hydrocortisone injection may be helpful while you continue to limit activity, perform stretching exercises, and change your individual activities to prevent recurrence. The latter may involve moving your activity to a softer surface, rerouting to avoid downhill or sidehill running, andnvarying mileage patterns (alternating short distances with long). A shoe insert or orthotic may also be beneficial if there is a mild malalignment of the knee or ankle.
PATHOLOGICAL SYNOVIAI PLICAE
The diagnosis of pathological synovial plicae is over-applied and over-discussed. Yes, it does exist, but it doesn’t deserve near the attention it has received.
Plicae were once considered a harmless developmental anomaly; today they are called by some authorities “the great imitators.” These are developmental leftovers that exist in anywhere from 18 to 60 percent of normal knees, depending on the medical authority who is reporting them and his or her care in detecting these folds of the knee lining. In order to understand this problem you must know a little about how the knee develops in a human body. By the eighth week of development the knee is formed of three synovial compartments, which are separated by thin, membranous walls. During the fourth fetal month these walls are usually reabsorbed back into the body, leaving the three compartments fused into one knee. However, sometimes these walls, or some portion of them, remain. These fetal remnants are called plicae.
Prior to the advent of the arthroscope, no one paid much attention to these remnants, which were considered incapable of causing any problems. They were an annoyance to the surgeon who sometimes had to get his equipment through toughened plica tissue, but for the most part they appeared to be a pretty insignificant knee structure. Then surgeons began reporting that in some painful knees the only internal problem they could find were the fibrous bands of tissue, and when these bands were divided the pain was relieved. Eventually physicians began to recognize these structures as capable of causing acute and chronic knee pain.
Trauma can injure the plicae, producing inflammation. This may be a simple stretch, tear, or contusion, but when the body repairs the injury the fold has lost some of its elasticity and becomes more fibrous and abrasive. Activity only increases the irritation and minor trauma increases the abnormal thickening of the once pliant tissue. Eventually pain may develop with activity or a single traumatic event may cause a knee-jerk response and plenty of pain.
Symptoms
Although the incidence of plicae in the general population may be quite high, only 15 to 20 percent are ever responsible for symptoms. The most common complaints include tendemess or aching pain, over the condyles or above the kneecap, that worsens with activity. There may also be swelling or a feeling of “tightness” In the knee, weakness or instability in the knee, and sound effects much as popping, snapping, or clicking. It is rare, however, to find a patient who is fully disabled by the symptoms and incapable of pursuing either work or school activities. Individuals with this condition generally do not have pain when standing still.
Pain is increased with repetitive activities, such as running and jumping, and is commonly aggravated by a quadriceps-strengthening program, but it will subside with rest.
Here, too, the diagnosis is typically one of exclusion. Frequently the symptoms suggest either chondromalacia patella, a meniscal tear, or a number of other internal derangements of the knee. These possibilities must be carefully ruled out before concluding that a plica is the sole cause of pain.
Treatment
If your screaming plicae have resulted from overuse, you have at least an 80 percent chance of responding well to conservative measures consisting of rest, ice initially and then heat, and keeping your legs extended while sitting. Medication, such as aspirin, may be beneficial, as are hamstring-s and quadriceps-stretching exercises. lf your symptoms followed blunt trauma, such as a fall or the striking of a solid object, or a twisting injury, the prospects are pretty much reversed: Your chance of relief by conservative measures is 20 percent or less. Fortunately, 90 percent of patients undergoing arthroscopic removal of these folds report good or excellent results. Complications are rare and recovery quick. So if, after three to four months, symptomatic plicae have failed to respond to conservative measures, it’s probably time to consider anthroscopy.
Symptoms
The first indication of IBFS will likely be a post-aerobic burning pain. It is a very specific pain that occurs at the end of your thighbone at a point known as the lateral femoral condyle. Soon it occurs during your aerobic acfivity and eventually prevents or limits your activity or, at the very least, limits your time due to pain. For example, the pain may become so severe that it is impossible to run more than a short distance, which may be only a fraction of your usual mileage. Sports such as squash or tennis may also produce discomfort, as will repetitive flexion-extension movements such as cycling, skiing, or weight lifting.
