FAQ Category: Knee

That does describe the typical contact trauma leading to ACL injuries from football, soccer, or rugby injuries. If the force from the outside across to the inside of the knee is enough, the ligament(s) inside the joint can rupture.

However, most of the time the mechanism of injury is from a noncontact injury. The quadriceps muscle is eccentrically contracted (going from a shortened to a lengthened position). The knee is in about 20 degrees of flexion (slightly bent). Then internal rotation of the tibia occurs and the ligament ruptures.

Picture this as the athlete is coming down from a jump. The foot is in contact with the floor, the knee is bent and then twists. Since the foot is planted and can’t move, if the force is great enough, the knee has to give. Not all noncontact injuries occur in just this fashion, but you get the general idea of how it happens without being tackled or kicked.

Improved technology in the area of advanced imaging such as magnetic resonance imaging (MRI) has made it possible to identify the extent of damage associated with anterior cruciate ligament (ACL) injuries. The location, depth, and intensity of bone bruising associated with ACL injuries are being studied more closely.

A classification scheme describing the depth of bone bruising is used to help guide the surgeon in making treatment plans. When the force of an injury is enough to rupture the ACL, the impact of the femur (thighbone) on the tibia (lower leg) is enough to leave a bruise called a footprint.

Superficial bone bruising means the footprint is seen beneath the subchondral bone. Subchondral refers to the layer of just below the cartilage of the joint. The deeper the bone bruising, the more damage has occurred in the nearby soft tissues such as the lateral or meniscal tears.

The long-term significance of bone bruising is unknown. Most of the time, the footprint is not seen on the MRI six weeks after the injury. There’s evidence of chondral damage but no idea of the long-term consequences at this time.

Your surgeon will do a detailed exam including physical tests and X-rays. Range of motion, strength, and joint laxity will all be carefully assessed. Most often, the patient is classified as Grade I, II, III, and IV. These grades guide the surgeon in planning and carrying out the second (revision) surgery.

For example, grade I is a simple repair. It is much like the original surgical procedure. New tunnels are drilled through which the graft tissue is inserted and sutured in place. The most common reason for graft failure is malposition of the original tunnels.

For grades II and III, bone grafting may be needed. The operation is often done in two or three stages (depending on what needs to be done). Grade IV revision surgery is more complex with multiple surgical steps.

There may be bone grafting, ligament reconstruction, and possibly an osteotomy required. An osteotomy is the removal of a wedge-shaped piece of bone that is then reinserted to correct a malposition of the knee.

The surgeon will still need to harvest tendon tissue to replace the graft that failed. This can come from the knee being operated on or it can be harvested from the other knee. There are several choices with pros and cons for each one.

Your surgeon will probably go over all the details with you. Let him or her know of your interest in the proposed procedure.

Many surgeons advise a three-to-six month trial of rehab before undergoing a revision operation. For those who are older or less active, this may be a good choice. But for younger athletes or older, very active adults, early reoperation is advised.

Studies show that an unstable or deficient knee will cause increased damage to the meniscus and joint cartilage. The result is early osteoarthritis. It may be best to have the revision surgery within three months of the reinjury. This will prevent further cartilage damage during the subacute stage.

The condition of the cartilage really dictates the final results. Any defects in the joint cartilage will inhibit twisting and turning activities. Strenuous sports activities are also limited.

Whenever possible, the surgeon will save the meniscus. This helps promote joint stability and possibly prevent degenerative changes. Technically correct surgical stabilization of the knee is the key to a good, functional outcome.

Painful snapping along the outside of the knee is not uncommon. Finding out what is causing it may be difficult. Some possible things to consider include iliotibial band syndrome, lateral meniscus tear, or snapping biceps femoris tendon. Other causes also include osteoarthritis (unlikely in a 16-year-old), joint instability, and snapping popliteus tendon.

The diagnosis requires a careful history and physical exam. X-rays, MRIs, and other imaging studies may be done but don’t always show anything to help diagnose the problem. There are a few hands-on clinical tests the orthopedic surgeon can perform.

