FAQ Category: Knee

Posterior cruciate ligament tears are often hard to detect. The symptoms are vague or subtle. The patient doesn’t remember a specific trauma or injury to account for the symptoms.

Recommended treatment is conservative care at first. Surgery is done when there is a completely ruptured ligament, knee instability, and/or the patient is a high-level athlete with both.

If the injury is diagnosed early, then bracing, ice, and elevation are used to contain the swelling. The patient may be advised to use crutches and avoid putting weight on the leg for a few weeks while it starts to heal.

For mild (grade one and two) injuries, range of motion and strengthening exercises are started around week two. The physical therapist will guide you in progressing both types of exercises. The rehab program is designed to avoid further damage to the ligament.

At first, the focus is on strengthening the quadriceps muscle. This is the large muscle along the front of your thigh. It inserts all around the knee and helps hold the tibia (lower leg) in place. Without the PCL, the tibia slides backward underneath the femur (thigh bone). A strong quadriceps muscle can prevent this motion and help stabilize the joint.

By the end of six weeks, you will probably be advancing in your rehab program. By now stationary bicycling is an additional part of the program. Between six and 12 weeks, leg presses, half-squats, light jogging, and endurance training will begin.

After 12 weeks, you should be able to return to full activity. This depends on daily compliance with the rehab program.

Chondropenia refers to changes in the articular cartilage of the joint. The articular cartilage is the smooth cartilage over the bone. This smooth surface is what allows the joint to slide and glide easily.

Microtrauma to the cartilage in athletes from high-impact loads can cause loss volume and stiffness of the articular cartilage. This is what is referred to as chondropenia. Lesions or defects in the cartilage make the surface uneven. Pressure on the area can cause further damage.

If other soft tissues in the joint occur at the same time, joint instability can occur. For example ligament tears or meniscal injury lead to further progression of the chondropenic cascade. The final result may be osteoarthritis (OA). Treatment to repair or replace the cartilage defect is advised to avoid this outcome.

Serious problems can occur when someone gets an infection in their joint replacement. These infections can be difficult to treat. The infection can travel throughout the body causing serious health risks. A person’s life can be at stake.

For bacteria that is resistant to antibiotics, the risk of losing the implant is much greater than when a mild infection is present. Patients who have had the infection for more than three weeks are at increased risk of losing the prosthesis.

Saving the knee often requires several steps. The implant must be removed. The joint is cleansed or debrided of all bacteria and infection. The empty space is filled with a special spacer that has been treated with antibiotics.

If the infection can be cleared up, then the spacer is removed and a new implant put back in. This revision procedure is called reimplantation.

Some patients can’t handle all this additional medical treatment. They may have other conditions such as diabetes or heart disease that compromise their health. Their ability to heal is limited. Some patients may do better with an amputation. This may be a reasonable option if they are already wheelchair bound.

If it means saving their life, an amputation may be the treatment of choice.

Infection in a joint can be very serious business. If it travels via the blood supply, it can cause many other problems, even death. Joint infection can be resistant to treatment. Sometimes an antibiotic isn’t enough and further surgery is needed.

There are many factors to be considered in each case. First, the general health and immune status of the patient is very important. Someone with good health and a strong immune system who doesn’t have other diseases or conditions has a better chance of recovery.

The type of infection is also an important factor. Some bacteria such as Methicillin Resistant Staphylococcus aureus (MRSA) have become resistant to most antibiotics. The longer the infection is present, the worse the prognosis.

Infection can cause loosening of the implant. This can put the stability and success of the implant at risk. The surgeon will do everything possible to save the implant. But if there are too many risk factors, then it may be necessary to remove the implant and revise the knee replacement.

Tenoxicam is a nonsteroidal antiinflammatory (NSAID). It can be taken orally in pill form or it can be injected into the joint. Direct delivery is called intraarticular injection. In either method, it provides pain relief and has antiinflammatory effects.

Some NSAIDs cause stomach upset and gastrointestinal (GI) bleeding when taken orally. Bypassing the GI system and giving the medication directly to the joint may be a good idea. It is one that is under investigation at this time.

Patients who have signs of acute synovitis are the most likely candidates for this type of treatment. Synovitis is the term doctors use to describe inflammation of the lining of the joints.

Fluid collection from the inflammatory process causes swelling. Swelling puts pressure on all of the nerve tissue and soft tissue resulting in pain. If the inflammation isn’t controlled, the joint can start to break down.

