FAQ Category: Knee

Dr. Ron Losee from Ennis, Montana, was the first to describe a test for ACL instability. It was called the Losee maneuver for many years. Now it’s sometimes referred to as the “pivot-shift” test.

When the test is done, the patient is asked, “Is this how your knee feels when it gives out?” The doctor doesn’t always feel a change in the knee during the test, so the patient’s report is important.

A positive pivot-shift may be a sign that surgery is needed to repair the torn ligament. There is a device that measures laxity between the two knees (a KT-2000). The results of one test usually aren’t enough to tell which patients need an operation. Tests like the pivot-shift, along with several others, are still important.

If you are interested, Dr. Losee has written a book about his experiences. It’s called Doc: Then and Now with a Montana Physician. To read more about this book, go to: http://www.smithsonianmag.si.edu/smithsonian/issues95/may95/book_may95.html#doc.

Chondromalacia refers to softening of the cartilage behind the knee. It causes pain and sometimes a feeling or even the sound of crunching called crepitus behind
the patella (kneecap). The pain and crepitus occur when the patella moves up and down.

Controlling the patella is important in treating this condition. Taping doesn’t always work. The patella doesn’t stay in place during physical activity and exercise. Studies show bracing does change the position of the patella.

Controlling the patella is important when dealing with chondromalacia. Finding the right brace can be a challenge. There are some braces on the market that offer pressure in all
directions to hold the patella. Keeping the kneecap from tilting is also important.

Look for a brace with a strap or support that will hold the patella firmly in place. A physical therapist or athletic trainer can help you find the right one for your knee.

There are three main taping techniques used here in the United States. There’s a technique using regular white athletic taping, McConnell taping, and Kinesio Taping®.
There are apparent differences but no studies yet comparing them to show results.

White athletic tape is rigid and requires a pre-wrap before putting it on. It is used to prevent injuries or for injuries right after they occur. It’s usually used just during
the activity. The tape often irritates the skin when moisture gets trapped under it. Some people are allergic to the latex in the tape. There’s no proven benefit to this method.

McConnell taping is a bracing or strapping technique using a super-rigid, cotton mesh tape. It’s very adhesive and is sold as EnduraTape® or LuekoTape®. Its use got started with a knee problem called patellofemoral syndrome (PFPS). Now it’s also used for
the back, shoulder, foot, and hip. It’s usually only left on for short periods, due to possible skin reactions. Some people say it’s too “tight” and feels “suffocating.” Studies show mixed results for this method.

Kinesio Taping® gives support while allowing full motion. It’s latex-free and doesn’t compress the skin. Some people use it for several days up to a week. It’s water resistant so moisture doesn’t get trapped under it and the patient can bathe with it on. Some physical therapists are trying it for a swelling condition called lymphedema. Studies are underway for this taping technique, too.

Doctors use what’s called a second-look arthroscopy to assess the results of knee meniscal repair. An arthroscope is a long needle-shaped tool with a tiny TV camera on the end. It’s inserted into the joint giving the doctor a look inside the joint.

A second way to judge the condition of the knee is with an MRI. An MRI scan can show any changes in the repaired or healing cartilage. Likewise, if the cartilage and a ligament was torn, both of these can be re-checked using MRIs even years later.

A recent study using both X-rays and MRIs compared the results of surgery after knee injury. One group had a torn meniscus repaired. The second group had a torn meniscus with a torn ligament repaired. Eight to 15 years later, the group with both cartilage and
ligament damage had more arthritis.

Repair, rather than removing torn knee cartilage is the latest direction in the treatment of this problem. Studies show less arthritis later on. However, repaired cartilage is
still weaker than normal. The cartilage can tear again later.

Doctors aren’t really sure the repaired meniscus will function normally. At this point, researchers think a repaired meniscus is still better than none at all. More studies are needed to answer your question.

We judge this based on the results of studies done after meniscus repair. An arthroscope is used to go inside the knee and take a “second look” after the first operation.

Normal healing takes about six to eight weeks. Full strength comes back in 12 to 18 months. If the patient doesn’t want to have an arthroscopy, MRIs can also judge meniscus healing.

There are two possible choices: steroid injection or hyaluronic acid. You will have to check with your doctor to find out which one is planned.

The steroid injection is a combination of three drugs. There’s a local anesthetic like Xylocaine or lidocaine. This agent gives fast pain relief. There are two steroid compounds given for their antiinflammatory properties. One is a slow-acting drug. The other is more quick-acting. Studies report combining the steroid with the anesthetic gives pain relief for up to three weeks.

The other type of injectable treatment is with a joint fluid replacement. Most often hyaluronic acid is used. This is actually made from the coxcombs of roosters. It’s injected into the joint in a series of about three injections over six months time. It acts to lubricate the knee in patients who still have some cartilage left. There’s a 50-50 chance it will work to give you less pain and more protection to the joint.

Walking speed and cadence or rhythm are often changed by pain and discomfort that comes with hip or knee osteoarthritis (OA). The first thing is to see your doctor for possible treatment options.

Pain is usually a way the body has to protect the joint. Shifting the weight to the other side and putting less load through the joint protects the joint. Weight loss can be a big help to anyone with hip or knee arthritis. Antiinflammatory and analgesic (pain
relievers) drugs can help with the symptoms.

Sometimes injections of steroids or a special lubricating fluid can help. An X-ray is needed to find out how much joint space is left and how much damage is present. After starting with medical treatment, pay a visit to a physical therapist to work on your gait pattern. A few short sessions can help find muscle imbalance and weakness that may be additional factors. Good luck!