With running, IBFS is often associated with a rapid increase in mileage, a course that involves hills, or a running surface that is at a slight angle.
Treatment
Initial treatment may include ice/friction massage and stretching of the iliotibial band. For specific stretching exercises see Appendix A. Anti-inflammatory medication, such as aspirin, speeds recovery, and if, after three weeks, the pain is still persistent, a hydrocortisone injection may be helpful while you continue to limit activity, perform stretching exercises, and change your individual activities to prevent recurrence. The latter may involve moving your activity to a softer surface, rerouting to avoid downhill or sidehill running, andnvarying mileage patterns (alternating short distances with long). A shoe insert or orthotic may also be beneficial if there is a mild malalignment of the knee or ankle.
PATHOLOGICAL SYNOVIAI PLICAE
The diagnosis of pathological synovial plicae is over-applied and over-discussed. Yes, it does exist, but it doesn’t deserve near the attention it has received.
Plicae were once considered a harmless developmental anomaly; today they are called by some authorities “the great imitators.” These are developmental leftovers that exist in anywhere from 18 to 60 percent of normal knees, depending on the medical authority who is reporting them and his or her care in detecting these folds of the knee lining. In order to understand this problem you must know a little about how the knee develops in a human body. By the eighth week of development the knee is formed of three synovial compartments, which are separated by thin, membranous walls. During the fourth fetal month these walls are usually reabsorbed back into the body, leaving the three compartments fused into one knee. However, sometimes these walls, or some portion of them, remain. These fetal remnants are called plicae.
Prior to the advent of the arthroscope, no one paid much attention to these remnants, which were considered incapable of causing any problems. They were an annoyance to the surgeon who sometimes had to get his equipment through toughened plica tissue, but for the most part they appeared to be a pretty insignificant knee structure. Then surgeons began reporting that in some painful knees the only internal problem they could find were the fibrous bands of tissue, and when these bands were divided the pain was relieved. Eventually physicians began to recognize these structures as capable of causing acute and chronic knee pain.
Trauma can injure the plicae, producing inflammation. This may be a simple stretch, tear, or contusion, but when the body repairs the injury the fold has lost some of its elasticity and becomes more fibrous and abrasive. Activity only increases the irritation and minor trauma increases the abnormal thickening of the once pliant tissue. Eventually pain may develop with activity or a single traumatic event may cause a knee-jerk response and plenty of pain.
Symptoms
Although the incidence of plicae in the general population may be quite high, only 15 to 20 percent are ever responsible for symptoms. The most common complaints include tendemess or aching pain, over the condyles or above the kneecap, that worsens with activity. There may also be swelling or a feeling of “tightness” In the knee, weakness or instability in the knee, and sound effects much as popping, snapping, or clicking. It is rare, however, to find a patient who is fully disabled by the symptoms and incapable of pursuing either work or school activities. Individuals with this condition generally do not have pain when standing still.
Pain is increased with repetitive activities, such as running and jumping, and is commonly aggravated by a quadriceps-strengthening program, but it will subside with rest.
Here, too, the diagnosis is typically one of exclusion. Frequently the symptoms suggest either chondromalacia patella, a meniscal tear, or a number of other internal derangements of the knee. These possibilities must be carefully ruled out before concluding that a plica is the sole cause of pain.
Treatment
If your screaming plicae have resulted from overuse, you have at least an 80 percent chance of responding well to conservative measures consisting of rest, ice initially and then heat, and keeping your legs extended while sitting. Medication, such as aspirin, may be beneficial, as are hamstring-s and quadriceps-stretching exercises. lf your symptoms followed blunt trauma, such as a fall or the striking of a solid object, or a twisting injury, the prospects are pretty much reversed: Your chance of relief by conservative measures is 20 percent or less. Fortunately, 90 percent of patients undergoing arthroscopic removal of these folds report good or excellent results. Complications are rare and recovery quick. So if, after three to four months, symptomatic plicae have failed to respond to conservative measures, it’s probably time to consider anthroscopy.
