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Knee Anatomy

Common Knee Problems

Acute injury:
Chronic Problems:
Surgery at the KneeFootAnkleCenter

Knee Anatomy

Common Knee Problems

Acute Injury

First Aid: Here are some general rules for treatment.

  • If you heard a pop - something is usually torn. Likely culprits are menisci, medial collateral ligament, and anterior cruciate ligament.
  • If your knee swells right away, something is bleeding inside. Most likely injuries are meniscal tears and anterior cruciate tears.
  • Use ice, and wrap you knee with an ace wrap.
  • If you can't walk - don't! Get crutches (local drug store).
  • It's pretty bad - very swollen, can't walk, painful. Get some help. Call your primary care MD, go to an ER or walk-in clinic, or call us at 425.899.6060 to schedule an appointment for an evaluation.
  • It's not too bad. Tolerable , stiff, sore. Start your own rehabilitation.

Contusion usually a blunt injury to the knee. May be very painful. Use standard approach - Ice, Ace, NSAI Medication, weight bearing as tolerated, early motion. Improvement should be dramatic in 2 - 5 days. If not see an MD. Achiness is typical. "Locking" or severe pain is not.

Medial Knee Pain
Medial knee pain generally comes on suddenly(acute) or slowly over time(chronic). Acute trauma usually causes meniscus tears, collateral ligament tears. Both may cause a "pop". Both may cause swelling. In fact, they may be difficult to tell apart - and may occur together. Ligament injuries often have a story of " the knee bent to the side". These knees feel unstable or "give way". Typical example: My ski tips went apart and I fell". "I got clipped by another player." Be aware that other ligaments may be injured. Meniscus tears usually have a twisting mechanism. You may hear a pop. These injuries usually swell within hours of injury. Sometimes the torn piece of cartilage jams in the joint and causes "locking". Chronic problems are usually the late result of old trauma or related to abnormal posture or mechanics. These problems may appear slowly - and without apparent cause. Sharp pain along the inner knee with twisting or squatting is most usually a meniscus tear. The pain may be caused by a joint surface roughness - a sort of pre arthritis.

MCL tear
A common injury. Usually the foot is bent outward, away from the midline and a pop or tearing sensation is felt on the inner side of the knee. The injury is graded or rated 1, 2, or 3. Grade I is bruised ligament with no instability. These injuries are painful but not unstable. Grade II injuries have mild to moderate instability. These injuries represent partial or incomplete tears. Treatment on grade I and Grade II injuries are the same ice, ace, anti inflammatory medication, early motion - especially stationary cycling. Many people use an immobilizer brace for 1 - 2 weeks for walking. Flexibility is usually normal in 2-4 weeks. Full return to vigorous pursuits in 3 - 6 weeks. Return to normal in 10-12 weeks. Grade III injuries are very unstable and are often associated with other injuries. These should be evaluated by an MD.

Meniscus tear
Meniscus tears are common and come in several varieties. The meniscus or cartilage is a cushion in the knee. The meniscus is between the joint surface of the femur and tibia. A tear usually occurs when the joint is compressed and twisted - pinching the meniscus and ripping it. Some tears are large, painful and lock the knee up entirely. Others are relatively small and minor.

Symptoms include pain at the joint line, fluid on the knee, stiffness, catching and locking. In some cases, the diagnosis is confirmed with an MRI (magnetic resonance image).

Meniscus tissue is valuable. The meniscus cushions and improves the fit of the femur to the tibia. Removal of large amounts of meniscus causes increased stress and wear - and - tear within the joint. Thus, treatments are based on maintaining as much meniscal tissue as possible.

A meniscus tear can often be "calmed down". Standard treatment is ice, wrap, motion, and anti-inflammatory medication. Surgical treatment is needed if the knee will not get better or if the motion is limited. Surgical treatment involves using a small microscope to look at and treat the tear. After anesthesia is established, the arthoscope is inserted into the knee and the meniscus tear is examined. If the tear involves the vascular portion of the meniscus, it can be repaired. Repairs are done with the arthroscope - passing sutures across the tear. If the meniscus is not repairable, the a microscopic shaver is used to remove the torn portion. The goal is to leave the joint surfaces smooth.

Most meniscal tears do not need immediate surgery. However, surgery is often required to eliminate the symptoms. Occasionally, a part of a torn meniscus becomes wedged into the front of the knee. The knee becomes stuck or locked. Arthroscopic surgery is usually done within a few days in order to relieve pain and prevent long term stiffness.

