FAQ Category: Knee

Despite more than 30 years of anterior cruciate ligament (ACL) repairs, therapists still haven’t nailed down the best way to go about rehabilitating this injury. Traditional strength training programs have used resistive exercises to help patients regain motion, strength, and function.

But studies showed that there was something missing. Knee stability isn’t always fine-tuned enough with this approach to get athletes back into action safely and without worry that the knee is going to give way underneath them.

So, a new approach was developed called neuromuscular exercise. This approach helps retrain the joint and all of the sensory and motor mechanisms needed to make sudden starts and stops and quick turns without buckling or otherwise slowing the athlete down.

You may be seeing the difference between these two types of programs. Some therapists are shifting from the traditional strength training more toward the neuromuscular approach. But there’s some evidence that perhaps each of these treatment protocols contributes positive benefits to athletes post-ACL reconstruction.

It appears that the neuromuscular program has the most benefit in the first year after surgery. Patients receiving therapy with this emphasis have better overall knee function and less pain compared with the strength-training exercise. The strength-training program is more effective in improving knee flexion muscle strength after two years. It really looks like both exercise approaches contribute something a little different at different times in the recovery process. It may be that both should be used together for the best total results.

Mention your observations and questions to your therapist. It’s possible the other patients you are seeing have a slightly different diagnosis than you do, which could explain the differences in treatment approaches. Or there may be some other explanation. There’s never anything wrong with letting your therapist know your interest in progressing ahead as quickly as possible. You may or may not be a candidate for the other treatment approach — the only way you’ll find out is to ask!

This type of knee replacement is designed to replace only the portions of the joint that are most damaged by arthritis. The operation is less invasive than a full knee replacement. There are significant advantages, especially in younger patients who may need to have a second artificial knee replacement as the first one begins to wear out. Removing less bone during the initial operation makes it much easier to perform a revision artificial knee replacement later in life.

Studies have shown that many patients experience continued muscle weakness after unilateral knee replacement. The reasons for this aren’t entirely clear. The incision, cutting through muscles, and surgical trauma may contribute to loss of muscle power. Loss of muscle bulk (called atrophy) from favoring that leg before surgery may also be a factor. Anytime there’s muscle weakness with loss of muscle power, there’s a decrease in muscle coordination. You need both strength and coordination to recover from a stumble or sudden loss of balance.

If you aren’t having any other symptoms, you may benefit from an exercise program designed to regain strength, coordination, and balance. The first step may be to check back with your surgeon. If all looks good with the implant, then a physical therapist may be the best one to help you out with this problem. A specific program of exercise focused on the problem areas may be all you need. With a few sessions, you may be well on your way to having solved the problem (and preventing future problems from falls and injuries from falls).

Perhaps, but probably not without a little help. Studies show that a loss of muscle strength and power are typical after unilateral knee replacement (UKR). UKR refers to the placement of an implant on one side of the knee (either medial on the inside half of the joint closest to the other knee or lateral on the outside of the joint). Walking speed, recovery from falls, and stairs can all be affected by persistent muscle weakness after this procedure.

The loss of muscle power affects muscles on both sides of the leg (front and back/extensors and flexors). It’s possible for the nonoperated (stronger) leg to compensate for the operated (weaker) leg when walking but it takes more muscle power than that for stairs. Stairs require the use of both sets of muscles and in both legs at the same time (the supporting leg and the moving leg).

It’s good that you haven’t just accepted this as the way it must be — you can improve your strength and get a normal stair-step pattern back. And it’s a good idea to address the problem now before it becomes even more long-term. All evidence to date suggests that your loss of strength won’t go away on its own — even after waiting months to years. You may need to consult with a physical therapist who can identify which muscles are affected and prescribe the right exercises to help with full recovery. Until you get your complete motor recovery, you will be at an increased risk of falls and injuries from falls.

Microfracture repair of defects (holes) in the joint surface has become a popular way to treat significant damage to the articular cartilage of the knee. The procedure involves several steps. First, the surgeon removes any ragged edges along the tear. This is called debridement. Then the layer of calcified (hard) cartilage is removed to expose the subchondral bone. Subchondral just means the bone is right below the articular cartilage — like subflooring in a house. Next, the surgeon takes a special tool and forms tiny holes (microfracture) in the subchondral surface.