Tuesday, October 2, 2012
PATELLA SUBLUXATION (Dislocated Kneecap)
The knee joint is created by the end of the thighbone (femur) sitting snugly on top of the shinbone (tibia). Near the end ofbthe femur there is a track that holds the kneecap as it protects thebjoint. At times the kneecap can be knocked completely off the bgroove; technically, this is a dislocated kneecap. At other times the bkneecap may be “riding” on the edge and not completely dislocated; this is when we say the patella has subluxated.
Sometimes individuals have a congenital defect and the kneecap tends to run off the track or “subluxate” in the face of a severe sudden twist or constant stress. Picture a sliding door with a tendency to run off the track momentarily because it wasn’t built right. For other people there may not be anything inherently wrong with the knee; a traumatic event, such as a fall, dislocates the kneecap and the next time it takes less trauma to cause a recurrence.
This is probably the second most common disorder of the kneecap. It is also one that has captured the imagination of many orthopedic specialists. For example, by 1959 there were at least 137 surgical methods designed to solve this problem. This is a sure sign that no one really knows what will consistently work.
Yet we have to keep trying because this problem comprises a significant segment of knee injuries and represents a major cause of intemal derangement. Each time a kneecap dislocates there will likely be cartilage or joint damage, a fracture of the undersurface of the kneecap, or even a fracture of the lateral femoral condyle, which is the bone end that the kneecap slides over as it dislocates. If that’s not bad enough, over time this condition can lead to the onset of arthritis and further degenerative damage.
Symptoms
Because the subluxation happens quickly, the patient rarely reports a completely dislocated kneecap. Instead, the complaint is generally of poorly localized knee pain and a history of vague complaints that the knee “gives way,” “pops,” “locks,” or “goes out of place.” In fact, what generally convinces someone to seek medical advice is not the pain of subluxation but rather the pain caused by the degenerative changes taking place inside the knee.
The pain is aggravated by both activity, especially stair climbing, and inactivity with the knee bent (such as in an automobile or theater). During sports participation, subluxation occurs when your knee gives way when you tum, cut back, or push oft during activity.
Typically, the first dislocation is recalled with great clarity: “I slid into second base, I hit the baseman, and ‘Pow!’—I thought my knee was coming off!” The next dislocation was almost as painful, but the third time not nearly so. After that the kneecap goes off its track and there’s a moment of instability and that’s about it. There’s little pain and hardly any swelling.
That first episode causes everything anchoring the kneecap to become stretched or torn. The muscles and tendons heal, but in a lengthened position, and after a while they become very stretched out. The longer the problem is ignored, the greater degenerative problem there will be to manage.
The complaints—locking, giving way, pain, and swelling-are the same symptoms associated with meniscal injuries, which means diagnosis can be difficult. I’ve seen people who have had their meniscus removed when in fact their problem was really a subluxating patella. This obviously didn’t solve the problem and often resulted in severe arthritic degeneration as the subluxation continued.
One of the key diagnostic features of this problem is something called the “apprehension sign.” People with subluxation often display marked apprehension when the doctor moves to push the patella laterally while testing for stability or increased mobility. This isn’t as sadistic as it sounds. A good examiner will note this apprehension and back off, hoping to avoid the “throat sign,” which is where the patient grabs the examiner if he goes one step further.
Treatment
The most notable feature of patella subluxation is a wasting of the vastus medialus muscles, which are part of the quadriceps. The quads hold the patella tightly against the femur, so retuming these muscles to peak condition is a primary goal of treatment. Nonpainful leg lifts and leg lifts with weights are important in getting the kneecap back on track. Support by bracing is also often recommended.
Studies suggest that with conservative treatment—that is, nonsurgical remedies-—dislocations become less frequent over time and there is little evidence of osteoarthritis. For people who have undergone surgery there is a higher recurrence rate, a risk that further surgery may be necessary, and a disturbingly high incidence of osteoarthritis. Therefore, surgery should be considered only after conservative rehabilitative techniques have failed.
BURSITIS (“I-Iousemaid’s Knee")
The letters -itis mean inflammation, so bursitis is inflammation of the bursa. The what? The bursa are little empty sacs around any joint that for the most part go unnoticed-—until they fill with fluid and swell. They’ re a little like air bags in cars, tucked away, out of sight and out of mind until—WHAMl-and they’re suddenly real hard to ignore.
