FAQ Category: Knee

The medial collateral ligament runs up and down the inside of the knee. Most injuries here don’t require operations. Some patients have chronic trouble and then an operation may be needed. The medial ligament is linked to the cartilage. Serious problems can occur
if the cartilage is torn loose, too.

There is some difference in opinion among doctors about the best way to treat medial ligament injuries. Most agree that allowing them to heal without surgery is the first choice.

A knee immobilizer can be used to assist in stabilizing the joint. Physical therapy helps the patient regain joint motion and leg strength. Since the medial ligament is outside the joint, it heals more easily than the internal cruciate ligaments. There isn’t a lot of blood supply to ligaments so the injury can take from weeks to years to heal completely.

Most patients with knee arthritis go into this type of operation with one thing in mind: pain relief. They usually want improved function, too. Studies show relief of pain and other symptoms from arthritis is achieved with total knee replacement (TKR). There’s a
high rate of satisfaction on the part of most patients.

The down side of this operation has also been reported. Muscle weakness is present in one-third of all TKR patients. They move and walk slower than they used to, especially on stairs. Quality of life after TKR is improved, but it’s less than adults the same age who don’t have a TKR.

The operation itself is less invasive with fewer complications. Recovery and release from the hospital or surgical center is also faster these days. In some cases, that means lower costs. The improved technology has raised costs so much, sometimes the price tag is
just as high, if not higher, even with less time in the hospital.

Your concern is certainly justified. Since we know knee replacements have a long, but limited life, it’s a good idea to take care of it as best as possible. Exercise is a key to preventing uneven wear on the joint. Strong muscles on either side of the knee and above and below the joint will also keep it from having too much pressure that can wear
it down.

Results of many studies using patients with arthritis support the use of an intense rehab program. Each program should be designed for each patient. One size does not fit all!

In general, it is true the early weeks of rehab focus on helping the joint heal. Gentle exercises, massage, and medications help reduce pain, swelling, and stiffness. After the
acute healing phase, more aggressive exercise and movement can be added.

In fact studies show weakness remains a problem for many patients with a total knee joint a year after the operation. Weak muscles around the joint put the knee at risk for problems later.

It’s not uncommon for tests to show a stable knee while the patient has symptoms of pain, swelling, and giving way. The opposite can happen, too. The patient may feel great and start playing sports again while the doctor is finding evidence of instability.

Why the difference? Scientists aren’t sure. It may be the ligament is fine, but other parts of the knee aren’t working normally yet. There are receptors that sense the joint’s
position and movement. Perhaps these have been damaged and aren’t “firing” properly yet.

Some studies suggest the muscles aren’t coordinated normally after injury and surgery. This is called motor control. You may need a rehab program to address these specific issues now that the ligament is stable. Talk to your doctor about your concerns
and ask about returning to rehab for a short time.

Studies show knee osteoarthritis (OA) occurs in six percent of adults 30 years of age and older. That figure goes up to 11 percent for adults over age 65. As we age, more and more adults are affected by OA.

In fact, together knee and hip osteoarthritis account for more disability than any other condition for older adults. Women are affected by knee OA more often than men, too.

Surgery is often used when the knee wears down more on one side than the other. An operation to change the angle of the knee (called osteotomy) is used with some success. There can be problems with this operation, so researchers are looking for some
other safe options.

One of these new options is the use of a special insole inserted into the shoe. The insole is made of a rubber sponge material so it’s firm enough to support the bones in the ankle, but it’s soft enough to be comfortable. The insole is wedged by eight to 12 mm
and held in place with an elastic strap.

A new study from Japan using the wedge showed patients could walk farther with fewer symptoms during activity and at rest. More studies are needed to find other alternatives to surgery for young patients with severe problems from osteoarthritis.

Wedge insoles made of a rubbery sponge material were used in a study of patients with uneven wear of the knee from osteoarthritis. Dr. Toda teamed up with a physical therapist and a nurse to try the insoles with 62 women in three age groups.