Microfracture works by stimulating a bleeding and healing response. Blood from inside the bone marrow seeps up through the holes and fills the hole or defect in the cartilage with a clot. The articular cartilage doesn’t have much of its own blood supply or an ability to heal itself. That’s why the surgeon tries to help it along with techniques like microfracture. There are other methods used to stimulate healing but microfracture has become popular with good short-term results.

Results can be measured in a wide range of ways. For the patient, improvement in symptoms such as decreased pain and swelling and improved function are usually important. Some patients may refer to their level of athletic activity and ability to perform strenuous work as the primary measures of results.

There are some well-known testing tools that the surgeon and/or physical therapist might use to compare knee function from before surgery to after surgery. For example, there is the well-known Western Ontario and McMaster Universities (WOMAC) index, the Cincinnati knee score and the Tegner activity scale. Other testing measures often used include the Baumgaertner score, Japanese Orthopaedic Association knee score, and the Knee injury and osteoarthritis outcome score (KOOS). In fact, there are more than a dozen different scales that can be used to measure knee function. The key is to choose one that most closely reflects the type of results you want and use it consistently over time to assess outcomes.

The surgeon may use MRIs or even a second-look arthroscopic exam to measure the fill in volume. This is a visual means of looking at the surgical site and seeing how well the defect has filled in and smoothed over. The need for further surgery is another measure surgeons use to indicate a failed response to microfracture treatment.

Without these methods of viewing the healing site, studies show that functional improvement is actually a good indication of how well the defect has filled in. The better the patient function, the more likely a good fill in grade has occurred. So long as nothing disturbs the clot that forms with this treatment, you can expect to have good quality of repair cartilage and a successful result.

The American Academy of Orthopedic Surgeons (AAOS) recently published Clinical Practice Guidelines for the nonoperative treatment of knee osteoarthritis. Guidelines like this help all health care professionals treating patients with knee arthritis using noninvasive approaches. Patient education, self-management techniques, physical therapy, and exercise are just a few ways this problem can be approached conservatively.

The 22 guidelines offered are based on an extensive review of published studies on this topic. A panel of 16 orthopedic surgeons, physical therapists, athletic trainers, sports specialists, and research analysts conducted the review of publications. The goal is to help health care practitioners guide patients in finding ways to treat knee arthritis short of having the joint replaced.

These guidelines are recommendations only. Each patient must be evaluated by his or her own physician. Your past history, current symptoms, past treatment and treatment results, and any important individual patient factors will be taken into consideration when planning the best treatment program for you.

Here’s what the JAAOS recommends (based on current evidence) for those adults have knee osteoarthritis:

The meniscus is a commonly injured structure in the knee. The injury can occur in any age group. In younger people, the meniscus is fairly tough and rubbery, and tears usually occur as a result of a forceful twisting injury. The meniscus grows weaker with age, and meniscal tears can occur in aging adults as the result of fairly minor injuries, even from the up-and-down motion of squatting.

Women seem to be affected more often than men. About one-third of all meniscal tears actually occur when other damage is sustained by the knee (e.g., fractures, anterior cruciate ligament (ACL) tears). But without a significant injury, older adults can indeed find themselves limping along with no idea why their knee hurts.

Sometimes there is a popping or catching sensation or the knee locks up, gives way, or buckles underneath the person. There may be tenderness along the joint line with or without swelling. It isn’t until the surgeon reviews the X-rays and MRIs that a final diagnosis is made. Those imaging studies can tell the surgeon a lot about how this happened.

X-rays show any fractures or loose fragments in the joint. X-rays also help the physician see what kind of shape the joint is in, how much degeneration has occurred, and any signs that the joint is thinning. MRIs show the pattern of meniscal tears. This helps the surgeon plan treatment. The tear could be across the meniscus (vertical), the length of the meniscus (horizontal), or at a diagonal (oblique). The severity of the tear can also be assessed with MRIs (mild, moderate, severe). Any other features such as the shape of the tear (e.g., flap tear, parrot-beak tear, or complex configuration) can be seen as well.

You don’t have to be an athlete to sustain a meniscal tear. The degenerative aging process helps level the playing field so-to-speak. Over the age of 50, we are all susceptible to this kind of injury with or without the glory of a home run, winning soccer goal, or perfect tennis score.