There are fourteen bursas around the knee and any one of them can become inflamed. What generally happens is that something initates the knee, maybe the knee strikes a sharp object, or maybe the knee’s owner has been kneeling a bit too much, and the bursa decides the knee could do with some extra protection. So it fills with fluid or blood and tries to protect the knee from further injury. That’s great for the knee but, if it’s your knee, you will find there’s a cost for this added protection: intense pain.
The bursa in front of the knee is what gets irritated by too much kneeling and the result is a bursitis known as “housemaid’s knee.” Of course you don’t have to be anywhere near a kitchen floor to have angry bursa; carpenters, bricklayers, plumbers, and even ministers are often victims.
If you have gout, gouty crystals may form in the knee causing irritation and bursitis.
Symptoms
Localized pain, swelling, and tenderness are the hallmarks of bursitis.
Treatment
The first order of business is to eliminate the irritant. For example, either get a long-handled mop or pray standing up. Then oral anti-inflammatory drugs will help calm the bursa. In severe cases the bursa may have to be drained, the area injected with cortisone, and the fluid checked for special conditions like gout or infection. One to three injections of cortisone generally brings quick relief.
Bursitis is usually a very self-limiting phenomenon, unless it is also associated with gout, or arthritis, or some other condition that will cause continued irritation and continually angry bursa.
PATELLAR TENDINITIS (“Jumper’s Knee”)
The kneecap is connected to the front thigh muscle and shinbone by patellar and quadriceps tendons. A small tear here causes tendinitis, or “jumper’s knee.” This condition is usually sport-related, represents overuse of the involved tendon, and is common among basketball and volleyball players, hurdlers, and dancers. It may also be a complicating factor of Osgood-Schlatter disease in children.
Symptoms
A sharp pain in and around the patella is usually exacerbated by jumping. The knee may show swelling, redness, even warmth around the kneecap. Straight leg raising also causes pain. Various stages have been classically described: Stage 1——aching after participation; Stage 2-—aching during participation; Stage 3-aching and pain during participation, which is now affecting ability to participate; Stage 4—the catastrophic event that is caused by deterioration of the tendon to the point that it ruptures. Ouch!
Treatment
Jumping must be avoided for one to three weeks until the pain stops. Anti-inflammatory agents and massage can be helpful. In ice/friction massage, ice is rubbed on the skin for several minutes until numbness occurs. (lce is also used with cross-fiber friction massage, followed by the use of a dry washcloth to rewarm the skin. This. is repeated twice, ending with ice to stimulate the circulation. )
For some people, shoe orthotics, knee wraps, or a “jumper’s knee brace” may be beneficial.
As with chondromalacia patellae, quadriceps-strengthening and -stretching exercises can prevent recurrence.
My own experience suggests that about 70 percent of patients seem to be able to arrest their condition at the Stage 1 level with braces, an exercise program, use of minimal anti-inflammatory medication, and ice/friction massage. Of the remaining 30 percent, two out of three end up with more aggressive medical management, including perhaps a steroid injection, a more prolonged period of rest and recovery, and, in truly severe cases, perhaps surgery. And 10 percent will have to significantly modify their activities and go to a different sport. For example, basketball or volleyball will have to be replaced with a less knee-demanding activity. Strangely enough, this problem was much more common several years ago than it is now. Although there’s no concrete proof, I would like to ascribe this to better training habits, improved training
surfaces, better shoes, and better exercise regimens.
Sometimes individuals have a congenital defect and the kneecap tends to run off the track or “subluxate” in the face of a severe sudden twist or constant stress. Picture a sliding door with a tendency to run off the track momentarily because it wasn’t built right. For other people there may not be anything inherently wrong with the knee; a traumatic event, such as a fall, dislocates the kneecap and the next time it takes less trauma to cause a recurrence.
This is probably the second most common disorder of the kneecap. It is also one that has captured the imagination of many orthopedic specialists. For example, by 1959 there were at least 137 surgical methods designed to solve this problem. This is a sure sign that no one really knows what will consistently work.