A recent study comparing oral versus intraarticular injection of tenoxicam showed that treatment by injection gives faster pain relief. And patients who received the injection had fewer flare-ups in the 12 months after treatment.

No one in the study had any bad side effects from the injection. Further studies will be done to verify these findings. If it turns out that locally delivered tenoxicam can regulate the synovium, then it may be possible to use this treatment to prevent future flare-up episodes.

Hyaluronan is a gooey molecule, present throughout the fluid outside our cells. It is a major part of the synovial fluid inside the knee joint. Being gooey helps increase the viscosity of the fluid. That means it lubricates the joint surface and helps the bones slide and glide during motion.

Hyaluronic acid injections may help improve or partially restore the viscosity of the joint fluid. The goal is to lubricate and cushion the joint in an effort to reduce painful symptoms.

The procedure involves a series of injections and is called viscosupplementation. However, it is not advised for patients with acute flare-ups. The acid products used can cause increased synovial fluid build up in some patients.

You may want to ask your doctor about having the fluid removed. This is called joint aspiration. Otherwise, conservative care is still the standard of care. Rest, ice or cold, and nonsteroidal antiinflammatory medications are the first line of treatment.

There are many possible factors that can contribute to patellar instability. Sometimes it’s a simple matter of anatomy. The patella (knee cap) sits over the bottom end of the femur. There’s actually an outward curve in the patella that matches a groove in the femur.

Anything that changes the alignment of these two bones can cause the patella to sublux (move to one side or the other of the midline) or dislocate. If the patella dislocates, it moves completely out of its groove and over to the side of the leg.

There can also be an abnormal Q-angle contributing to dislocation. The Q-angle is the angle formed by the quadriceps muscle and the patellar tendon. This angle represents the force the muscle can place on the patella. An imbalance in muscle pull can displace the patella.

An excessive position of genu valgum also contributes to patellar dislocation. Genu valgum describes the position otherwise known as knock knees.

Surgeons have also reported during surgery for this condition that there is often a very tight retinaculum along the outside edge of the patella. The retinaculum is a band of connective tissue. Releasing this tissue is often the first and simplest step to overcoming the forces contributing to patellar dislocation.

You may be describing a dislocating patella (knee cap). An exam and an X-ray will be needed to diagnose the problem accurately. Two special views taken with X-rays may be used.

The first is the sunrise view. This X-ray shows the knee from up above when it’s bent. You should see the patella lined up at the end of the femur (thigh bone). With a dislocating patella, the knee cap is often out to the side instead of in its natural groove. X-ray views from the front and side with the joint straight and then bent may also be ordered.

You may not be having symptoms now, but pain, crepitus, and loss of motion are common with this problem. Crepitus refers to the grating, crackling, or popping sounds and sensations felt under the skin and joints.

With chronic dislocations, the cartilage on the back of the patella starts to soften and shred. This causes a painful condition called chondromalacia.

Restoring the knee to its normal position and function may require more than a brace or splint. Surgery may be needed for some patients. Before spending money on a brace, see an orthopedic surgeon and find out what are all your treatment options.

You can begin with conservative care and see if that’s all that’s needed before having surgery. For some patients, a series of three or four operations are needed to correct this problem.

Iliotibial band syndrome (ITBS) is a common problem for many athletes. The ITB is a thick but flat band of fibrous connective tissue. It connects between the pelvic crest and the tibia (lower leg bone). This means it crosses over the hip and the knee.

Constant and repeated hip and knee flexion and extension cause the ITB to rub against the femur (thigh bone). Friction builds up until pain develops from irritation. Most likely you feel the pain when your knee is about 30 degrees away from full extension.

There are several possible causes of ITBS. In some people, this band is just naturally in a shortened position. Stretching is needed to keep it flexible, especially when overuse causes it to tighten up.

There may be other muscles around the ITB that are tight contributing to the problem. This can include the gluteus maximus (buttock muscle), hip adductors, or the tensor fascia lata (TRL). Adductor muscles along the inside of the thigh pull the leg toward the midline. The TFL is another portion of connective tissue that inserts along the ITB.

Besides stretching the ITB, gluteus maximus, and adductors, you can also lower your bicycle seat height. This decreases the amount of knee extension during cycling. The result is less tension across the ITB. Seat position may also be important.