Chondral Injury
Each of the bony surfaces within the knee is covered with articular cartilage. This surface may be injured in sport, a trauma or with overuse - especially with a malalignment. Injury may include bruising or a break / fracture of the surface. Symptoms include joint line pain, swelling catching or locking. The diagnosis might be confirmed with an MRI or with arthroscopy. Treatment varies with the extent of the injury. Bruising often responds to non-impact conditioning for 2 - 3 weeks. Broken surfaces often require arthroscopy to smooth the edges and remove broken fragments. Treatment may include stimulating a biologic repair (drilling or micro fracture). Cartilage culturing with replantation or cartilage transplant procedures are also useful for select cases.

Lateral Knee Pain (outer side)
Lateral knee pain generally comes on suddenly(acute) or slowly over time(chronic). Acute trauma usually causes meniscus tears, collateral ligament tears or a dislocating patella. Each may cause a "pop". Each may cause swelling. Also, tendinitis along the outer side of the knee is common - specifically involving the ileotibial band (ITB).

LCL tear
A common injury. Usually the foot is bent outward, away from the midline and a pop or tearing sensation is felt on the inner side of the knee. The injury is graded or rated 1, 2, or 3. Grade I is bruised ligament with no instability. These injuries are painful but not unstable. Grade II injuries have mild to moderate instability. These injuries represent partial or incomplete tears. Treatment on grade I and Grade II injuries are the same ice, ace, anti inflammatory medication, early motion - especially stationary cycling. Many people use an immobilizer brace for 1 - 2 weeks for walking. Flexibility is usually normal in 2-4 weeks. Full return to vigorous pursuits in 3 - 6 weeks. Return to normal in 10-12 weeks. Grade III injuries are very unstable and are often associated with other injuries. These should be evaluated by an MD.

Meniscus tear
Meniscus tears are common and come in several varieties. The meniscus or cartilage is a cushion in the knee. The meniscus is between the joint surface of the femur and tibia. A tear usually occurs when the joint is compressed and twisted - pinching the meniscus and ripping it. Some tears are large, painful and lock the knee up entirely. Others are relatively small and minor.

Symptoms include pain at the joint line, fluid on the knee, stiffness, catching and locking. In some cases, the diagnosis is confirmed with an MRI (magnetic resonance image).

Meniscus tissue is valuable. The meniscus cushions and improves the fit of the femur to the tibia. Removal of large amounts of meniscus causes increased stress and wear - and - tear within the joint. Thus, treatments are based on maintaining as much meniscal tissue as possible.

A meniscus tear can often be "calmed down". Standard treatment is ice, wrap, motion, and anti-inflammatory medication. Surgical treatment is needed if the knee will not get better or if the motion is limited. Surgical treatment involves using a small microscope to look at and treat the tear. After anesthesia is established, the arthoscope is inserted into the knee and the meniscus tear is examined. If the tear involves the vascular portion of the meniscus, it can be repaired. Repairs are done with the arthoscope - passing sutures across the tear. If the meniscus is not repairable, the a microscopic shaver is used to remove the torn portion. The goal is to leave the joint surfaces smooth.

Most meniscal tears do not need immediate surgery. However, surgery is often required to eliminate the symptoms. Occasionally, a part of a torn meniscus becomes wedged into the front of the knee. The knee becomes stuck or locked. Arthroscopic surgery is usually done within a few days in order to relieve pain and prevent long term stiffness.

Chondral fracture
Each of the bony surfaces within the knee is covered with articular cartilage. This surface may be injured in sport, a trauma or with overuse - especially with a malalignment.

Symptoms include joint line pain, swelling catching or locking.

The diagnosis might be confirmed with an MRI of with arthroscopy. While MRI is an extremely useful tool, and very accurate for meniscus tears (95 -98%), it is only 50% - 70% accurate for chondral pathology. Arthroscopy is the gold standard.

Treatment includes cleaning the roughened surface (debridement) and or stimulating a biologic repair (drilling or micro fracture). Cartilage culturing with replantation or cartilage transplant procedures are also useful for select cases.

Patellar Subluxation / Dislocation
Patellar subluxation occurs when the patella slips away from the front of the knee - almost always to the outer side(lateral). The slip may be minor (subluxation) or major (dislocation). The patella may return by itself - or be stuck. Often the under surface of the patella is injured during a sublux or dislocation. The patella is scraped against the outer rim of the femur. Either or both surfaces may be bruised, abraded or fractured. Loose chips of cartilage or bone within the knee are common after a dislocation. As the patella slides laterally the ligaments and muscle are often torn free from the inner portion of the patella. This muscle injury is a common reason for difficult rehabilitation, quadriceps atrophy and poor patellar tracking afterward.