Taking a quick look at the anatomy of the meniscus, we find that it is a C-shaped disk of fibrous cartilage between the tibia (lower leg bone) and the femur (thigh bone). There are two menisci: one on each side of the knee joint. The medial meniscus (along the inside of the knee closest to the other leg) is torn most often. The lateral meniscus (along the outside of the knee away from the other leg) is injured less often.

The menisci have several functions. They help spread the load from forces directed from the foot up through the knee and into the hip. They act as mini-shock absorbers while lubricating the joint and helping the joint surfaces slide and glide smoothly against each other. Without these fibrocartilage disks, the knee is less stable and more likely to give way underneath the person. An unstable knee is at increased risk for another injury.

Even at age 66, the optimistic view is that those knees may have to last another 40 years! based on the average lifespan of American adults today, in all likelihood, you’ll need them for another 20 years at least. Saving the cartilage can protect you from advancing, degenerative knee arthritis and delay the need for a total knee replacement.

There are plenty of studies to support your surgeon’s treatment plan. Repair and restoration of the knee to as normal as possible preserves the biomechanics and function of the joint. Preventing long-term problems later is the goal. We never know where our paths will take us. You may not appreciate the need to save the meniscus now but years ahead, the value of such a plan may become more obvious. Who knows? You may even start running marathons! It’s been known to happen in adults in their 70s and 80s.

Chondrolysis refers to the loss of articular cartilage, the smooth cartilage that allows the two joint surfaces to slide and glide against each other easily. Thinning of the cartilage narrows the joint space, putting more pressure on the joint and causing painful symptoms that eventually lead to joint arthritis.

With chondrolyis of the knee, the cartilage can be fragmented in one or all three compartments of the knee. That includes the top and bottom and both sides (medial and lateral) of the femur (thigh bone), tibia (lower leg bone), and patella (kneecap). The cartilage may be worn down partially or all the way to the bone in all three areas. Full-thickness chondrolysis is the precursor to joint degeneration leading to arthritis.

Treatment isn’t always successful in stopping the degenerative process. It may depend on what caused the problem in the first place. There are some reports that have linked the use of a pain-pump after ACL surgery to chondrolysis. Evidently, the drug contains a numbing agent called bupivacaine that is toxic to the chondrocytes (cartilage cells). Not only does it kill these cells, it also keeps the joint from forming new chondrocytes to replace the damaged ones.

Depending on how severe the problem is, conservative care may be the first line of treatment. Rest, steroid injections, microfracture, activity modification, and the use of antiinflammatories are often tried. Some patients are encouraged to manage their symptoms for as long as possible before eventually having a total knee replacement. Viscosupplementation (injection of a slippery fluid into the joint) may be helpful for some patients with chondrolysis but it has not been shown effective with chondrolysis linked with pain pump use.

Successful treatment options for bupivacaine-induced chondrolysis are limited at the present time. There is a need for further research in this area. Your surgeon will be able to best advise you what steps to take and what course of action might be the most successful in your case.

The problem of patellar instability is fairly common, especially among the young, athletic population. Instability usually means the patella (kneecap) has dislocated more than once. This condition poses a treatment challenge because of the unique and complex anatomy and biomechanics of the patellofemoral joint (where the kneecap articulates or moves against the leg bones).

The Q-angle figures in because it is the angle of pull of the quadriceps muscle on the patella. An increased Q-angle results in pulling the patella laterally (toward the outside of the joint away from the other knee). With enough pull and not enough restraint, the patella can be pulled so far over that it pops out of the groove and dislocates.

But there are other important anatomical features contributing to patellar stability/instability. For example, the surrounding fascia (connective tissue), shape of the patella, depth of the trochlear groove, and other ligaments (e.g., meniscofemoral ligament, posterior oblique ligament) can affect how the patella moves up and down over the leg.

Most of these soft tissue structures provide restraint, a force known to hold the patella in place where it belongs. Change in any one of these factors can result in rotation or translation of the patella away from the trochlear groove. When that happens the patella can sublux (partial dislocation) or fully dislocate.

