FAQ Category: Knee

Knee injuries so severe that there is dislocation, fracture, and/or multiple ligaments ruptured require careful consideration when planning treatment. The surgeon must quickly but thoroughly assess the extent of damage to the bones, soft tissues, nerves, and blood vessels in the leg. Knee dislocations are notorious for causing nerve injury even when the patella (knee cap) automatically reduces (goes back into place).

Tools used to conduct the evaluation begin with visual inspection (e.g., location of the injuries, signs of blood loss) and include testing for blood supply (e.g., Doppler, CT angiography, ultrasound). The presence of any damage to blood vessels or loss of blood supply to the area means a vascular surgeon must scrub up along with the orthopedic surgeon to perform the necessary procedures.

Before surgery can be done, X-rays and MRIs are taken to identify the extent of ligament injury (location and severity). This information helps the surgeon plan what must be done in the operating room. A plastic surgeon may be needed if there has been so much soft tissue damage that the wound can’t be closed without a graft. Sometimes there are torn or ruptured ligaments that get put on the back burner (repaired later) because of the need to restore blood supply and save the leg first.

Most complex injuries with fracture, dislocation, and/or ligament rupture of the knee require staged procedures. That means everything that needs to be done can’t be completed in one day or during one operation. They try and treat any fractures or dislocations the first day. Blood supply is restored and stabilized.

Reconstruction of soft-tissue injuries may be delayed for up to one week before the next stage of treatment can begin. Ligament reconstruction (phase three) takes place three to four weeks later. There may even be a stage or phase four if the knee is still unstable and further reconstruction is needed.

Now that we have technology like magnetic resonance imaging (MRI), we know that bones can be bruised. What does it look like on the MRI? MRIs are made of signals that show up as an image on the computer screen. The signals have various levels of intensity from light to dark. Changes in the signal pattern alert the radiologist to any problems.

In the case of bone bruises, blood pooling, fluid build up (swelling), and increased blood flow to the area show up on the MRI. Water that moves seen within the bone marrow (center of the bone) is another sign of bone bruising. If the injury is severe enough, there can even be tiny fracture lines in the bone referred to as microfractures.

Bone bruises of the knee from trauma in athletes affect the subchondral bone. This is the first layer of bone underneath the cartilage of the knee. The most common injury associated with bone bruising is a rupture of the anterior cruciate ligament (ACL). In fact, 80 per cent of all patients who suffer an ACL rupture also have evidence of bone bruising on MRIs.

Repeat MRIs show that the bruising goes away over time (usually within 60 days). Studies done so far don’t show any problem with returning to normal function after a bone bruise. Most athletes are back on the field within six months’ time.

The real question on everyone’s minds is whether or not the bruising will result in arthritis later. We simply don’t know yet. Long-term research is needed to follow athletes with bone bruising over a period of years to determine what happens and just how significant these injuries can be.

Knee pain is a common problem among the young and old alike. From athletes to middle-aged adults to seniors, knee pain can develop suddenly. There are many potential causes owing to the fact that there can be ligament involvement, cartilage tears, muscle strains, cysts, arthritis, and more.

Most of the time, knee pain is felt in the front of the knee or along either side. Posteromedial pain (inside back corner) like what you are describing is less common and more puzzling.

One possibility for the symptoms you describe is a condition called semimembranosus tendinopathy. The semimembranosus muscle is part of what you might know otherwise as the hamstring muscle. It is made up of three separate but conjoined parts. This portion starts at the base of your “sit bone” (called the ischial tuberosity).

It travels down from the pelvis to the knee and inserts right along the posteromedial corner. The job of the semimembranosus is to flex or bend the knee. You may be feeling this tendon. It is palpable when you touch under the back of the knee on the side closest to the other knee while in the sitting position.

When musculoskeletal problems of any kind develop, it’s always a good idea to have an expert (your physician, a physical therapist, or other health professional) take a look and advise you. This can save you time, pain, and money in the long run.

It’s often the case that the longer we put something off, the more complicated it becomes. Other areas of the knee get involved and instead of one problem, we end up with a combination of difficulties.