Yet we have to keep trying because this problem comprises a significant segment of knee injuries and represents a major cause of intemal derangement. Each time a kneecap dislocates there will likely be cartilage or joint damage, a fracture of the undersurface of the kneecap, or even a fracture of the lateral femoral condyle, which is the bone end that the kneecap slides over as it dislocates. If that’s not bad enough, over time this condition can lead to the onset of arthritis and further degenerative damage.
 |
| The sites of major knee problems |
Symptoms
Because the subluxation happens quickly, the patient rarely reports a completely dislocated kneecap. Instead, the complaint is generally of poorly localized knee pain and a history of vague complaints that the knee “gives way,” “pops,” “locks,” or “goes out of place.” In fact, what generally convinces someone to seek medical advice is not the pain of subluxation but rather the pain caused by the degenerative changes taking place inside the knee.
The pain is aggravated by both activity, especially stair climbing, and inactivity with the knee bent (such as in an automobile or theater). During sports participation, subluxation occurs when your knee gives way when you tum, cut back, or push oft during activity.
Typically, the first dislocation is recalled with great clarity: “I slid into second base, I hit the baseman, and ‘Pow!’—I thought my knee was coming off!” The next dislocation was almost as painful, but the third time not nearly so. After that the kneecap goes off its track and there’s a moment of instability and that’s about it. There’s little pain and hardly any swelling.
That first episode causes everything anchoring the kneecap to become stretched or torn. The muscles and tendons heal, but in a lengthened position, and after a while they become very stretched out. The longer the problem is ignored, the greater degenerative problem there will be to manage.
The complaints—locking, giving way, pain, and swelling-are the same symptoms associated with meniscal injuries, which means diagnosis can be difficult. I’ve seen people who have had their meniscus removed when in fact their problem was really a subluxating patella. This obviously didn’t solve the problem and often resulted in severe arthritic degeneration as the subluxation continued.
One of the key diagnostic features of this problem is something called the “apprehension sign.” People with subluxation often display marked apprehension when the doctor moves to push the patella laterally while testing for stability or increased mobility. This isn’t as sadistic as it sounds. A good examiner will note this apprehension and back off, hoping to avoid the “throat sign,” which is where the patient grabs the examiner if he goes one step further.
Treatment
The most notable feature of patella subluxation is a wasting of the vastus medialus muscles, which are part of the quadriceps. The quads hold the patella tightly against the femur, so retuming these muscles to peak condition is a primary goal of treatment. Nonpainful leg lifts and leg lifts with weights are important in getting the kneecap back on track. Support by bracing is also often recommended.
Studies suggest that with conservative treatment—that is, nonsurgical remedies-—dislocations become less frequent over time and there is little evidence of osteoarthritis. For people who have undergone surgery there is a higher recurrence rate, a risk that further surgery may be necessary, and a disturbingly high incidence of osteoarthritis. Therefore, surgery should be considered only after conservative rehabilitative techniques have failed.
BURSITIS (“I-Iousemaid’s Knee")
The letters -itis mean inflammation, so bursitis is inflammation of the bursa. The what? The bursa are little empty sacs around any joint that for the most part go unnoticed-—until they fill with fluid and swell. They’ re a little like air bags in cars, tucked away, out of sight and out of mind until—WHAMl-and they’re suddenly real hard to ignore.
There are fourteen bursas around the knee and any one of them can become inflamed. What generally happens is that something initates the knee, maybe the knee strikes a sharp object, or maybe the knee’s owner has been kneeling a bit too much, and the bursa decides the knee could do with some extra protection. So it fills with fluid or blood and tries to protect the knee from further injury. That’s great for the knee but, if it’s your knee, you will find there’s a cost for this added protection: intense pain.
The bursa in front of the knee is what gets irritated by too much kneeling and the result is a bursitis known as “housemaid’s knee.” Of course you don’t have to be anywhere near a kitchen floor to have angry bursa; carpenters, bricklayers, plumbers, and even ministers are often victims.
If you have gout, gouty crystals may form in the knee causing irritation and bursitis.
Symptoms
Localized pain, swelling, and tenderness are the hallmarks of bursitis.