It might be a good idea to see an orthopedic specialist for an evaluation of your knee before jumping to any conclusions about surgery. A sports medicine physician or orthopedic surgeon examines the patient, performing necessary tests to document patellar instability. Knee range-of-motion and quality of patellar motion are observed and measured. The various ligaments can be palpated and/or tested for integrity or deficiency.

The strength and quality of muscular contraction are assessed for the quadriceps muscle. The Q-angle, which is the angle of pull of the quadriceps muscle on the patella is measured. An increased Q-angle results in pulling the patella laterally (toward the outside of the joint away from the other knee). With enough pull and not enough restraint, the patella can be pulled so far over that it pops out of the groove and dislocates.

Sometimes imaging studies can be helpful. X-rays have the least value in this area. Unless the patella is fractured or there are bone spurs, X-rays don’t really show any problems that would confirm a diagnosis of chronic patellar instability or offer information as to why the problem is occurring. CT scans can show an abnormal tilt of the patella and give some information about the bony prominence (the tibial tubercle) that inserts into the trochlear groove. MRIs can show ligament damage and even bone bruises from a recent patellar dislocation.

The first-line of treatment is nonoperative with activity modification, taping, bracing, and exercises. Surgery is only indicated when conservative (nonoperative) care fails to improve symptoms and/or the patella continues to dislocate.

There are many different types of braces on the market for the knee. Prophylactic braces are used to prevent or decrease the risk of a knee injury. Functional braces stabilize a wobbly knee when the anterior cruciate ligament (ACL) is deficient or after surgery to repair the ligament. Rehabilitative braces limit the amount of knee motion that’s allowed during recovery and rehab after knee surgery. You might be a good candidate for the unloader (sometimes called offloader) brace used to give patients with osteoarthritis of the knee some pain relief.

The off-loader brace just got rated an A for consistent, good-quality patient-oriented evidence based on a review of the literature. All evidence points to the use of off-loader braces as a good way to improve knee stability while reducing knee pain. The brace is meant to be used by patients like yourself who have unicompartmental knee osteoarthritis. Unicompartmental arthritis affects one side of the joint (usually the medial side — the side closest to the other knee).

Unicompartmental knee osteoarthritis is a common problem associated with alignment problems, obesity, and aging. Some people have a slightly inward angle at the knee that results in more weight being placed on one side of the knee. It could be a valgus angle, which is more toward a knock-kneed position that leads to lateral unicompartmental osteoarthritis. Or (more commonly), it could be a varus angle, a bow-legged position resulting in medial unicompartmental osteoarthritis. Either of these two malalignment problems causes cartilage degeneration and ligament laxity, bringing the joint surfaces closer together. The result is an increased load on one side of the joint.

The unloader or off-loader brace uses adjustable straps and pads to apply an external force to distract the involved compartment. It’s a mechanical intervention meant to reduce pain, which in turn, increases function. The long-term goal is to keep the arthritis from getting worse. By improving the alignment of the knee, compressive force and load are shifted off the already damaged area of the joint.

You may be a good candidate for this brace. X-ray evidence of unicompartmental knee osteoarthritis is required. Patients who have failed to get benefit from standard medical care are also recommended for this type of bracing. Standard first-line medical treatment includes nonsteroidal antiinflammatories, steroid injections, and viscoelastic supplementation.

If you have already gone through at least six-months of conservative (nonoperative) care with little to no improvement (or even worsening of symptoms), ask your doctor about this type of brace. If you have not tried some (or all) of the standard measures of care, talk to your doctor about best options for you given your history, clinical presentation, and personal goals.

Your surgeon is the best one to answer this question. He or she will probably have a specific protocol that you will follow after surgery. Some of this depends on the surgery you have done (e.g., repair versus reconstruction) and how it’s done.

There isn’t one specific surgical procedure that can be used for everyone with patellar instability (that’s the medical term for a kneecap that repeatedly dislocates). The surgeon takes into consideration the age of the patient, activity level, anatomical factors, and the overall condition of the patellofemoral joint (where the kneecap moves up and down over the leg). If there is generalized joint laxity or congenital changes (present at birth) in the shape of the patella, further reconstruction may be necessary before patellar stability is fully restored.

Usually the first step is to restore the natural movement of the patellar as it moves up and down the trochlear groove (anatomical track that holds the patella in place). Then everything necessary to keep the patella tracking normally must be done. The surgeon does whatever is necessary to restore the soft tissue restraints needed to prevent a lateral pull on the patella. It may be necessary to perform a tendon graft or shave off some of the bone that is preventing normal trochlear tracking.