It might help you understand what is happening if we review the anatomy of the meniscus (menisci for more than one). In each knee, the menisci sit between the femur (upper leg bone) and the tibia (lower leg bone). These structures are sometimes referred to as the cartilage of the knee, but the menisci differ from the articular cartilage that covers the surface of the joint.

The menisci of the knee are important for two reasons: (1) they work like a gasket to spread the force from the weight of the body over a larger area, and (2) they help the ligaments stabilize (hold) the knee.

Imagine the knee as a ball resting on a flat plate. The ball is the end of the thighbone as it enters the joint, and the plate is the top of the shinbone. The menisci actually wrap around the round end of the upper bone to fill the space between it and the flat shinbone. The menisci act like a gasket, helping to distribute the weight from the femur to the tibia.

The dynamic loading pattern differs from person to person due to alignment and surface structure (how curved the meniscus and joint surface are and how well they match up).
As we get older, the menisci can get pretty beat up. They start to dry out and stiffen up. This effect can alter the match up even more.

Degenerative changes within the joint such as bone spurs, thinning of the articular cartilage, frayed edges of the menisci change the way load and force are transmitted through the knee. If there are any alignment issues causing uneven wear on the joint, then these problems are amplified.

So it can look like an older adult spontaneously tears the meniscus without any injury at all, when in fact, these changes have been developing over a period of many years. For some people like your aunt, the simple act of walking was enough to create the injury. For others, an equally minor trauma (stepping off a curb, walking up stairs) might be the precipitating factor. Really, those events are just the final straw for a body part that was ready to go anyway.

There’s a lot of confusion right now about the best treatment for tears of the knee meniscus. For sure, we know that removing this C-shaped cartilage in the knee is a bad idea. That just leads to degeneration of the joint and painful arthritis. Repairing the damage and letting the body heal has proven to be a much better alternative.

But even with a partial meniscectomy (removing the ragged edges) and/or repair (stitching the rest back in place), there are still a fair number of patients who do better than others. Or to turn that around, there’s quite a few patients who don’t do as well as others.

The natural question is why not? What gives some patients good outcomes while others still end up with knee arthritis? Reports from various studies are all over the place on this one. And what about exercise instead of surgery? You ask a very good question.

There aren’t very many studies comparing surgery against exercise without surgery as two separate treatment approaches. There is one study that was included in a recent systematic review of outcomes after meniscectomy. The researchers only looked at patients with degenerative meniscal tears. That research method is good but it leaves out a lot of other types of patients with meniscal injuries.

In the study, one group had surgery with exercise afterwards. The other group just did the exercises. The results (measured in terms of activity level, pain, and motion) were the same between the two groups. Follow-up was limited to six months so there’s no report on the long-term results.

Obesity defined as a body mass index of 30 or more was an independent risk factor for both osteoarthritis of the knees and poor outcomes after meniscal surgery. That means being overweight puts people at risk for both knee arthritis (with or without a meniscectomy) and poor function after meniscectomy. We bring that up because in addition to trying exercise, weight loss (if needed) might be helpful, too.

You should really talk with your orthopedic surgeon about your choices. Treatment options may depend on your age, level of activity, gender (male vs. female), and type/severity of your meniscal tear.

Bone bruising can occur with both contact and noncontact activities.

Bone bruises of the knee in athletes affect the subchondral bone. This is the first layer of bone underneath the cartilage of the knee. The most common injury associated with bone bruising is a rupture of the anterior cruciate ligament (ACL).

You’ve probably heard of ACL injuries. The ACL is one of two ligaments that criss-cross each other inside the knee. An injury severe enough to pull the ligament off the bone where it attaches can also cause bone bruising. In fact, 80 per cent of all patients who suffer an ACL rupture also have evidence of bone bruising on MRIs.

Without the ACL to hold the tibia (lower leg bone) from sliding too far under the femur (thigh bone) the impact of the injury, the loss of the ligament, and the movement of bone-on-bone leaves the site of the rupture bruised. In fact, there’s even a telltale sign on the bone called the footprint that shows where the impact left the bruise.

Studies have shown that the severity of bone bruising is a direct result of the energy of the injury. Contact injuries (the athlete is hit by another player or falls and makes contact with the ground) have more energy behind them than noncontact injuries (the foot is planted on the ground and the player makes a sudden change in direction).

