FAQ Category: Knee

Among competitive athletes, even the type of surgery they had can become a competition!

Anterior cruciate ligament (ACL) reconstruction usually involves harvesting a piece of tendon from some other area to use as a graft. The two most common places the donated tissue comes from are the quadriceps tendon (bone-patellar tendon-bone) and the hamstrings tendon.

Until recently, the bone-patellar tendon-bone graft was the preferred choice by many. But new fixation methods have made the hamstrings tendon more appealing as a graft choice. The bundles refers to number of strands of tendon that are harvested and/or doubled over to form the graft.

Using bundles of tendon grafts allow the surgeon to shape and form the tendon for optimal function. The bundle may be placed vertical (straight up and down) or oblique (on a diagonal). The purpose is to restore joint rotational stability.

Single-bundle grafts may not provide stable knee rotation. But double-bundles require extra tunnels in the bone to hold it in place. This can create problems much later if the knee requires revision surgery.

Various tendon grafts are fixed or held in place with different techniques. The most common fixation device is the interference screw. The screw is bioabsorbable or biodegradable. This means that it doesn’t have to be removed later.

Another type of fixation device is the endobutton. A loop of polyester tape with a clasp at one end offers a way to secure the soft tissue to the bone. This type of fixation has good results with few problems or failures.

Bioabsorbable crosspins can be used to hold a hamstring-tendon autograft to the femur (thigh bone). A femoral press-fit fixation may be used with the bone-patellar tendon-bone reconstruction. This is a way to avoid using screws.

There are actually many graft fixation options. When you see your orthopedic surgeon at the next pre-op visit, ask him or her to explain to you just exactly how the procedure will be done. Your surgeon may even have a videotape of the surgical procedure you can watch ahead of time. Many of your questions may be answered this way.

Chondrocyte (cartilage) implantation has been around for about 20 years. It has become the number one choice to repair large lesions in the articular cartilage of the knee. When using your own cells, the procedure is referred to as an autologous chondrocyte implantation (ACI).

The procedure is in two parts. First the surgeon harvests donor cells from another area in the knee. Cells are preferred from an area of minimal weight-bearing status. Then the surgeon will clean up the damaged area. Any frayed tissue will be shaved smooth.

A small patch from the outer most layer of bone is harvested. The patch is stitched over the lesion. Then the donor cells are injected under the patch. The patch is then sealed with sutures and a special glue.

There are plusses and minuses about this procedure. The advantages are that the lesion fills in with desirable cartilage. The repair is durable and will hold up under normal use. This treatment is very good for large areas of cartilage damage.

On the downside, it is a staged-procedure (two operations). The rehab time is considerable and requires the patient’s time and dedication. Some studies report a high rate of failure and reoperation. There are other less complicated procedures but for a large full-thickness cartilage injury, recent studies hold this one up as the best choice.

Joint cartilage has a limited ability to heal itself. After an injury, the cartilage cells called chondrocytes set up a healing response. But there is a limited attempt at best. And if the injury is a full-thickness articular cartilage tear, then self-healing probably won’t be enough.

Scientists have found ways to help healing along in this area. They have discovered that using cartilage cells from other areas of the uninjured joint can aid in the repair process. Cells are usually taken from a relatively non-weight bearing area of the joint and transplanted to the injured site.

This may be the best way to reproduce tissue similar to the natural cartilage. Restoring the biomechanical abilities and durability of the cartilage is especially needed for athletes. Return to play with the full function of the knee is possible with this type of treatment.

The most common way to repair a ruptured quadriceps tendon is with interlocking continuous sutures. The sutures are used to reattach the tendon to the bone. The stitches are passed through the torn end of the tendon then through holes drilled in the patella (kneecap).

The use of suture anchors is a newer technique. Surgeons who know how to use suture anchors say that it is relatively simple and very effective. A smaller incision line is needed. This looks better cosmetically. But it also means less soft tissue around the knee is disrupted. The end-result if a faster recovery time with fewer complications.

When a problem does occur, it tends to be infection. This can occur at the site of the incision and/or infection in the joint. In these cases, there is a definite drawback of suture anchors. They are not easily removed (which is required for infection control).

Overall the multiple advantages of suture anchors make this a method that is gaining in popularity for many operations of all kinds. Early results have been positive with faster return to work, sports, and daily activities.

It would be best to find out directly from the surgeon just what he or she had in mind with that precaution. If your daughter is in physical therapy, the therapist will also know what postoperative limits must be followed.