The surgeon will also check the Q-angle and correct it if necessary. The Q-angle is the angle of pull placed on the patella by the quadriceps muscle. An increased Q-angle pulls the patella laterally (toward the outside of the joint away from the other knee). With enough pull and not enough restraint, the patella can be pulled so far over that it pops out of the groove and dislocates. Exactly how the Q-angle is corrected depends on the underlying pathologic (abnormal) anatomy and altered biomechanics.

No matter what kind of surgery is done, a hinge-brace is worn for about six weeks after surgery. This protective brace limits motion and weight-bearing. You’ll probably be allowed to put about half your weight on that leg at first. Motion is usually restricted to 30-degrees of flexion. The physical therapist directing your rehab program will advance the motion allowed by 30-degree increments every couple of weeks.

Quadriceps strengthening is the main focus of rehab but the physical therapist will also make sure the patient’s posture, joint proprioception (joint sense of its own position), and kinesthetic awareness (leg sense of movement) are fully restored as well. Sports specific exercises enable the athlete to return to sports approximately 12 weeks after surgery. For those who are less athletically inclined, recovery may take slightly longer. The therapist will provide a home program of exercises that will help you progress along at the pace you are most comfortable until you reach the goals you have determined for yourself in conjunction with the surgeon and therapist.

Unicompartmental knee osteoarthritis is a common problem associated with alignment problems, obesity, and aging. It means that degenerative changes have affected one side of the joint — either the medial side (closest to the other knee) or the lateral side (outside half of the joint).

Misalignment problems appear to be the root cause of unicompartmental osteoarthritis. Uneven wear on the joint leads to cartilage degeneration and ligament laxity, bringing the joint surfaces closer together. The result is an increased load on one side of the joint.

The unloader or off-loader brace uses adjustable straps and pads to apply an external force to distract the involved compartment. It’s a mechanical intervention meant to reduce pain, which in turn, increases function. The long-term goal is to keep the arthritis from getting worse. By improving the alignment of the knee, compressive force and load are shifted off the already damaged area of the joint.

What are patients saying who are using this brace about their results? Questionnaires evaluating knee pain and function show that the majority of carefully selected patients who use the off-loader report significant improvement in pain and function. They can walk longer and climb stairs with greater ease. Many patients were able to double their pain free walking time from an average of 51 minutes before bracing to 138 minutes with bracing. Improvements in daily function continue throughout the first year of wear. Patients were also able to reduce the amount of pain medication taken each day when using the brace.

There were some studies that did not show an overall benefit from bracing. Patients were able to get some pain relief but their function and quality of life did not improve over time. Others found that the benefits only lasted as long as they wore the brace. Patient compliance dropped over time, possibly contributing to a decline in perceived benefit.

Current evidence supports the use of an off-loader brace as a cost-effective way to treat unicompartmental knee osteoarthritis and delay surgery. Patients report decreased pain, better stability, and fewer falls. The overall level of evidence from analysis of all the updated data puts the strength of this recommendation at 76 per cent for the success of off-loader braces treating unicompartmental knee osteoarthritis. The higher the percentage, the higher the strength of the recommendation based on scientific evidence.

Whether to use a one-size-fits-all (off-the-shelf) variety or get a custom-made brace is an individual decision. Not enough studies have not been done to present a definite answer on this one. Some research has shown that custom braces help reduce stiffness and thus increase function more than off-the-shelf bracing. But other studies didn’t show any difference in function or quality of life in patients using one type over the other. The only significant finding was that wearing either brace helped reduce the amount of pain medications patients were using.

Your orthopedic surgeon will be able to help you decide which one might be best for you based on your individual factors such as age, body mass index, signs and symptoms, posture, and alignment. Some patients find it is worth it to try the off-the-shelf brace and wear it for a year or two and then have a custom brace made if the results are good. Again, this is an individual decision made in conjunction with your physician. Consulting an orthotist (brace maker) may also provide you with further insights that can sway you one way or the other.

Chondrolysis refers to the loss of articular cartilage, the smooth cartilage that allows the two joint surfaces to slide and glide against each other easily. Thinning of the cartilage narrows the joint space, putting more pressure on the joint and causing painful symptoms that eventually lead to joint arthritis.