But many times, the diagnosis is made by trying different treatment techniques and seeing what works. Nonsteroidal anti-inflammatory medications are often the first line of treatment. Likewise, the physical therapist can try a variety of interventions. These may include ultrasound, manual therapy, taping, icing, and immobilization with a splint.

If nothing helps and long-term pain relief isn’t possible, then exploratory surgery may be the next step. The surgeon can use an arthroscope to look inside the joint first. This may help avoid an invasive, open-incision operation. But if everything looks normal (as it often does in a young child), then a more complete surgical procedure may be needed.

Once the surgeon identifies the abnormal structure, steps can be taken to alter the cause of the problem. This could be to shave off a bump on the bone or to remove and reattach a tendon that may be snapping over the bone.

Many athletes are helped by conservative (nonoperative) care. Before waiting much longer, have your daughter evaluated by an orthopedic surgeon. She may be only a few weeks away from a successful solution.

Finding out the cause of painful snapping along the lateral (outside edge) of the knee can be very challenging. It’s actually a fairly common problem with many possible causes.

No matter what the cause, conservative (nonoperative) care is still always recommended first. So even if they were able to identify the problem, you would have still been advised to try physical therapy first. Most of the time, the symptoms resolve and surgery isn’t needed.

But persistent symptoms despite conservative management can point to the need for surgery. You were one of the few who needed a mechanical relignment of the muscle/tendon unit. The preoperative rehab program may have actually helped prepare you for a faster recovery after surgery. Improving flexibility, strength, and stability before surgery often yields more positive results afterwards.

A physician will be able to diagnose your problem. Using a series of questions, X-rays, and clinical tests, the diagnosis of knee osteoarthritis (OA) is fairly straightforward.

The American College of Rheumatology (ACR) has a classification system used by most doctors to make the diagnosis. Knee pain and stiffness are the most common symptoms. Stiffness is more pronounced in the morning but the pain is less. Once you get up and moving, the stiffness usually goes away. As the day goes on, pain may increase.

X-rays show bone spurs, loss of joint space, and poor knee joint alignment. All of these are common findings in patients with OA. X-rays are not relied upon by themselves. Many people have positive X-ray findings but no pain and no limitations.

The ACR supports the diagnosis of OA if these three conditions are met:

Your situation is common for many people with arthritis. Pain limits motion, which limits function. The less you move, the more it hurts. The more it hurts, the less you want to move. It can create a vicious cycle.

But it’s also true that motion is lotion. And strengthening the muscles around the knee improves general joint stability. The more stable the knee, the more functional it will be.

The best way to approach this problem is by making changes slowly but steadily. First, talk to your doctor about getting better control of your pain so you can start exercising more. The careful use of the right medications can make all the difference.

Many people don’t want to take drugs. Consider this a temporary solution until you can get back up on your feet, so-to-speak. Once you can progress in an exercise program, it may be possible to reduce and even stop taking pain relievers.

The right type and amount of exercise is also important. You may want to consult with a physical therapist to get you started. Once the therapist assesses your motion, strength, and stability, then an exercise program geared toward your needs can be prescribed.

You’ll be able to do this on your own at home with occasional guidance from the therapist. If you find it difficult to motivate yourself to exercise, think about joining an exercise group. Your therapist will be able to help you find community resources for this type of program.

Infections can happen any time to anyone. Unfortunately, infections in joint replacements can be hard to treat for a variety of reasons. First, it isn’t always easy to tell what type of bacteria is causing the infection. This means that it can be difficult to choose the best type of antibiotic.

When deciding how to treat an infection in an artificial knee, the doctor has to take into consideration the condition of the patient, how long the infection has been present, how much damage may have been done, and what the options are. In some people, opening up the knee and clearing out the infected tissue may do the trick, along with antibiotics. However, in others, the knee may have to be completely removed and replaced with a new one.

Clearing out dead and infected tissue from a joint is called debriding it. It’s a job that must be done meticulously to ensure that no dead or infected tissue is left behind at all.