It’s possible that you sustained a noncontact injury. Sudden shifts in direction as just described is the most likely mechanism. You may not have collided with another player but it is possible that you fell on your knee at some point during practice or play and sustained a bone bruise.

Hyperextension injuries of the knee or overload along the side of the knee are other ways bone bruising can occur. You may not be able to discover (or remember) the exact event that led to this injury. MRIs and other imaging studies will help detect other associated injuries that might be present. These injuries may help explain what happened.

Patellofemoral Syndrome (PFS) is a condition that causes pain in and around the patella (knee cap). In the normal, healthy adult, the patella moves smoothly up and down over a groove on the femur (thigh bone) as the knee bends and straightens. PFS can develop when the patella is not moving or tracking properly over the femur. This is a common knee problem in teens and young adults (especially runners and athletes) but anyone can be affected.

Being overweight does increase the risk of developing early knee arthritis. New information from research has revealed that fat called adipose is actually an active hormone. Adipose is as powerful as any of the other chemical in the body. It has the ability to speed up the loss of cartilage cells as we age. This happens even in people who don’t have arthritis yet.

One of the possible treatments for patellofemoral pain syndrome is taping. A physical therapist examines the knee and devises the best way to tape the patella (knee cap) in place. The goal is to hold the knee cap in the middle of the knee so that it tracks (moves) up and down where it is supposed to be. Your ablity to avoid early arthritis and chances of being able to benefit from this noninvasive treatment are better if you are at a lower body mass index (BMI).

Patellofemoral Syndrome (PFS) is a condition that causes pain in and around the patella (knee cap). In the normal, healthy adult, the patella moves smoothly up and down over a groove on the femur (thigh bone) as the knee bends and straightens. PFS can develop when the patella is not moving or tracking properly over the femur. This is a common knee problem in teens and young adults (especially runners and athletes) but anyone can be affected.

Patellofemoral syndrome (PFPS) is a complex condition that may not have one singular cause. It is likely that there is more than one cause and possibly more than one factor present at a time. There are some anatomical considerations. Studies have shown that there is an increased risk of developing PFPS when abnormal patellar tracking and abnormal muscle activation are present.

Several important angles (Q-angle,lateral patellofemoral angle, lateral patellar dispacement) present in the knee must be considered. These three angles help describe the tilt of the patella, position of the patella, and amount of lateral displacement (placement off to the outside of the patellar track). You may have one or more of these anatomic variations present and contributing to your symptoms. Sometimes specific exercises prescribed by a physical therapist or the use of taping around the knee cap help realign the knee and reduce or even eliminate pain.

A new study from the Mayo Clinic Sports Medicine Center in Rochester, Minnesota adds a short list of specific patient characteristics that suggest taping can help. Those three factors include: lower body mass index (BMI), smaller lateral patellofemoral angle, and larger Q-angle.

Don’t spend any time wondering what you are doing wrong. Get an evaluation from an orthopedic surgeon or sports medicine physician or physical therapist. Once any risk factors are identified, you can begin a program to modify posture and alignment while improving knee strength and motion. This should help you take care of this problem as much as is possible and maintain pain free participation in all sports of your choice.

The two surgical techniques used to reconstruct a ruptured anterior cruicate ligament are: 1)bone-patellar tendon-bone (BPTB) graft and 2) hamstring graft. In each case, the surgeon harvests a piece of the tendon and uses it to create a replacement for the damaged ligament.

Both of these procedures have advantages and disadvantages. To say one approach is better than the other has been difficult. Many studies have been done to compare them. It’s clear that taking a tendon graft from the front of the knee (bone-patellar tendon-bone) makes kneeling painful and sometimes even impossible. Some patients also report numbness or loss of sensitivity at the graft site. Knee pain and difficulty kneeling isn’t a problem when using the hamstring graft. Instead, stiffness and decreased stability may develop.

There are many ways to measure the results of surgery for a torn anterior cruciate ligament (ACL). Pain, stability of the knee, and range-of-motion are commonly used. In a recent study, quality of life (QOL) was the main measure used to assess outcomes. And for the first time, the two main repair methods are compared using quality of life as the primary measure of results.