There are several different causes of this condition. Most of them have to do with complications after joint surgery. For example, chondrolysis has been known to develop when bone cement is used for joint replacements and it leaks into the joint or when gentian violet is used as a dye to test the integrity of the shoulder rotator cuff. The rotator cuff is made up of a group of four tendons and the attached muscles that surround the shoulder joint. The dye shows any tears or ruptures of the tendons of the rotator cuff.

Radiofrequency (heat) energy used in some surgeries has also been linked with chondrolysis. But none of these causes is likely the reason for your daughter’s problem. If she has had an anterior cruciate ligament (ACL) repair and now subsequent chondrolysis formation, she may be experiencing a long-term side effect of an intra-articular pain pump.

The pain pump infuses the knee joint with a numbing agent called bupivacaine mixed with a pain reliever such as morphine. The purpose is to control post-operative pain and get the patient back up and moving as quickly as possible. Pain pumps have been in use after joint surgeries for many years now. But animal studies and human cadaver studies have shown that the bupivacaine kills 99 per cent of the chondrocytes (cartilage cells) that it comes in contact with.

And a recent first-time report of three patients who had surgery to repair ACL injuries confirmed this association between chondrolysis and the use of a bupivacaine pain pump. This problem may occur more often than has been appreciated before because there is such a lag time between when the cartilage cells are exposed to the chemical and when symptoms first develop. Not only that, but the first symptoms of pain and swelling seem to precede any obvious damage by many months’ time.

There may be no known cause of the problem. For further information as it specifically relates to your daughter and what to do next, you will need to visit with her surgeon.

Sports injuries command a lot of attention in the orthopedic world. Keeping athletes in tip top shape and in playing or competitive mode is a top priority for sports medicine specialists. Toward that end, researchers are trying to understand what causes tendon problems (called tendinopathies) in this group of individuals.

Sports athletes like you are often faced with chronic problems like this that they can’t seem to rehab or exercise away. If we can understand how and why tendon disorders develop, then maybe we can prevent them from occurring in the first place.

If the idea is correct that repeated overload of the tendon is the underlying problem, then examining the way you move, your postural alignment, and your training techniques should help. It may be possible to find ways to prevent abnormal loads on the patellar tendon and thereby reduce your painful symptoms. Your coach, athletic trainer, or a sports physical therapist can be consulted for help in this area. By observing the way you move on the field, an objectively trained individual may be able to see something that is contributing to the problem and could be easily changed or modified.

You can review the number of hours you are on the field practicing each week and see if that is a contributing factor. Patellar tendinopathy has been linked in other soccer players with a high number of hours and number of training sessions per week.

It has been suggested (but not proven yet) that overload deforms the tendon cells until they can no longer support the repeated stress of weight-bearing loads. Some experts think that the patellar tendon is getting compressed or pinched (called impingement) by the lower edge of the patella (kneecap) when you bend your knee. Again, postural and/or biomechanical factors such as muscle weakness leading to imbalance of muscle pull may be part of the problem.

The patellar tendon is also more susceptible to injuries when athletes train (especially running) on hard surfaces such as concrete (e.g., sidewalks). Any areas of decreased joint motion above or below the knee (hip, ankle) can contribute to the problem. Females seem to be at greater risk than males for patellar tendon disorders. There may be a hormonal factor but evidence suggests differences in the female anatomy also contribute.

Anterior cruciate ligament (ACL) injuries are often accompanied by damage to other soft tissue structures of the knee. Patients are advised to have surgery sooner than later, especially when there are combined injuries, but also to prevent additional injuries. Surgeons are advised to carefully evaluate the joint for any additional ligament or cartilage tears before doing surgery for the ACL.

Sometimes patients like yourself opt out of surgery for any number of reasons. They decide to wait before having the operation. It’s natural to wonder what effect that might have on your injury and recovery. Surgeons know that without the stabilizing force of the ACL, patients can end up with meniscal tears that weren’t present at the time of the ACL injury. And it’s possible that in patients with combined ACL and meniscal tears, the meniscal tears get worse over time.