Treatment
The first order of business is to eliminate the irritant. For example, either get a long-handled mop or pray standing up. Then oral anti-inflammatory drugs will help calm the bursa. In severe cases the bursa may have to be drained, the area injected with cortisone, and the fluid checked for special conditions like gout or infection. One to three injections of cortisone generally brings quick relief.
Bursitis is usually a very self-limiting phenomenon, unless it is also associated with gout, or arthritis, or some other condition that will cause continued irritation and continually angry bursa.
PATELLAR TENDINITIS (“Jumper’s Knee”)
The kneecap is connected to the front thigh muscle and shinbone by patellar and quadriceps tendons. A small tear here causes tendinitis, or “jumper’s knee.” This condition is usually sport-related, represents overuse of the involved tendon, and is common among basketball and volleyball players, hurdlers, and dancers. It may also be a complicating factor of Osgood-Schlatter disease in children.
Symptoms
A sharp pain in and around the patella is usually exacerbated by jumping. The knee may show swelling, redness, even warmth around the kneecap. Straight leg raising also causes pain. Various stages have been classically described: Stage 1——aching after participation; Stage 2-—aching during participation; Stage 3-aching and pain during participation, which is now affecting ability to participate; Stage 4—the catastrophic event that is caused by deterioration of the tendon to the point that it ruptures. Ouch!
Treatment
Jumping must be avoided for one to three weeks until the pain stops. Anti-inflammatory agents and massage can be helpful. In ice/friction massage, ice is rubbed on the skin for several minutes until numbness occurs. (lce is also used with cross-fiber friction massage, followed by the use of a dry washcloth to rewarm the skin. This. is repeated twice, ending with ice to stimulate the circulation. )
For some people, shoe orthotics, knee wraps, or a “jumper’s knee brace” may be beneficial.
As with chondromalacia patellae, quadriceps-strengthening and -stretching exercises can prevent recurrence.
My own experience suggests that about 70 percent of patients seem to be able to arrest their condition at the Stage 1 level with braces, an exercise program, use of minimal anti-inflammatory medication, and ice/friction massage. Of the remaining 30 percent, two out of three end up with more aggressive medical management, including perhaps a steroid injection, a more prolonged period of rest and recovery, and, in truly severe cases, perhaps surgery. And 10 percent will have to significantly modify their activities and go to a different sport. For example, basketball or volleyball will have to be replaced with a less knee-demanding activity. Strangely enough, this problem was much more common several years ago than it is now. Although there’s no concrete proof, I would like to ascribe this to better training habits, improved training
surfaces, better shoes, and better exercise regimens.
Monday, October 1, 2012
Chronic Knee Problems
The majority of people do not suffer from one inglorious moment, but rather develop problems over time and then wonder why their knee is so angry. This type of injury is called chronic—it takes a long time to develop, and once it’s around, it’s hard to get it to leave.
Here’s a collection of conditions, a summary of symptoms and treatment, and a look at the general prognosis.
CHONDROMALACIA PATELLA (“Runner's Knee”)
The most common knee complaint is kneecap pain and the most common cause is deterioration of the cartilage on the undersurface of the kneecap. The deterioration is called chondromalacia, the kneecap is the patella, hence the mouthful chondromalacia patella. According to the latest figures (1980), this condition is diagnosed twice as often in women as it is in men; however, in athletes in general, it appears to affect men and women equally. ‘
It is often associated with running and aerobics. Individuals whose feet pronate, or tend to roll toward the inside, are more susceptible to this condition. Dancers and weight lifters are at greater risk due to the number of deep knee bends they perform. Occasionally this condition is caused by some other problem, such as rheumatoid arthritis, recurrent bleeding into the knee, or infection. It may also be associated with long-forgotten knee injury. For example, a severe blow to the kneecap—or several over the course of time—may years later creep up on you as chondromalacia. And if you have ever sustained a knee injury requiring repeated cortisone injections or prolonged immobilization, this, too, may predispose you to this degenerative process.
The onset of chondromalacia patella is insidious, progressing slowly and often involving both knees. The exception, of course, is when it’s associated with injury to just one knee, such as in an automobile accident with the front of the knee striking the dashboard. If you find yourself victim to this disease, it is not to be ignored. Chondromalacia can lead to degenerative arthritis.