Three sizes of wedges were used. They found the biggest wedge gave the best correction of ankle and knee angle, but it was the most uncomfortable. A lower wedge (eight or 12 mm) works well for regular day-to-day use. Sponge rubber was used at first, but the
researchers switched to urethane foam, a softer blend of plastics.

The researchers reported the best tilt of the wedge may be decided by the patient’s age.
Older patients may need a lower tilt. Muscle weakness in the lower leg may interfere with the wedge working well. Because problems can occur, it’s best to work with a physical therapist and an orthotist (someone trained in specialized shoe inserts) instead of buying something off the shelf and treating yourself.

Most patients have a fair amount of pain, swelling, and stiffness the first eight weeks. They aren’t always able to advance their rehab program. The first two weeks are usually focused on warm-ups, specific exercises to strengthen the muscles, followed by a cool-down exercise period.

From two to six weeks more time is spent on functional skills like walking and stair climbing. Exercises get harder and last longer starting at five minutes and moving up to 20 minutes. By the end of six weeks the knee joint is ready to handle more demanding activity and exercise.

You’ll want to check with your doctor about how far and how fast you can go now. Having a physical therapist to supervise your home program is often a good idea.

The KT-1000 arthrometer is a small device that’s strapped to the leg during knee examination. It’s used when the doctor thinks there may be a tear in the anterior cruciate ligament (ACL).

The examiner pulls on the uninjured knee and the gauge on the KT
1000 shows how many millimeters of motion occur between the lower
leg bone (tibia) and the upper leg (femur). This motion is called
a drawer sign. The reading is compared between the injured
knee and the normal knee.

If there’s more than three millimeters difference between the
knees, the ACL is torn. It’s considered more accurate than an
MRI.

If you’d like to see a photo of this tool go to:
http://www.medmetric.com/kt1.htm or

http://www.ismoc.net/procedures/kt1000.html.

The trend in treating torn knee meniscus has gone from removing it to repairing it to leaving it alone. Studies show removing the cartilage changes the weight-bearing surface
of the joint. Changes in force through the knee lead to arthritic changes in the joint.

Researchers have shown leaving the meniscus alone can result in healing. By leaving the meniscus alone, there’s less damage to the blood vessels and nerves in the area.

Tears more than one cm long may need some help. Doctors can shave down the area and remove any fragments. The tear may be long enough to flap over on itself during movement. This can be painful and lock the knee up. In such cases, the doctor may choose to stitch
the cartilage down in place without risking further damage to the knee.

There’s been a change in the way doctors think about meniscal tears these days. Studies show long-term problems occur when the meniscus is removed. For a while they were repairing the tear. They did this by shaving off any frayed edges and stitching it back down to the bone.

More studies showed even this wasn’t needed. The meniscus seems to be able to heal itself better when left alone.

Repair isn’t needed if the tear is “stable.” Stable means the torn piece doesn’t move around, flap over, or get stuck inside the joint causing clicking, catching, or locking. The doctor can test this by using a probe and trying to move the injured meniscus.

Usually tears in the back half of the knee are stable. Tears smaller than one cm are also more likely to remain stable.

The dominant leg is usually the same side as the preferred hand. Sometimes people do have mixed dominance. This means like you they use the hand on one side and the leg on the other side most often. There is also eye and ear dominance based on which side is preferred.

Some soccer coaches think being able to use either leg equally is better than being strongly dominant on one side of the other. Your coach may not know you already use either leg equally well. You may want to discuss this further before training one side more than the other.

It’s true studies show female athletes are four to six times more likely to injure the knee. One factor may be the difference in proprioception between men and women. Joint proprioception is the ability to sense joint position.

Fatigue of the leg or overall body fatigue may affect proprioception. Men seem to be affected by this more than women. This factor may help explain injuries in men. Some other mechanism of injury may be important for women.

Researchers get a better picture of results by studying just men or just women instead of a mixed group. Both kinds of studies are underway.

Trephination comes from the Greek and means “auger” or “borer.” More to the point, it involves an opening made by a circular saw of any type.