That’s one reason why surgery is advised sooner than later. How long can you delay? Well, the ideal time for surgery isn’t really known yet. According to one recent study investigating this very question, waiting more than six months was too long. MRI studies clearly showed degeneration of the meniscus and joint because of the delay. Waiting two months is under the six month deadline, but any amount of waiting increases your risk of reinjury and further trauma to the joint and surrounding soft tissue structures.

Your surgeon will be the best one to advise you. After looking over your imaging studies and perhaps with the benefit of an arthroscopic exam, you will have enough information to guide you. Your activity level may be curtailed if you decide to wait — just to prevent further injuries on that unstable knee. Your surgeon may have you see a physical therapist during the interim. A nonoperative approach with a rehab program to restore strength, motion, and coordination may be all that’s needed.

Dimethyl sulfoxide (DMSO) is a chemical compound that was first made in 1866 by a Russian scientist. It is a colorless liquid penetrates the skin and other membranes easily without damaging them. This quality makes it an excellent compound for carrying other compounds into the body.

Its use has been tried for everything from muscle and joint pain to bladder infections. So far, the Food and Drug Administration (FDA) has approved its use only for the palliative treatment of interstitial cystitis (painful bladder syndrome). It was recently approved for study in the treatment of swelling associated with traumatic brain injury.

It might interest you to know that some studies have shown that a topical form of nonsteroidal antiinflammatory drug called diclofenac added to a base of DMSO and applied to the skin around the knee has been shown safe and effective for use with mild-to-moderate knee osteoarthritis. It has a bit of a drying effect on the skin but skin lotions can counteract that side effect.

One of those studies compared the use of DMSO alone with topical diclofenac. As a result of this study, we have some proof that the DMSO is not an effective agent for knee osteoarthritis. Topical nonsteroidal agents have the distinct advantage of reducing the adverse gastrointestinal effects that occur more commonly with oral (pill) forms of these medications.

All drugs come with benefits and possible side effects or adverse events. For anyone suffering joint pain from osteoarthritis, acetaminophen (i.e., Tylenol) can be an effective pain reliever. There are no acidic components like with aspirin and no antiinflammatory effects, so it’s used for pain control.

When inflammation and swelling develop, nonsteroidal antiinflammatory drugs are often used. Reducing pain from inflammation helps improve function and quality of life. But since osteoarthritis is a chronic condition, that can mean taking these medications for a very long time. And that increases the risk of problems or complications.

One way around this is with the use of topical (lotions or gels applied to the skin) NSAID formulations. One topical NSAID in particular may be helpful for those people who have mild to moderate knee arthritis. Diclofenac in a topical form has been shown just as effective as the oral form but without the adverse side effects (e.g., nausea, gastrointestinal bleeding). Joint stiffness does not seem to be affected by topical diclofenac, but some other topical antiinflammatory may work better.

Before doing anything else, it’s always best to check with your primary care physician or orthopedic surgeon for his or her recommendations. Your age, general health, past medical history, and the use of other medications for other health problems are all important factors in how you approach your arthritis. It may be necessary to complete some lab work and/or have X-rays taken to confirm the diagnosis. In any event, it’s a good idea to establish a baseline for your disease. This will be invaluable information as the years go by in determining the rate of progression and best approach in treatment.

There has been some concern that the number of grafts or the graft size harvested makes a difference in the final results of osteochondral transplantation. It’s possible that taking larger grafts or a greater number (sometimes as many as three plugs are transplanted) could negatively affect the outcomes.

But a recent study from Germany involving more than 100 patients found that the size and number of grafts harvested had no bearing on functional results of the donor joint (which happened to be the knee).

Instead, a higher body mass index (BMI) indicating obesity was the major negative factor in the outcomes. A secondary factor was patient satisfaction. Two specific tools were used to measure function and patient satisfaction. The first was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The second was the Lysholm score. They also looked at age as a possible factor, but age did not have a significant effect on donor site recovery.

The WOMAC is a standardized set of questions that evaluates 17 functional activities. It was designed as a pain scoring system for patients with osteoarthritis. The Lysholm is a well-validated questionnaire used to evaluate knee function after injury (including after surgery). It includes questions about limping, need for support when standing or walking, locking or catching sensations within the knee, and stability (knee gives way). Previous studies of donor site morbidity following autologous osteochondral grafts for similar problems used these two measures as well. This helps researchers study and measure the same variables in the same way thus making research more consistent across the board.