Risk factors include a person with generalized ligamentous laxity, prior dislocations, a long patellar tendon (high riding patella - "alta"), knocked knee posture, externally rotated tibias (duck footed), and flat or pronated feet.

The diagnosis is usually made by the patient;"my knee cap went out". Tenderness may occurs on both the inner and outer side of the patella. Usually the knee develops a large amount of fluid (effusion). X-rays are usually negative but may show a subluxation or loose body.

Early treatment involves bracing and early range of motion. Strengthening should also start within a week - consisting of quadriceps tensing, straight leg raising, and advancing to cycling and closed chain strengthening.

Some catching or a mild sense of grinding is common after any knee injury. Severe or persistent catching, locking or grinding may indicate a damaged joint surface. Further diagnostic tools such as an MRI or arthroscopy may be necessary.

McConnell Taping or knee cap taping may be extremely useful to allow earlier return to aggressive training and earlier return to sport.

Patellar bracing is also very helpful as a protective tool during the first few weeks and during early return to sports.

Multiple dislocations may require surgical stabilization. (Extensor mechanism reconstruction).

ACL tear
Anterior cruciate ligament tears occur with a twist, clip or hyperextension mechanism. The athlete often feels a tear or hears a "pop". The knee usually swells within 4 hours. Sometimes the knee feels better after a few minutes and the athlete attempts to return to play. Often, knee the "gives out" - with great pain. The knee with a isolated ACL injury will begin to feel much better within a week. Linear activities such as walking, cycling, etc. become easy. Accelerated moves:jumping, cutting will cause the knee to give way ( and reinjure). Often the injury involves more than just the ACL. Small fractures or bone bruises of the top surface of the tibia are common. The meniscus or other ligaments are often injured during the initial accident - or in subsequent give way episodes. Risk factors include fatigue and poor strength, a narrow notch (space between femoral condyles), hyperlax joints, knees which hyperextend, and bad luck (most are in this category). The diagnosis is by history and physical exam. Torn ligaments allow too much motion when the knee is stressed. The physical exam can usually determine the magnitude of the injury. X-ray or MRI may be needed - especially for additional injuries to cartilages, other ligaments, and bones.

Early treatment involves icing, wrapping and working towards full flexibility. Difficulty with weight bearing usually indicated other injuries. An isolated ACL may cause very little pain.

Cycling is encouraged as soon as possible. The first sessions are on a stationary bike. The knee should be iced for 10 - 20 minutes prior to exercise. Gentle stretching should follow for 2 - 3 minutes. Next, get onto the cycle and "play" with the petals. The injured knee will often not be capable of completing a revolution. So, start by rocking back and forth. Gradually increase the range until revolutions are possible. This process may take 2 -3 days. Try to maintain a level pelvis while riding. This "warm up" may be required at the beginning of each session for a week. Cycle for 30 min per day . Several shorter sessions may be easier.

Strengthening should be started within a week. Exercises should be " closed chain ". This means that forces should be applied through the foot into the floor or petal. Examples: step ups, leg press, lunges, and calf raises. Quadriceps extensions should be avoided.

Return to vigorous sport requires the ability to run without a limp, and stability. Stability may be a sports brace or surgical reconstruction. The right choice of treatment is base on many factors including overall stability of the knee, associated injuries, age, activity level and motivation. Example : 40 yr old accountant who enjoys cycling and occasional soccer, ACL exam shows only moderate instability. Treatment: closed chain strengthening for 3 - 6 weeks, brace for high velocity sports. Example : 16 yr old female athlete with chronic patellar pain. Treatment: ACL reconstruction with a hamstring graft.

Chronic Problems:

Chronic problems are usually the late result of old trauma or related to abnormal posture or mechanics.

Anterior Knee Pain, Chondromalacia, Arthritis of the Patella
Anterior knee pain refers to pain coming from the patella or surrounding structures - patellar tendon , or quadriceps. Often the patella does not track properly in the groove on the front of the femur. Usually a painful patella drifts to the outer side(lateral) of the knee.   Fluid within the knee(water on the knee), causes the patella to track poorly. A painful patella causes a reflex atrophy in the quadriceps. The quadriceps helps to maintain correct patellar alignment. Thus, chronic pain leads to poor tracking, poor tracking causes chronic pain.

"chronic pain leads to poor tracking,
poor tracking causes chronic pain."

How do you break the cycle? Hold the patella "on track", strengthen the quadriceps, "stroke" the joint surfaces.

Motion clears fluid and "pumps" joint fluid into the joint surfaces (articular cartilage). Examples: Tape the patella into its proper position(McConnell taping) and start non-impact conditioning i.e. cycling, elliptical trainer, stair climber.

Anterior knee pain is common and very treatable. First, let's define terms.