Symptoms
Typically this condition affects an otherwise healthy young person between the ages of twelve and thirty-five who complains of a poorly localized, dull aching pain on the front of the knee. The first pain is likely to result from activity such as running or hiking or after prolonged sitting, such as a long car or plane trip. The symptoms can be aggravated by climbing, walking inclines, or running hills. A crackling sound or grating feeling also often accompanies this problem, but itsshould be noted that to at least some degree this particular symptom is common in people over the age of twenty.
When your knee is straightened the kneecap is quite mobile, almost “floating.” However, when your leg is bent (flexed), the patella sits tightly in its groove. If the kneecap starts to soften around the edges, there are nerve endings that can’t take the pressure like they used to and eventually they let you know they are not pleased. So after sitting in one position for a while the classic “theater sign” occurs: Your legs take on a mind of their own and say, “Hey, dummy! Either stand up and stretch or at least grab an aisle seat.” Either way, you’ll take the pressure off your patella and it will feel better.
Treatment
If your complaints are mild, rest and avoidance of those activities that cause pain are best. This means no kneeling, extensive stair climbing, or prolonged sitting. When you do sit, stretch your legs or put your feet up and relax. Aspirin, or some other non-steroidal anti-inflammatory medication, three to four times a day for a couple of weeks may bring some relief. Warm soaks are also recommended.
Braces can be helpful when symptoms are related to specific activities. The best braces for chondromalacia consist of an elastic sleeve with a central opening for the kneecap and a pad that helps hold the patella in place. There are braces that have pads that totally surround the kneecap. These, however, should be avoided since they can actually hold the kneecap down in the flexed position even during activity. If symptoms are severe, crutches can be used until the pain subsides.
Isometric exercises for the quadriceps may also be started, but if they irritate the knee, back off. Don’t quit, just back off. Exercising improves quads strength, which will improve patellar tracking and reduce pain. Although you may worry about exercising while in pain, as long as your leg is straight during exercise, pain should be limited. However, exercises that have the knee going through its full range of motion (isotonic exercises) should be avoided, as should squatting. (You’ll find appropriate progressive resistance exercises
to help you overcome chondromalacia patella in Appendix A.)
If you have chondromalacia, the worst exercises are full deep squats, leg presses, “hack squats,” and lunges. Jumping activities, such as basketball and volleyball, are also not advised. Runners who suffer from chondromalacia need to take it easy during their recovery, but jogging (on flat land) is not considered as stressful as deep squatting or jumping.
If medical management has failed, you may have to consider surgical treatment. There are certain realignment measures that can be done arthroscopically; these will take pressure off of sensitive areas. Arthroscopic shaving is another alternative. In this procedure loose fibers of cartilage are removed, which decreases some of the breakdown products that may cause inflammation. Operative results in general, however, have really been too inconsistent to recommend surgery as an early approach.
So conservative management is preferred. If you can achieve your ideal weight range, avoid activities that involve repetitive squatting or kneeling, and rebuild thigh muscles to normal strength, probably 85 percent of symptoms can be brought under control. That does not mean complete freedom of symptoms, but it does mean results that are as good or even better than currently attainable by surgery.
Here’s a collection of conditions, a summary of symptoms and treatment, and a look at the general prognosis.
CHONDROMALACIA PATELLA (“Runner's Knee”)
The most common knee complaint is kneecap pain and the most common cause is deterioration of the cartilage on the undersurface of the kneecap. The deterioration is called chondromalacia, the kneecap is the patella, hence the mouthful chondromalacia patella. According to the latest figures (1980), this condition is diagnosed twice as often in women as it is in men; however, in athletes in general, it appears to affect men and women equally. ‘
It is often associated with running and aerobics. Individuals whose feet pronate, or tend to roll toward the inside, are more susceptible to this condition. Dancers and weight lifters are at greater risk due to the number of deep knee bends they perform. Occasionally this condition is caused by some other problem, such as rheumatoid arthritis, recurrent bleeding into the knee, or infection. It may also be associated with long-forgotten knee injury. For example, a severe blow to the kneecap—or several over the course of time—may years later creep up on you as chondromalacia. And if you have ever sustained a knee injury requiring repeated cortisone injections or prolonged immobilization, this, too, may predispose you to this degenerative process.