After the tendon is repaired (and before closing the skin up), the surgeon takes the knee through a range-of-motion to find the stress point. That’s the place where excess force would be needed to move the knee further.

The surgeon usually tells the patient not to move the knee past this point. Most of the time, it does not go past 90 degrees of flexion. But again, you’ll want to double-check this with the surgeon.

The reason for this guideline is to avoid rupturing the healing tendon. Too much stress and the repair could rupture just like the tendon did the first time. Usually the patient is in a brace for the first two weeks. At the end of two weeks, the brace can be taken off to do range of motion exercises. These are prescribed with a safe amount of motion.

Full motion can be resumed when the brace is removed (around the end of six weeks post-op). Full healing doesn’t occur until three to four months after the surgery. The patient may continue to wear the brace during this time. The surgeon decides when the patient can stop wearing the brace and put full weight on the leg. Strengthening of the quadriceps muscle begins when full healing has occurred.

Researchers who study the question you asked don’t have an exact answer yet. A recent finding among several studies confirmed a definite relationship between patellofemoral pain syndrome (PFPS) of the knee and hip motion and strength. They found that a difference in hip internal rotation from one side to the other seems to contribute to knee pain. That difference was also accompanied by decreased hip muscle weakness.

Moving the sacroiliac joint (SIJ) through an adjustment or manipulation may have several beneficial effects. There may be a reflexive change in muscle activity at the knee joint. Electrical activity in the muscles may decrease leading to pain relief from a muscular source. It’s possible that a stimulus of any kind makes a difference.

There’s some evidence that manipulation has a direct effect on the central nervous system to reduce pain. More than likely there are many factors that combined together influence the SIJ-knee dynamics. More Further studies are needed to sort this all out.

It may be best to try and schedule at least one appointment with a recommended physical therapist (PTs). Many PTs have specialty areas. Try to find someone with an interest and active practice in knee rehab. This may be a sports medicine or orthopedic therapist.

Let your therapist know your situation right away. It should be possible to set you up on a home exercise program geared to your specific problem. New research has shown us the importance of lower extremity movement in patellofemoral pain syndrome (PFPS).

There’s evidence that muscles in the hip and alignment of the lumbopelvic region may be important links in the treatment of PFPS. For example, a difference of more than 14 degrees in hip internal rotation from one side to the other may be a risk factor for PFPS.

At least one study has shown that manipulation of the lumbopelvic spine or sacroiliac joint can make a difference in your symptoms. This treatment should be followed with an overall program to address any imbalances in the lower extremity and body as a whole.

Your therapist can set you up on a home program you can do on your own. You may need some minimal supervision and occasional check-ups to progress the program. Most therapists are very willing to make necessary financial arrangements for any patients with financial constraints.

As your surgeon has already told you, there are some differences between the bone-patellar tendon-bone (BPTB) and hamstring tendon graft. Results have improved over time with both types of grafts.

This is because surgical techniques have improved. Better methods of attaching the tendon graft material are available. There is less slippage with the hamstring grafts. Patients report less knee pain and less joint stiffness with both graft types compared to even just 10 years ago.

The surgeon’s skill and experience with ACL repairs is an important factor. Surgeons who perform many of these procedures each year have better results. It’s important to pay close attention to correct graft placement. Treatment of other meniscal or ligament damage to the knee is as important as the choice of graft materials.

There is one new study that may be of interest. Researchers from the bioengineering lab of Harvard Medical School and Orthopedic Research Lab from Duke University studied knee motion after a BPTB graft.

With special testing, imaging, and computer software, they were able to measure the position, angle, and movement of the patellofemoral joint (PFJ) after ACL reconstruction. Both knees were tested for each patient. This gave a comparison between the involved (surgical) side and the uninvolved (normal) knee.

They found that ACL surgery does improve patellofemoral joint function. But it does not fully restore rotational stability of the knee. There was altered patellar tracking (kneecap moving up and down over the femur) and changes in cartilage contact between the patella and femur.

As a result, the patellofemoral joint may be at increased risk for degenerative changes. BPTP graft for ACL reconstruction is still the “gold standard” method of repair right now. Further study is needed to pay attention to fine tuning these procedures. New technology and new studies may guide patients and surgeons to favor the hamstring tendon graft.

If you have not had your surgeon re-evaluate your knee, now would be a good time for a follow-up visit. There may be a simple explanation for the pain you are experiencing. Or perhaps your rehab program needs tweaking a bit.

The surgeon will examine your knee structures, motion, and strength. The graft site will be included in the exam, too. Some of the possible causes of chronic knee pain after ACL reconstruction depend on the type of graft you had.