Quality of life looks at how the patients view the results. Would they rate their outcomes as poor, fair, good, or excellent? Would they have the same surgery done if they had to do it all over?

The unique feature of this study is the fact that all patients (a total of 148) were randomly divided into two groups. One group had the bone-patellar tendon-bone graft. The other had the hamstring graft. Everyone was followed and tested periodically for at least eight years. That length of time is considered long-term. All other published studies have been short-term.

Here’s what they found after gathering all the data and analyzing the difficulty between the two groups. First, there were equal results when comparing knee joint stability and knee function. Stability refers to how stiff versus how loose the joint is when force or load is applied. The stiffer the knee, the more stable it is. Looseness called joint laxity is a sign of an unstable joint. Knee function was defined as a combination of daily activities and sports or recreational activities. Health-related quality of life reflected things like level of pain or other symptoms and how those symptoms affected emotional and mental health.

Second, early reconstructions (within five months of injury) had better results in both groups. This finding was true no matter which type of graft was used. Third, those patients who had a damaged meniscus along with the anterior cruciate ligament injury were more likely to have problems later on. They developed osteoarthritis of the knee and were less likely to continue participating in sports or recreational activities.

And finally, the majority of patients (94 percent) were satisfied and said they had no regrets after their surgery. The bone-patellar tendon-bone group did report knee pain and difficulty kneeling more often than the high school group.

The reported results of this study don’t end the debate of which technique is best for anterior cruciate ligament reconstruction. But the added information that patient quality of life and satisfaction in the long run are the same between these two repair techniques gives patients and surgeons additional information to consider when choosing one approach over the other.

From this one study it looks like a more important factor in final outcomes is the timing of the surgery. Earlier is better and yields improved results. Patients can be assured that no matter which technique is used, the results will be favorable and satisfaction is likely. For patients who want to avoid the possibility of knee pain with kneeling, the hamstring graft may be the best way to go.

The PLC is in the knee where two ligaments and one tendon meet. Posterior refers to the back side of the knee joint. Lateral tells us the affected area is to the side. So we are talking about the posterolateral (side of the knee toward the back) area where the lateral collateral ligament, popliteofibular ligament (PFL), and the tendon of the popliteus muscle all meet.

These soft tissue structures at the posterolateral corner help keep the tibia (shin bone) from sliding backwards under the femur (thigh bone). When the posterolateral corner is injured, knee instability can develop. Injuries in this area occur most often as a result of a car accident, during sports play, or from a work injury.

Return to work (especially if it involves manual labor) and/or return to sports (competitive or recreational) is possible with adequate treatment. Surgery to reconstruct the posterolateral corner is the usual treatment. The technique used varies from surgeon to surgeon and no one method has proven to be the best.

Damage to the soft tissue structures that make up the posterolateral corner can mean the tibia (lower leg bone) slides and shifts too far from side-to-side and front-to-back. The goal of treatment is to restore the natural alignment and stability of the knee. Many patients are able to get back to full sports participation. Be sure and let your surgeon know of your personal sports goals and plans. Treatment (including rehab) may vary slightly given this information.

The posterolateral corner (PLC) of the knee designates a group of ligaments and muscles along the back and outside edge of the knee joint. These include the lateral head of the gastrocnemius (calf) muscle, the popliteus (muscle), and three specific ligaments.

Damage to this corner of the joint is rare but can occur with traumatic injury from a sports-related accident, car accident, or fall. An isolated injury to the posterolateral corner can occur. But usually it’s linked with trauma to some other part of the knee — most often the meniscus or the cruciate ligaments that criss-cross inside the knee.

A person with a weak posterolateral corner will experience hyperextension of the knee when walking or going up and down stairs. Hyperextension means the knee goes back past a straight (extended) position because the mechanism that holds it in neutral is torn or damaged in some way. Every time you take a step, the knee pushes back farther than it should. The natural response to this awkward problem is to walk with the knee slightly bent and t avoid full extension.