Moving the seat forward may take extra tension off the gluteus maximus. A more upright position and forward seat combined together reduce the amount of hip flexion. This releases tension on the gluteus maximus, which in turn, decreases tension on the ITB.

If none of these suggestions work, then there may be some other problem that needs addressing. You may have to seek out the services of an orthopedic surgeon or physical therapist for a proper diagnosis and treatment suggestions.

Without knowing your training regimen, it would be difficult to say exactly what is the problem. We can tell you some of the more common mistakes cyclists make. Perhaps changes in one (or more) of these areas would be helpful to you.

First of all, advancing your training program too fast and too intensely could be the biggest factor. An athletic trainer or fellow cyclist may be able to help you identify how you can progressively build up frequency, intensity, and duration of your training schedule.

Secondly, have someone review your equipment. Using the right kind of shoes is important. Having your bike seat set at the correct height and angle can be a key risk factor for leg injuries.

Overuse and repetitive motion are often the straw that broke the camel’s back, so to speak. Underlying anatomical malalignments of the leg may be what bring on the problems as the training program increases over time. An orthopedic surgeon or physical therapist can examine you and provide direction in this area.

Most overuse or repetitive injuries are preventable. By paying attention to the areas discussed, you should be able to avoid these problems while still advancing your training schedule. Good luck!

Bone grafts are needed for certain orthopedic surgeries performed. For example, any neck or spinal fusion requires bone graft material. Mosaicplasty is another procedure that uses donor bone graft.

Mosaicplasty is a method of treating damage to the cartilage of a joint. Cylindrical-shaped plugs of cartilage and the bone underneath are moved to damaged areas. The plugs are very tiny. When a group of plugs are used, the graft site takes on a mosaic or tile-like appearance.

Graft material can come from the patient. This is called an autologous graft. Or it can be obtained from a donor through a bone bank. Recovery of the donor site is only an issue with autologous donations.

The defect left by removing donor tissue is packed with bone wax during the operation. This helps cut down on the amount of bleeding that occurs after the surgery. MRIs taken later show that the hole fills in with fibrous scar tissue. There is no apparent loss of function at the donor site.

Long-term studies are still needed to see if any degenerative process is started by the donation procedure. MRI signals are not always completely normal after harvesting bone plugs. It’s possible that patients may experience problems years later. This remains to be determined.

There isn’t a formula worked out to predict recovery (or failure) from osteochondral grafting of the knee. Many studies have looked at specific types of treatment. Researchers are trying to find the best way to treat this complex problem.

One factor to consider is how much and what kind of other damage was done. Often when the cartilage is pulled away from the bone, other soft tissue and bony structures are affected, too. For example, there may be ligament or meniscal damage along with the cartilage defect.

Any additional injuries complicates treatment and recovery. The smaller the cartilage tear, the better the chances are for a complete return to full function. In fact, many patients are able to go back to their chosen sport at the same level.

There are patients who do not practice sports at all after this operation. And there are others who return to a level lower than the preinjury level but they are able to play. Predicting who will be in each category isn’t possible yet with the information we have thus far.

Post-operative time lines and rehab programs may vary from surgeon to surgeon. In general, you’ll probably be non-weightbearing at first. This reduces the risk that the graft will get dislodged or damaged in any way.

A physical therapist will help you learn how to use crutches and keep the joint moving while off that leg. You’ll be discharged to home to continue your home program for a month.

At the end of the first month, you may begin to put partial weight on the leg. Again, when and how much weight can be placed on the leg is determined by the surgeon. You will gradually progress to full weightbearing.

A strengthening program is usually begun during the third month after the grafting. The goal is to recover full leg muscle strength. This is done gradually and carefully with monitoring from time to time by the surgeon and/or the therapist.

Athletes who want to return to sports may be allowed to participate in noncontact activities at the end of 12 weeks. Sports involving body contact and potential trauma are not permitted until six month after the procedure.

Total knee arthroplasties, or replacements, can be done with or without special cement to hold them in place. One of the drawbacks of using cemented implants is the cement needs to be applied into the marrow cavity without causing any problems around the area and the cement can crack as it ages, causing debris in the joint. Therefore, doctors do like the idea of cementless implants.

However, cementless implants have their own problems, the main one being that the bone that will hold the implant has to be in good enough condition to do so. Therefore, the doctor has to decide what type of implant is best for each patient, individually, taking into account the reason for the replacement, the general health of the patient, the bone health, the patient’s age, and the patient’s lifestyle.