The onset of chondromalacia patella is insidious, progressing slowly and often involving both knees. The exception, of course, is when it’s associated with injury to just one knee, such as in an automobile accident with the front of the knee striking the dashboard. If you find yourself victim to this disease, it is not to be ignored. Chondromalacia can lead to degenerative arthritis.
Symptoms
Typically this condition affects an otherwise healthy young person between the ages of twelve and thirty-five who complains of a poorly localized, dull aching pain on the front of the knee. The first pain is likely to result from activity such as running or hiking or after prolonged sitting, such as a long car or plane trip. The symptoms can be aggravated by climbing, walking inclines, or running hills. A crackling sound or grating feeling also often accompanies this problem, but itsshould be noted that to at least some degree this particular symptom is common in people over the age of twenty.
When your knee is straightened the kneecap is quite mobile, almost “floating.” However, when your leg is bent (flexed), the patella sits tightly in its groove. If the kneecap starts to soften around the edges, there are nerve endings that can’t take the pressure like they used to and eventually they let you know they are not pleased. So after sitting in one position for a while the classic “theater sign” occurs: Your legs take on a mind of their own and say, “Hey, dummy! Either stand up and stretch or at least grab an aisle seat.” Either way, you’ll take the pressure off your patella and it will feel better.
Treatment
If your complaints are mild, rest and avoidance of those activities that cause pain are best. This means no kneeling, extensive stair climbing, or prolonged sitting. When you do sit, stretch your legs or put your feet up and relax. Aspirin, or some other non-steroidal anti-inflammatory medication, three to four times a day for a couple of weeks may bring some relief. Warm soaks are also recommended.
Braces can be helpful when symptoms are related to specific activities. The best braces for chondromalacia consist of an elastic sleeve with a central opening for the kneecap and a pad that helps hold the patella in place. There are braces that have pads that totally surround the kneecap. These, however, should be avoided since they can actually hold the kneecap down in the flexed position even during activity. If symptoms are severe, crutches can be used until the pain subsides.
Isometric exercises for the quadriceps may also be started, but if they irritate the knee, back off. Don’t quit, just back off. Exercising improves quads strength, which will improve patellar tracking and reduce pain. Although you may worry about exercising while in pain, as long as your leg is straight during exercise, pain should be limited. However, exercises that have the knee going through its full range of motion (isotonic exercises) should be avoided, as should squatting. (You’ll find appropriate progressive resistance exercises
to help you overcome chondromalacia patella in Appendix A.)
If you have chondromalacia, the worst exercises are full deep squats, leg presses, “hack squats,” and lunges. Jumping activities, such as basketball and volleyball, are also not advised. Runners who suffer from chondromalacia need to take it easy during their recovery, but jogging (on flat land) is not considered as stressful as deep squatting or jumping.
If medical management has failed, you may have to consider surgical treatment. There are certain realignment measures that can be done arthroscopically; these will take pressure off of sensitive areas. Arthroscopic shaving is another alternative. In this procedure loose fibers of cartilage are removed, which decreases some of the breakdown products that may cause inflammation. Operative results in general, however, have really been too inconsistent to recommend surgery as an early approach.
So conservative management is preferred. If you can achieve your ideal weight range, avoid activities that involve repetitive squatting or kneeling, and rebuild thigh muscles to normal strength, probably 85 percent of symptoms can be brought under control. That does not mean complete freedom of symptoms, but it does mean results that are as good or even better than currently attainable by surgery.
| CHONDROMALACIA PATELLA | - | |
| Common Name | Who Gets It | Where It Hurts |
| Runner’s Knee | Runners Aerobic dancers The overweight (may be secondary to subluating patella) May follow traumatic injury ("dasboard knee") | The kneecap |
| Other Symptoms | What to Do | Often Confused With |
| All bent-knee activities cause discomfort | Avoid bent-knee activities | Tear of the medial meniscus |
| Grinding, occasional swelling, sensation of locking | Strengthening leg muscles is critical | |
| Weakness Knee fatigues quickly | Orthotics may be beneficial. Use cold packs and anti-inflammatory medication. |
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