A closer look at the results of this study showed that for every point increase in the body mass index, the Lysholm score dropped a point and the WOMAC scores went up slightly (an indication of worse function).

The authors concluded that a higher body mass index is more of a negative predictor of outcome for the graft donor site than how many bone plugs are taken. Surgeons should take this into consideration when planning osteochondral transplantation from the knee. Patients should be chosen carefully for this procedure with special attention to the presence of obesity. Patients who are overweight should be cautioned that this is a risk factor for less than optimal results.

Age may or may not be against you. It’s natural to assume that the older you are, the less likely you will heal or recover quickly and completely. But, in fact, age may not be the main factor. That doesn’t mean that the consequences of a repeat ACL tear aren’t there.

Studies show that unresolved ACL tears eventually go on to add damage to the medial meniscus. The meniscus is a tough, rubbery C-shaped piece of cartilage that acts like a shock absorber in the knee. It forms a gasket between the tibia (shinbone) and the femur (thighbone) to help spread out the forces that are transmitted across the joint. Walking puts up to two times your body weight on the joint. Running puts about eight times your body weight on the knee. Besides protecting the joint surface, the menisci (plural for meniscus) also help the ligaments stabilize the knee.

In a recent study of ACL injuries, 31 patients with a chronically ACL-deficient knee delayed surgery for unknown reasons. Their surgeons took MRIs of the knee every six months after the injury. At the time of the initial injury, only half the group with an ACL tear had a meniscal tear. When the next MRI was done, only five of the 31 knees no longer had a medial meniscal tear. Not only that, but of the patients who did have a meniscal tear right from the start, almost half of them had a worse meniscal condition when the second MRI was done.

The researchers involved in the study did a separate analysis to see if age or activity-level was a factor. It was not. The biggest determinant of additional injury to the meniscus was the delay in surgery past six months. Medial meniscal tears occurred more often the longer the patient delayed ACL reconstructive surgery.

That begs the question: when it comes to protecting the status of the medial meniscus, is there an ideal time to have ACL surgery? Other researchers who have looked at this issue have concluded from their studies that reconstruction should take place between three and 12 months after the injury. And the results of this study not only confirm that conclusion but also offer the knowledge that the earlier the better. Delaying reconstruction surgery puts the medial meniscus at increased risk for tears.

Treatment choices will be much clearer after you have had an orthopedic examination and consult. Some surgeons still want their patients to complete a pre-operative rehab program. This puts you in the optimum position to go into surgery with a strong leg, a potentially quicker recovery time, and faster progression through rehab.

Cartilage covers the ends of bones that make up the knee joint. This type of cartilage is called hyaline or articular cartilage. It is made up of cartilage cells called chondrocytes. Damage to this structure can cause holes called defects or lesions. Continued daily use of the joint puts pressure on the damaged area leading to pain, swelling, and sometimes locking or catching of the knee.

When these symptoms result in loss of function, the surgeon can perform a debridement or microfracture procedure. Debridement removes any loose fragments and smoothes the cartilage surface of the joint. Microfracture is the drilling of tiny holes through the cartilage to the joint surface. This technique stimulates bleeding and sets up a healing response.

A third treatment option for first-line care of cartilage injuries is an osteochondral autograft transplantation. This involves harvesting a layer of cartilage and bone from a healthy area of the same patient’s joint and transferring it to fill in the hole. Any of these first-line treatment approaches work well for inactive or low-demand patients with a small lesion.

Being active increases the risk for failure of the procedure but patients are encouraged to stay as active as they like. Revision surgery is always possible. The surgeon will also evaluate you for alignment problems that may have contributed to the problem in the first place. Many times, the cartilage wears down through all its layers because the bones forming the knee joint are angled unevenly. The surgeon can correct this by performing a procedure called an osteotomy. A wedge of bone is placed along the side of increased pressure in order to shift the point of weight-bearing contact over toward the other side of the joint. This helps even out the weight-bearing surface of the knee.

A postoperative rehab program is also a good idea. Once you regain knee joint motion, then you can start to build up strength in the muscles around the joint. Good muscular support can help take pressure off the joint and protect you from other types of injuries, especially during the healing recovery phase of this procedure.