As a surgical procedure, trephination of the skull has been around since early
civilization. No one knows exactly why, but it is thought that it was done to allow spirits to come or go. It may have been done for headaches, fractures, infections, insanity, or for convulsions.

Some think it was done to get the disks of bone to use for charms, amulets, or talismans.

Today, trephination is sometimes used on damaged meniscus to stimulate blood flow by opening channels for blood to pass through. Many holes or shavings are made in the torn part of the meniscus. The idea is to promote healing with better blood flow to the area.

You can see a drawing of this procedure at
http://www.steadman-hawkins.com/meniscus/treat.asp and an animated video at http://www.emedx.com/emedx/diagnosis_information/knee_disorders/meniscus_trephination_sur
gery_animation.htm.

Studies do indeed show the greatest chances of injury to skiers occur in the afternoon. It’s also true that injuries to football players are higher in the third quarter of a game. Coincidence?

Researchers don’t think so. They say general fatigue in athletes may be the key factor in these injuries. Fatigue leads to a decline in knee proprioception. Proprioception is the joint’s sense of position. Fatigue and then decreased proprioception can result in ligament injuries.

Change in neuromuscular control may be a factor, too. This is the link between messages to the nerve telling the muscle what to do and when to do it. Special exercise to improve motor control may help reduce these “third quarter” injuries.

Jenny McConnell is a physical therapist from Australia. She came up with a treatment plan using taping and exercise for a condition called patellofemoral pain syndrome (PFPS). It’s been used for the last 20 years with good results.

The taping is designed to pull the patella (kneecap) over the middle of the knee. This helps the patella track or glide up and down properly.

McConnell taping is done by trained physical therapists and athletic trainers. They use a special kind of tape that holds in place while the leg moves. Once the therapist or
trainer decides the right taping method to use for your problem, you can learn how to apply it to yourself.

Cold therapy is usually used to reduce pain and swelling. It works by closing down blood vessels. This helps reduce swelling by decreasing the amount of fluid volume near the joint.

Cold also slows down the tissue metabolism. This means the tissues need fewer nutrients. It also stops the release of enzymes. This reduces damage to the tissues. There’s less swelling and less pain.

Using heat on a joint that’s already painful and swollen can cause the symptoms to get worse. Heat opens up the blood vessels and brings more blood to the area. More fluid puts pressure on all the soft tissues in the area. There is a place for heat when a joint or
injury is more chronic. A new (acute) condition responds better to cold.

It’s best to follow your doctor’s guidelines. Your age and overall health make a difference. The amount of disease present in your other knee is also a factor. Wear and tear on the new implant can be affected by increased load when the other knee doesn’t carry its fair share.

The type of implant used will also dictate how often you see the doctor. Early detection of problems like cracking, loosening, or uneven wear can save the implant and keep you from having major surgery again. Since the average joint implant lasts 10 to 15 years, it’s reasonable to have your doctor follow you throughout that time.

Anyone with a total knee replacement (TKR) should see the doctor every one to two years for follow-up. X-rays and exam can find problems early before symptoms occur. Cracking or wear of the implant can be treated early before extensive surgery is needed. The same is
true for loosening of any part of the TKR. A delay in diagnosis can lead to many other problems later.

Keeping track of patients also helps doctors see what kind of results they are getting with their surgical methods. The information helps doctors give each patient the best care possible.

These days more and more doctors are keeping long-term records. It helps give them an idea of what works well and what doesn’t. For example problems with joint replacements can develop years later that could have been stopped early with regular follow-up exams.

Patient education is the first key. Patients must be told about the importance of keeping their follow-up appointments. Sometimes patients get “lost” because they move or die.
They should be reminded to let the doctor’s office staff know if there’s any change in their address or phone number. Family members can be asked to notify the doctor’s office in case of a major change in health, location, or even in the case of death.

The internet is also a useful tool. Various free search engines can be used to find
patients who are lost in follow-up. The Social Security Death Index (http://www.ancestry.com) can be used to find patients who
have died. Telephone directories such as
http://www.anywho.com or
http://www.superpages.com are also available.