To perform a thorough debridement of the knee, even the lining inside the knee replacement must be removed so that the doctor can get underneath to be sure that all the tissue has been removed.

While both the cartilage and tendon are soft tissues in the knees, they play different roles. The tendons are the very strong, fibrous tissues that attach muscles to bone. They are what allow you to move you knee back and forth – and have it stop where it should. They also help your knee maintain its stability. The cartilage joins two bones together, acting almost like a tether.

Cartilage often acts as a shock absorber in the joints and also as a stabilizer, keeping the joints steady. If a cartilage is torn, there could be friction between the joint bones and pain results. Long-term damage could be arthritis developing in the joint.

Yes, sometimes when a cartilage is torn, it is removed – this is called a meniscectomy (removal of the meniscus, which is another name for cartilage). A meniscal repair or ligament repair is just that – the surgeon repairs the damaged ligament or he or she can do a ligament reconstruction.

The decision is based on the extent of the injury, the cause, and the location of the injury.

Many of the movements you see in the Cirque du Soleil performers are just the result of natural flexibility and dedicated training. Some have natural flexibility we refer to as joint laxity. Most have been involved in gymnastics and/or dance from a very young age, which has helped mold and shape the joints to accommodate extreme movements.

You may also notice that many of the performers are Asian women. Young, females of black and Asian origin appear to have natural hypermobility (loose ligaments in the joints). This also contributes to their ability to look like body contortionists.

People with generalized joint laxity may be born with some differences in the connective tissue that account for this degree of looseness. There are at least 18 different types of collagen fibers making up the various soft tissue structures in the body. It may be that joint laxity is the result of changes within the collagen structure, a different type of collagen fiber in the joints, or a combination of both.

Scientists are studying these differences in hopes of helping to prevent joint injuries in young athletes as well as prevent joint stiffness as we age.

Being double-jointed really refers to an excess amount of motion in the joints. There aren’t really two joints. The joints look the same as in the everyday, average person.

Another term for this condition is hypermobility. For example, some hypermobile people can bend their thumbs backwards to their wrists. Others can bend their knee joints backwards, or put their leg behind the head.

Most people with hypermobility have this in all the joints. This is referred to as generalized joint laxity. The basic difference between people with normal joints and hypermobile joints is that joint laxity allows hypermobile joints to stretch farther than is normal.

Although it may seem that having loose ligaments would prevent injuries, excessive joint laxity actually increases the risk of ligament rupture. This is especially true for the anterior cruciate ligament (ACL) of the knee. Without strong muscles on either side of the joint, loose joints have less stability. There is less tension to hold them from sliding too far in one direction and tearing or rupturing.

It seems that joint stiffness is a natural part of the aging process. Many people mention stiffness as they get older. And in fact, joint laxity decreases with age as well. This suggests a similar process in those who were seemingly double-jointed.

If you have had a knee replacement, it’s likely that you are an older adult with arthritis or at least some type of joint degeneration. An exercise program to maintain motion, strength, and balance is still very important for you.

You may be able to drop back from a daily program of specific exercises for your knee and leg to one that’s done three or four times each week. But you should keep up with other activities such as walking, biking, golfing, tennis, or other recreational sports that you enjoy.

If you are having any trouble with walking, stair climbing, or other daily functional activities, then it may be time to have your exercise program re-evaluated. Your physical therapist can do this quickly and easily and help you get on a better track for what you need and/or want to do.

Knee range of motion has clearly been recognized as a very important part of function. Without it, walking, stair-climbing, and everyday activities can be difficult. Being unable to complete these tasks alone or even with some help can be very disabling.

For most patients, getting enough motion back to accomplish the type of tasks you mention is possible. It may take persistence on your part. A daily exercise program of range of motion and strength training is definitely needed. You’ll need at least 90 degree of knee flexion to do stairs and another three to five degrees to rise from a chair.