Part of a knee replacement implant, a total knee arthroscopy implant, is made of polyethylene, a type of plastic polymer, usually on the tibial (shin bone) and patellar (kneecap) surfaces. After a while, the wear and tear that the knee undergoes can cause the polyethylene parts to become damaged. If this wears away completely, the prosthesis will likely need to be replaced.

One thing to also be aware of is if the polyethylene is wearing away, particles may break loose and irritate the tissue. This can cause pain and swelling.

Studies have shown that the anterior cruciate ligament isn’t a single, individual bundle of tissue fibers. Instead, it’s clear that there are two separate bundles or segments of ligament.

The anteromedial bundle is the front and inside portion of the ligament. The posterolateral segment is the back and outside section. Together, these two bundles help provide the stability needed by the joint.

When the ACL is torn or deficient for any reason, the tibia (lower leg bone) slides forward too much. This laxity or looseness can cause the leg to give out from underneath the person. Surgical repair of the ACL may be needed.

New research shows that both bundles may need to be reconstructed separately. The anteromedial portion helps prevent too much forward translation or glide of the tibia. The posterolateral bundle is important in reducing the rotation of the tibia during knee motion.

Improved technology and computer-assisted surgery has made it possible to identify both bundles. Surgical technique is changing from a single-bundle reconstruction to a double-bundle repair.

Patients who report that their knee feels like it’s going to give way may have an ACL deficiency. ACL stands for anterior cruciate ligament. It’s one of two ligaments that criss-cross inside the knee and hold it together while it moves.

The giving way instability occurs mosts often during side-stepping movements or when the player has the foot planted on the ground and tries to rotate the leg around it.

There is a test called the pivot-shift test that may help pinpoint the problem. This test is used by orthopedic surgeons, physical therapists, and athletic trainers. It is the most reliable sign of this type of functional instability of the knee.

Sometimes a mild deficiency of the ACL can be rehabilitated. It takes a concentrated effort for about eight to 12 weeks at least. If there is still too much laxity or looseness and instability after rehab, then surgery to repair the ACL may be needed.

A stiff knee after joint replacement can be a difficult problem to overcome. It’s not likely to resolve on its own. Patients with poor motion before surgery often have poor results after the operation.

It takes a big effort on the part of the patient to regain motion but it can be done. You’ll probably need the help of both your surgeon and a physical therapist to accomplish this.

Besides receiving individual treatment by the therapist, you will have to diligently follow a home program of stretches and exercise. Range of motion will increase but it’s often slow going. Be patient with yourself and with the process.

Your surgeon may suggest a manipulation procedure. Under anesthesia, he or she will move the joint through its full motion. Any scar tissue and adhesions will be stretched or broken. Swelling and more scarring may occur if you don’t keep moving it. Again, your surgeon and therapist will guide you through this process if it’s needed.

Most operations don’t come with a 100 per cent guarantee. There are too many factors that can affect the final outcome. Sometimes patients don’t follow the rehab program carefully. Stiffness, loss of motion, and loss of function are the final outcomes.

In other cases, factors out of the patient’s control can affect the results. For example, an infection can cause implant loosening and failure.

Revision surgery may be more helpful for some problems than for others. When soft tissue tightness called contracture prevents motion, then implant revision may work well.

If there’s a problem with the implant size, design, or other structural problems, then gains in motion and function following revision surgery may only be modest.

Total knee replacements (TKRs) have developed and changed several times in the last 30 years. In the 1970s, the Oxford knee was used. Survival rates of 10-years were excellent at 97 per cent.

But there were problems with tiny particles and debris from wear causing breakdown of the implant. In the 1980s a low contact stress (LCS) implant was designed. This type of TKR allowed for more mobility. The results were very favorable after 10 years. However, the survival rate dropped from 97 per cent at 10 years to 83 per cent at 16 years.

Studies continue to examine different types of TKRs and their overall survivorship. Long-term follow-up of 15 years and beyond still show implant failure is common. The implant may come loose. The plastic liner can fracture. Infection, instability, and dislocation are other reasons reported for implant failure.

Research is ongoing to find better designs for implants used. Improved surgical technique and more advanced technology are also paving the way for less invasive methods of TKRs. But the long-term results of these changes are still 10 years away.