Walking with the knee bent is a functional solution (it works), but it’s not a very good long-term solution. You can try a rehab program to strengthen the muscles around the knee. Surgery may be needed to fix the problem. Without surgery, an unstable knee joint remains at risk for further injuries (and subsequent damage). Early joint degeneration and subsequent osteoarthritis may develop as a result of the uneven forces and load placed on the joint.

Your surgeon can give you a better idea of what to expect based on the extent of damage present and the condition of the surrounding soft tissues. Your own personal goals for level of activity (e.g., exercise, sports or other recreational activities) can make a difference, too.

Over the years, it has been discovered that removing the meniscus entirely is not a good idea. Too many people developed early osteoarthritis after a meniscectomy. So, the standard procedure has gradually changed from complete removal to repair of the torn meniscus whenever possible. And when it has to be removed, as little as possible is taken out whenever possible.

The meniscus is a C-shaped piece of thick cartilage in the knee. It has several main functions. One is to provide optimal weight-bearing through the knee. Another purpose is to absorb shock. The meniscus also helps stabilize the joint and help the joint slide and glide smoothly during movement.

There are two menisci: one on each side of the knee. Most often, the medial meniscus (side closest to the other knee) is damaged when athletes and sports players plant the foot on the ground and rotate or pivot the leg to change directions suddenly.

Studies show that the success rate for the arthroscopic repair of meniscal tears ranges from a low of 64 per cent to a high of 97 per cent. Why the extreme ranges? There is evidence to suggest the location of the tear is a big factor.

For example, patients with a full (all the way through the full thickness of the meniscus) but small (less than one centimeter long) tear are good candidates for a repair procedure. Partial removal (meniscectomy) is more likely when the rupture is located where the blood supply is poor or when the tear is too large to repair.

Compared with even 10 years ago, today there are newer and better surgical instruments that have helped improve the chances of reaching and repairing meniscal tears. Patients
aren’t negatively impacted by how long they wait to have surgery or the type of sutures used to repair the damage as much as they are affected by the location of the rupture.

Your post-operative rehab program may depend on several things. First, the extent of surgery is a deciding factor. Repairing the meniscus is different from removing it. Second, each surgeon has his or her own preferences and protocols. As much as possible, rehab is based on the evidence gleaned from studies about what works for each type of tear and type of surgery (repair versus removal).

The type of surgery that is done is usually determined by the type of rupture. Tears that go all the way through the full thickness of the meniscus but are small (less than one centimeter long) can often be repaired. Ruptures located where the blood supply is poor or when the tear is too large to repair can be partially removed and the edges shaved down to smooth them out.

Patients having either procedure often end up in a rehab program after surgery. The specific protocol used can depend on whether the procedure was a repair or a partial meniscectomy. For example, the repair group may be more limited in the amount of knee motion that is allowed compared to the meniscectomy group.

There is a need to protect the healing repair site. For this reason, a brace to protect and limit knee motion is more likely for the patients who have the repair done. Patients having a partial meniscectomy have physical therapy right away. Exercises can be started without any bracing after partial meniscectomy.

Sports activities are allowed four weeks after a partial meniscectomy. The therapist guides the patient through weight-bearing activities that are modified according to the patient’s pain levels.

Starting similar activities may not be allowed in the repair group until at least six weeks after surgery. Some surgeons limit the patient’s ability to put weight on the leg for the first four weeks unless the knee is in full extension (completely straight).

During this time, the therapist moves the knee through passive motion (without the patient’s help moving the joint). Isometric muscle contractions are allowed with the foot in contact with the floor.

More motion and activity are allowed during weeks five and six until the patient is able to return to full function during daily activities. Sports specific exercises are introduced at that time and gradually advanced until the patient can return to his or her full preinjury level of sports participation.

Older age can make a difference in outcomes after anterior cruciate ligament (ACL) repair or reconstruction. Graft rupture, increased stiffness, and decreased activity level are reported more often in older groups. But it’s not always clear whether this is a result of age following ACL surgery or a natural response to aging.

Many people decrease their participation in sports and recreational activities as they get older. For those who remain active, the frequency, level of intensity, and endurance (duration engaged in the activity) declines over time.