For some people, deformity or misalignment at the knee may be holding back restoration of greater motion. A flexion contracture (unable to straighten fully) causes a loss of full extension needed for normal gait (walking). And without full flexion, going up and down stairs can be very difficult.

It’s probably about time for you to check back with your surgeon for a follow-up visit. Ask about your limitations. You may need some additional surgery to correct a problem. Or perhaps another round of rehab is appropriate. The benefit you will get from obtaining additional motion is well worth the time and effort.

The purpose of supportive bracing after ACL reconstructive surgery is to protect the healing graft from excess strain. A functional knee brace or neoprene sleeve can also serve to keep the new tissue from stretching out too much, thus preventing joint laxity (looseness).

Many active athletes are under the mistaken belief that wearing the brace protects them no matter what they do. As you have found out, it’s still possible to reinjure the ligament. Sometimes this is just a fluke. You move the knee in just the right direction with just the right amount of torque and the healing fibers give.

In other situations, the activity is too strenuous too soon. The healing fibers cannot withstand the force or load and retear. And early on in the rehabilitation process, you may not have regained enough neuromuscular control or proprioceptive input (sense of joint position) to protect that knee.

Wearing a brace or protective sleeve decreases (but doesn’t eliminate) strain on the reconstructed ligament.

Knee braces designed to support and restrict the knee joint are often used after ACL reconstructive surgery. The main goal is to decrease the strain on the healing and recovering ligament. A supportive device may also improve joint proprioception (sense of joint position).

Some surgeons use these routinely with any athletes who are eager to get back into action. Others do not see the need for a rigid knee brace but suggest using a neoprene sleeve instead during strenuous activities. The knee sleeve provides compressive support but has an opening for the patella (kneecap). It allows unrestricted movement.

And there are those experts who believe no support is even needed. There are some studies that show no difference in outcomes for patients with or without support. It’s possible that there are subgroups of patients who need a brace and others who do not. And it’s even possible that certain groups would do better if they wore one supportive device over another.

More studies are needed to find out who can benefit from knee support and specifically what kind is best. This may depend on the age of the patient, the length of time from the injury, sex (male versus female), and type of reconstructive surgery that was done.

Conservative care before surgery won’t hurt and may help. In fact, a rehab program can get you back on your feet sooner — if the knee is stable enough to play without surgery. It’s important to wear your brace as prescribed. Protecting the joint from further damage during this healing and recovery period reduces the risk of reinjury.

Early surgery does have some advantages. For one thing, it is a faster way to return to full activities. Having surgery right away puts you into rehab that much sooner. The initial delay is no longer an issue.

Another advantage of early ACL reconstruction is avoiding further damage to the cartilage and other ligaments in the knee. If you return to sports activity with an ACL-deficient knee, you are at increased risk of cartilage injury. A small meniscal tear can become a full-thickness tear. This is especially true if the joint is subjected to trauma or force during the recovery period.

Your surgeon can really guide you in making the best decision for your particular situation. The results of your examination and imaging tests will help identify your risks and the treatment approach best suited to the specifics of your injury.

There is a commonly held belief that surgical repair of the ACL should be done when the knee is calm. Active inflammation leads to increased scar tissue. Doing surgery on top of an already acutely injured joint has been avoided.

Some studies have supported this thinking by their results. Some experts have advised against surgery after ACL injury for at least three weeks. Loss of motion and poor results with early surgery are the reasons given for waiting. But other studies don’t support these findings.

In a recent study of active duty military personnel with ACL injuries, two groups who had surgery were compared. The first group had surgery withi21 days. This is considered to be during the acute phase. The second group delayed surgery for at least six weeks (sometimes longer).

Patients were tested and measured before the operation and again every six months for up to three years. There was no difference in results between the two groups. The concern that motion would be less and scar tissue more in the early surgery group was unfounded.

Strength, motion, and function were equal between the two groups. Most of the patients in both groups were still making improvements during the first six months. After that, later results were about the same as what they had at the end of six months. It appears that with proper rehab after surgery, the timing of the procedure may not matter.