Anterior knee pain does occur in patients with bone-patellar tendon-bone grafts taken from the front of the knee. Any kind of pressure (e.g., kneeling) along that area can cause pain. Scar tissue and adhesions pulling on the soft tissue structures can occur with either kind of graft.

Studies show that ACL reconstruction can stabilize the joint. But it doesn’t always restore normal joint kinematics (motion). Even small changes in the angle, tilt, or rotation of the patella (knee cap) can result in how the patella moves against the femur.

Altered tracking motion of the patella up and down over the femur can lead to a shift in cartilage contact. Pain might be the first indication that something isn’t line up straight or moving correctly. Now is the time to identify the problem and change it if possible before degenerative joint changes occur.

PLC stands for posterolateral corner injury of the knee. This usually means there’s been a partial or complete tear of the soft tissue structure(s) around the back, outer side of the knee. There are a number of complex ligaments in this area, along with two muscles: the gastrocnemius (calf) and the popliteus.

All of these ligaments and muscles work together to keep the knee stable. They prevent too much rotation and/or translation (sliding and gliding) of the bones that form the knee joint.

Any ligamentous injury can be classified by grade. Usually, the grade is based on how much disruption has occurred. A sprain of the ligament without joint instability is a grade I. Rest and rehab may be all that’s needed for this level of trauma.

Grade II injuries show up as a small amount of joint laxity. There’s a partial tear and mild-to-moderate change in joint motion. Grade III injuries result in joint instability and abnormal motion. In grade III PLC injuries, the soft tissues have been completely ruptured.

Treatment is based on the identified grade of injury. Grade I and less severe grade II injuries can be treated conservatively. A physical therapy rehab program often yields good results without surgery. Surgery is advised for more severe grade II and all grade III injuries.

Return to sports play depends on the severity of injury. The timing of treatment as it coincides with the off-season is also an important factor. The sooner the athlete gets the necessary treatment, the greater the chances of returning to play within the next season.

A PCL injury refers to damage to the posterior cruciate ligament. The PCL is one of two important ligaments inside the knee. The other is the anterior cruciate ligament (ACL). These two main ligaments criss-cross each other between the femur (thigh bone) and the tibia (shin bone). Together, they hold the joint stable during motion.

The PLC stands for posterolateral corner. It 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 PLC can occur. But usually it’s linked with trauma to some other part of the knee (including a PCL injury).

In some cases, the PLC injury was present along with the PCL injury. But symptoms of the PCL injury were most predominant. It wasn’t until much later that the presence of a PLC injury became obvious. It can take quite a bit of examination and testing to sort out the specifics of such an injury.

And often, it’s not until the surgeon performs an arthroscopic exam (or even the surgical procedure itself) before the PLC injury is noticed.

Most hamstring avulsion injuries are related to skiing — water skiing, cross-country skiing, or downhill skiing. Falling or slipping with the hip flexed forward and the knee straight is just too much stretch on the hamstring muscle. Violent overstretching of this type pulls the tendon right off the sit-bone on the pelvis.

Surgery is usually recommended. The sooner the better for the best results. The patient comes out of surgery with an elastic bandage to support and protect the surgical site. Some surgeons use a leg immobilizer; others don’t.

The patient uses crutches at first with no weight-bearing or just light (toe) touch to the ground for balance. Sitting is not allowed for the first two weeks. Stretching the hamstring is not allowed for at least four weeks (sometimes longer). Full weight-bearing is allowed gradually.

If there’s no infection or problems with wound healing, pool therapy can be started four weeks postop. A physical therapist will work with your grandfather. You will probably be able to observe and even help with the program.

Range of motion exercises begin four to six weeks after the operation. A strengthening program doesn’t begin until several months after the procedure. The surgeon and therapist will advance the program appropriately.

You will need an orthopedic surgeon to evaluate your injury and make recommendations based on the findings. An MRI may be needed to see the condition of the soft tissues. Your symptoms and clinical presentation will help identify any additional problems such as nerve entrapment.

It’s not uncommon for the untreated torn hamstring tendon and muscle to retract. This means the tissue pulls away from the insertion point on the bone. Scar tissue and adhesions develop in the area. These two factors can increase the technical demands of surgery.

But studies do show that “better late than never” applies in this situation. Good-to-excellent results are possible for surgically treated chronic problems of this type. Many patients are able to get back to full activity of recreational sports. Beware that the delay does increase the chances of a poor result.