Some studies have shown that waiting more than five months between injury and repair can have a negative effect on results. But whether older age contributes to this result is not always clear.

Most surgeons recommend conservative (nonoperative) care at first for patients who aren’t athletes and who don’t plan on running marathons. With strength training, the muscles around the knee can support and stabilize the joint in the absence of an intact ACL.

Your surgeon is really the best one to advise you on an optimal management plan. Age, activity level, general health, strength, and your personal goals are all taken into consideration when planning your surgery and the timing of that procedure.

There is still quite a bit of controversy and debate over the way to do total knee replacements. Does a smaller incision and less invasive approach really make a positive difference? There are studies reporting benefits of minimally invasive over traditional and others showing no differences between the two.

Some studies have shown that the benefit with minimally invasive total knee replacement is early on in the post-op period. Patients report less pain, faster recovery of knee motion, and shorter stay in the hospital. But there are other studies that fail to show any benefit (early or late) of the minimally invasive technique compared to the conventional (full incision) approach.

Scars range in length for the minimally invasive approach from about four and a half inches up to five and a half inches. The scar used with a traditional open approach is more like seven to eight inches.

Sometimes a minimally invasive approach ends up being a conventional approach. This can happen when the surgeon sees it is necessary to make a longer incision to get to the knee joint. It may be that getting the implant situated in the joint with perfect alignment requires a larger incision. In some cases, there is so much soft tissue around the knee that a minimally invasive incision just won’t be enough to get to the joint.

Anyone thinking about having a knee replacement may be wondering whether to stick with the standard surgical procedure or go for the minimally invasive technique. That may surprise you since it would make sense that a smaller incision would be better.

With a minimally invasive approach, there’s less disruption of the surrounding soft tissues and less blood loss. But studies have reported in both directions: minimally invasive is better/minimally invasive is not better.

Some studies have shown that there is a benefit with minimally invasive total knee replacement early on in the post-op period. Patients report less pain, faster recovery of knee motion, and shorter stay in the hospital. But there are other studies that fail to show any benefit of the minimally invasive technique compared to the conventional (full incision) approach (early or later on).

Does it just boil down to cosmetics then with a smaller incision? Minimally invasive techniques require additional training on the part of the surgeon. Implant alignment can be a problem for less experienced surgeons. Does the improved external looks outweigh the risk of improper alignment

These are all questions surgeons are searching for answers. More studies are needed before a final recommendation can be made.

Patients with malalignment of the knee that leads to arthritis face some unique challenges. The alignment problems usually mean one side of the knee wears out faster than the other. They can’t just have a knee replacement — or even a unicompartmental procedure. Unicompartmental means just the side that’s arthritic is replaced.

And why not? Because the cause of the arthritis is the way the bones fit together to form the knee. In most cases, there is too much pressure on the medial compartment (that’s the side of the knee closest to the other knee). Replacing the joint (or the medial half of the joint) doesn’t change the alignment issues. That’s where a procedure called tibial osteotomy comes in handy.

In this operation, the surgeon removes a wedge- or pie-shaped piece of bone from one side of the tibia/i (lower leg bone). The purpose of the osteotomy is to correct the malalignment and take pressure off the medial compartment.

Research results do show very favorable responses to osteotomy as a treatment for unicompartmental arthritis from malalignment problems. On average, at least 90 per cent of the patients from all studies report good results.

Some studies have a 97 per cent success rate in the first five years. Their pain is reduced or relieved and their function is improved. They are able to remain active and delay the need for joint replacement by at least five to seven years.

For the type of problem you have, it may be best to consult with an orthopedic surgeon. The exact cause of your knee problems should be diagnosed first before making your decision based on information found on-line.

Patients often have individual factors that can influence treatment decisions. An orthopedic surgeon will assess all aspects of your situation and advise you. The information you have gained from your Internet searches will help you ask the right questions and aid you in making the best decision.

Many people develop unicompartmental arthritis (i.e., arthritis that only affects one side of the joint). Usually the medial compartment (sie closest to the other knee) is damaged but some patients do experience lateral unicompartmental arthritis (side away from the other knee).