The knee cap or patella is a bone in the front of the knee. The patella connects the quadriceps muscle with the tibia. The quad, patella and patella function together to extend the knee( straighten the knee). Problems with the patella or surrounding structures are referred to as anterior knee pain. (anterior referrer to front side of the knee).

The joint surface of the patella is covered with articular cartilage. This surface is normally very slippery and smooth. If the patella is injured, the joint surface often becomes roughened. This roughening of the cartilage is called chondromalacia - literally "sick cartilage". The patella can easily start to ride "off center" - nearly always toward the outside. This poor alignment is called maltracking . This process is worsened by knock kneed posture, hyperpronating feet, poor muscle tone, high body weight, high impact activity, inadequate shoes, and fluid in the knee (effusions). Maltracking tends to worsen chondromalacia and visa versa.

 

Treatment - based on reducing swelling and inflammation, restoring a normal tracking pattern, and restoring quadriceps tone.

  • Non impact Conditioning
    • Nonimpact conditioning 30 min per day
      • Walking / jogging /treadmill is too stressful for an acute knee injury,
    • Start with a stationary bike. Set the seat high, low resistance. Start by rocking you feet "to and fro". Eventually, work up to spinning.
    • Swimming is another good choice. Swim laps, walk or "run" in chest high water. Avoid breast stroke or whip kicking at first.
  • Anti-inflammatory Medication
    • Ibuprophen Take 3 with food three times a day
    • Aleve Take two with food twice a day.
    • Prescription Medication- see your MD
    • Anti-inflammatory medication reduces pain and swelling. These medicines are all quite similar. Use the one with a cost and dosage schedule that suits you.
    • Avoid these medications if you have a history of stomach problems or ulcers, kidney problems, allergy to aspirin, or take the medication coumadin.
  • Return to High Velocity Sport
    • Run full speed without a limp
    • Don't compromise this one!
  • McConnell Taping
    • Physical therapy for a home program.
    • McConnell taping is a biofeedback technique. The tape pulls the knee cap inward - helping to reestablish normal tracking. Normally, taping will cause in immediate improvement. The program involves taping every day, prior to 30 minutes of nonimpact exercise.
  • Arch Supports
    • Off-the-shelve arch supports
    • Spencoe
    • Superfeet - available at R.E.I. - find the style and arch height that fits you best. (approximately $28.)
  • Weight Loss
    If appropriate - usual goal 10% Good shoes   Must absorb impact - no thin soles, no high or wooden heals   "air" soles, crepe, rubber Examples: athletic cross trainers Dress: Easyspirit, Rockport, Bass  
  • Glucosamine Sulfate
    1500 mg per day Builds joint lubrication.
  • Custom molded arch supports
    Gait analysis and orthotic fabrication
    Designed to "center" biomechanic forces and reduce pronation 80 % of patients with knee pain respond.
  • Hyaluronic Acid Injections
    Series of three weekly injections Hyaluronic acid is a natural lubricant within joints. Injections help arthritic surfaces to glide more smoothly. Studies suggest that 80% of patient will experience reduced pain for 6 months.

Arthritis
Others start slowly and progressively worsen. Risk factors include ligament injury, high body weight, a hyperpronating foot(flat foot), deep squatting or kneeling, "bow legged" or "knock kneed" posture.

 

Surgical Treatment

ACL reconstruction involves replacing the torn ligament with another tissue - a graft. The graft may be taken from the patellar tendon, hamstring tendon or a cadaver (allograft). Each method has advantages a disadvantages. Surgery is performed Arthroscopic ally, as a outpatient. Crutch walking is required for about 3 weeks.

Return to sedentary work takes about a week. Moderate activities - i.e. stand , walk all day 4 - 8 weeks. Return to full velocity sports takes 5 months. [ Post op instructions and rehabilitation ]

Arthroscopic Debridement
Outpatient procedure, approximately 1 hr, no crutches, ice and rest for 2 days, then progressive rehabilitation. Debridement smoothes the joint surface - relieves pain and "grinding" - allows rehabilitation.

Biologic Resurfacing
Outpatient procedure, approximately 1 hr,crutches or brace for one month, early swim / cycle Several techniques, all stimulate new cartilage to form in region of damage or disease.

Arthroscopic Lateral Release
Outpatient procedure, approximately 1 hr,crutches or brace for 10 days, early swim / cycle Ideal for knees with tight lateral ligaments, lateral side pain - and otherwise normal alignment

Extensor Mechanism Realignment
Outpatient procedure, approximately 1 hr,crutches or brace for 10 days, early swim / cycle Ideal for knees with significant lateral patella alignment / forces.