The chair height may not have anything to do with your problem. The first thing to look at is your muscle strength and joint motion. Any deficits there can cause problems. It is possible you have enough strength and motion in the knee. In that case, it may be the way your muscles contract to create movement.

Altered strategies for movement or abnormal movement patterns are often the problem behind this type of problem. When you were in pain, your legs automatically changed the way the force was distributed. You probably shifted load from the painful leg to the uninvolved side.

It is also possible to unload the painful limb by changing the way you use your muscles. For example, using more hip flexor strength when rising from a seated position reduces the demand on the knee extensor muscles. Even when the pain is gone and the strength is restored, the altered strategy may persist.

You may need some additional rehab to overcome this problem. A physical therapist can help you with a retraining program to restore normal motor movement. And this is important because altered loading patterns place extra load on the other leg. Over the long-term, you could develop arthritis in the other knee.

Studies show that strength deficits can persist months to years after a total knee replacement. And even when strength is normal, movement patterns learned when you were in pain don’t go away without retraining.

You may be in this second category. Patterns of movement adopted to avoid use of the quadriceps muscle before the knee replacement may still be present. A physical therapist can help you change the way you move.

Compensation patterns used to avoid pain can actually place extra load on the other leg. The long-term result can be arthritis on that side. The therapist will test your muscle strength to be sure this isn’t part of the problem. Functional tests of speed and endurance can help identify the specific problems to be addressed.

Iontophoresis is a way to use electrical impulses to push a steroid drug through the skin to the site of local inflammation. The hoped for goal is to pass the antiinflammatory drug through the skin to a specific area (usually a tendon or bursa). In this way, the local effects might occur faster and without the side effects of an oral drug (taken by mouth).

Research on iontophoresis has been unable to answer your question. Animal studies have been tried but animals seem to absorb the chemicals through the skin seven times more than humans. Clearly there are some differences between humans and animals when it comes to iontophoresis.

Even when humans have been studied directly, the amount of steroid transmitted through the skin varies considerably from one person to another. In one study, half the patients had no steroid whatsoever detected after iontophoresis. In that same study, skin thickness was not shown to be a factor. In other words, thin skin didn’t transmit the drug faster or better.

Research shows that iontophoresis has the potential to affect skin, blood, nerve tissue, and tendons. The mechanism by which this occurs is unknown. More studies are needed to help identify who is a good candidate for this treatment.

The gastrocnemius (calf) muscle is a large muscle that crosses both the knee and the ankle. It can easily overpower the anterior muscles of the lower leg. Soreness along the front of the shin called shin splints can occur when the calf muscles are tight or overused.

Ankle joint flexibility depends on a number of different factors. Ligaments (tight or loose called laxity) is one important determinant of ankle flexibility. Condition of the joint capsule is another.

But there isn’t much you can do to change the structure or flexibility of either of those sturctures. Another way to approach improving ankle joint flexibility is through the Achilles’ tendon and gastrocnemius muscle belly. Stretching the Achilles’ tendon increases the length of the gastrocnemius muscle, which in turn, increases ankle extensibility.

Studies show that stretching too far and too hard can actually cause shortening and further tightening of the gastrocnemius. If you start to feel pain with stretching, you are likely increasing muscle activity. The end result will be a tighter muscle. The saying, “No pain, no gain” does not apply to stretching muscles.

Passive stretching must be held long enough to change the structure of the tendon and muscle belly. This means the soft tissues become more elastic. They don’t fully recover within a minute after the stretch is ended. This usually takes at least 30 seconds. Holding the stretch to a place of slight discomfort (but no pain) a full minute is better.

Exercise in warm water is highly recommended for arthritis. The warmth and buoyancy of the water is soothing and makes it possible to move more easily and through a greater range of motion.

The warmth may also increase blood flow in general. This helps cleanse the joints and helps muscles relax. The increased hydrostatic pressure has numerous positive effects on the nervous system, cardiovascular system, and musculoskeletal system.

Many people report improved health from a regular aquatic exercise program. They feel more rested, have less joint pain, and benefit from improved strength and coordination.

However, studies don’t always support these subjective reports. In a recent review of published literature from 1980 to 2006, aquatic exercise did not reduce pain more than land exercise. It was, however, better than no exercise program at all.

More studies are needed to identify who can benefit the most from aquatic therapy. There are many factors that need to be studied. Pain relief is only one measure of results. Other outcome measures include fitness, joint range-of-motion, muscle strength, endurance, and flexibility.

There are no clinical studies comparing MIRE with other treatments. According to a recent review, individual case studies appear to be favorable, decreasing pain and improving function without any side effects.