In either case, joint replacement is an option as you discovered. But, depending on certain factors, there are some other potential options. For example, unicompartmental arthroplasty can be done. In this procedure, just the side of the joint that is painful, damaged, and arthritic is replaced. Of course, this is a type of joint replacement and you may not want that.

Another possibility is a procedure called an osteotomy. In this operation, the surgeon removes a wedge- or pie-shaped piece of bone from one side of the tibia/i (lower leg bone). The purpose of the osteotomy is to correct the malalignment and take pressure off the medial compartment. There are two ways to do this surgery. Both remove bone from the upper tibia near the knee. The medical term for this type of osteotomy is high tibial osteotomy (HTO).

The first way to do the high tibial osteotomy is called a medial opening wedge tibial osteotomy. Bone is removed from the medial side of the tibia, shifting the weight off the medial compartment and more toward the midline. The two edges of remaining bone are held open with a metal plate or special device called a fixator.

The second method is a lateral closing wedge osteotomy. In this type of osteotomy, bone is taken from the lateral side of the tibia (side away from the other knee). The two edges of the bone are then allowed to shift closer together. The effect is the same as the opening wedge osteotomy: to take pressure off the damaged medial compartment.

Osteotomy is offered to patients who have malalignment of the joint contributing to the arthritic problem in the first place. Replacing the painful, arthritic joint without balancing the weight-bearing load will just result in the same problem later.

Conservative care for the early stages of osteoarthritis does indeed include exercise. Before beginning a program of increased activity and exercise, efforts are made to reduce the pain and inflammation. Antiinflammatory drugs are used when painful knee symptoms first start. Once the symptoms are under control, then an exercise program is more manageable.

As your physician has mentioned, many high-quality studies have confirmed that exercise is helpful in reducing pain and improving function. Muscle strengthening is especially helpful in reducing pain. So even before your pain is completely gone, exercise can begin.

Aerobic exercise contributes to long-term improvements in function. Of course, these programs only work if the patient does them consistently. Once the exercises are stopped, the pain returns and the patient loses ground quickly.

The management of knee osteoarthritis often includes other tools to help enhance correct alignment and restore function so that exercise is possible. Knee braces can be helpful for some people. Former athletes who have hurt themselves while in action and who want to remain active may benefit from a knee brace.

Patients who benefit the most from knee bracing have arthritis on one side
of the joint (unicompartmental arthritis) and don’t want (or are too young for) a knee replacement. Bracing helps redistribute the weight and load placed on the joint so that it isn’t all on one side. This type of biomechanical unloading doesn’t work forever but it can delay the need for surgery while still allowing activity.

There are some studies that support the use of foot orthoses (inserts placed in the shoe to correct leg alignment) for patients with medial compartment arthritis. The medial compartment is the side of the knee joint closest to the other knee. Uneven wear on the joint is caused by misalignment of the bones. Placing a specially designed wedge inside the shoe helps shift the foot and realign the knee. The result is to redistribute weight evenly across the entire joint and unload the medial side of the joint.

Knee movement, especially repetitive motion that is part of your preferred activity is made easier by some of these other tools. If you are trying to exercise but are stopped by your pain, go back to your physician to get better pain control. Then exercise will be easier to incorporate into your daily life.

Many younger or more active patients faced with a knee joint replacement have it in mind that they will be able to rejoin the world and get active again. It sounds like you may fall into this group.

Returning to normal activity and sports participation may be more likely after a unicompartmental knee replacement (just one side of the joint is replaced) compared with a total knee replacement. Some activities are not advised at all after a total knee replacement, whereas other activities can be a routine part of patients’ lives with experience.

For example, there are no restrictions on activities like walking, low-impact aerobics, golf, bowling, swimming, horseback riding, and dancing. Rock climbing, soccer, singles tennis, football, gymnastics, jogging, handball, racquetball, and handball are on the no-no list.

Activities that fall in between must be done with common sense and experience. The questionable activities include road cycling, hiking, cross-country skiing, speed walking, ice skating, and weight machines.

Your surgeon is the best one to advise you on this decision. Your age, overall general health, bone condition and personal goals are all part of the factors that will determine your current and future management plan. The idea is to provide pain relief and improved function while protecting the new joint (implant) for as long as possible.