Quality of life (QOL) goes beyond just the physical. It also takes into account the patient’s social and emotional responses. Is the patient happy with the results? Is he or
she sleeping better? What’s the patient’s energy level after the recovery from the operation?

Other measures of QOL include mood and mobility. Is the patient emotionally stable? Can he or she get around better?

QOL is more about the patient’s sense of well-being than the physical results.

Most patients get relief from symptoms of pain and stiffness after a total knee replacement. Many have improved physical function. In other words they can do more with less pain.

There may be several factors at work in your mother’s case. First, it takes at least 12 months for full recovery after this type of surgery. At six months your mother still has a ways to go in terms of healing, symptoms, and function.

Second, what is her overall, general health? The presence of any other problems or conditions may delay her recovery from the total knee replacement (TKR). Finally, how does she view the results?

Many times patients’ quality of life is much better after a TKR. You might not know this without asking your mother some specific questions about her own satisfaction with the results.

Most doctors will send you to a physical therapist who can guide you through this process. Exercises at the beginning of rehab are different from what your knee can handle later. The goal is to get as much motion back as possible without damaging the knee any
further.

The healing graft is under increased strain when the knee is in the fully extended position. Closed kinetic chain exercises with the foot on the floor or other surface strain the ACL less when the hip is bent. An example of this activity would be the mini-squats often prescribed in the early phase of rehab.

High demand exercises such as the lunge can be done when the squat is deemed safe to do after ACL repair. Then comes the step-up, step-down, and sit to stand exercises. These can all done on one leg. Each one puts about the same amount of strain on the healing graft.

Good question and one that is under investigation. Researchers in Sweden, for example, tried to measure the strain on the anterior cruciate ligament (ACL) during four exercises commonly used in the early phases of rehab.

They found that the position of the knee joint was the key factor. The straighter the knee, the greater the strain. At this point in the research of this topic, we don’t have actual strain measurements on the ligament for different positions and movements.

Researchers are also looking at differences in the kind of strain. Strain from
compression through the joint may be very different from a shearing force across the knee. So twisting the knee when the foot is planted on the ground with the knee straight and the body weight over it may be more dangerous than other positions with the knee
bent.

You may want to discuss this with your therapist. It’s best to work out a schedule that will enable you to exercise throughout the day at regular intervals. It’s understood that
early on in the rehab program patients are still recovering from the operation. This is also the crucial time for getting as much motion as possible.

Maintain a good diet and get plenty of sleep at night. Check with your doctor about your fatigue level if it seems excessive. It may be drug-induced or you could have some other medical reason for it.

Some patients choose two times during the day when they set aside what they are doing and carry out their exercises. Others prefer to set a timer and do one or two exercises every hour. Your therapist will be able to advise you on which is best for you depending on how much joint motion you have.

Find out what your joint motion is and how much you need to increase it for each day, week, and over the next month. Make that your goal and work towards it everyday.

It sounds like the therapist was measuring joint position sense. This is called proprioception. The joint is bent or straightened by the therapist and the patient tells when movement is first felt.

Right now researchers are trying to find out more about proprioception. What’s normal? Does it change as we get older? Is it the same for men and women? What happens when the joint becomes arthritic? Scientists hope to find an exercise program to restore
proprioception–maybe even reverse the effects of arthritis.

Not likely or you would probably have had knee problems at a young age. There are two ligaments that criss-cross inside the knee joint–the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). Together, these ligaments help hold the joint together and keep it stable during movement.

Torn or damaged knee ligaments can occur with trauma, injury, or age. Many patients having a total knee replacement have a deficient ACL. An earlier injury and torn ligament often lead to knee arthritis. Less commonly, the PCL is involved.

It’s rare to have both ligaments missing at the same time. This is a sign of severe injury, probably more than one–since the mechanism of injury is different for each one.

The sense of joint position is called proprioception. Research shows that proprioception is altered with osteoarthritis. The more severe the patient’s symptoms, the longer it takes for the knee to register its position.

Scientists aren’t sure if the arthritic changes cause the change in joint position sense or the other way around. There could be other causes for your problem such as loss of joint motion and muscle weakness. It might be a good idea to have this checked out before a misstep causes a serious problem.

The jury is still out on this one. We can give you the results so far. Studies show balance and strength training are important. Flexibility is also a key feature in prevention programs. Training in all three of these areas is advised for the ankle, knee, and hip.

Single-leg balance drills have been shown to decrease knee injuries in female athletes. Forward and backward motion of the joint is improved with these exercises. Side-to-side motion is not as likely to change.

The results of studies so far suggest preseason training works well for athletes at risk for ACL injury. This includes female athletes with increased forward joint motion of the tibia (lower leg) against the femur (upper leg). Team training is good, but preventing injury works best by looking at each player’s needs and providing individual training.

There are many parts to recovery after ACL reconstruction. Rehab can move forward quickly if there aren’t any complications and the joint is mechanically stable. Your doctor and
your physical therapist will help you know when the time is right to start each phase of your rehab program.

Studies show the joint’s sense of position, called proprioception, comes back slowly over the first nine to 12 months. Most rehab programs focus on balance and proprioception during this time. Strength training and flexibility are also important.

Agility training to restore functional stability comes in later phases of rehab. You probably won’t be 100 percent at six months but if all goes well, you’ll be safe to
resume sports. Follow your doctor’s advice carefully for the best long-term results.

Female athletes are six times more likely to injure the anterior cruciate ligament (ACL) of the knee than male athletes. The exact reason for this remains a mystery. There may be
several factors involved. Scientists suggest anatomy, poor exercise training, or hormones as possible causes.

Sports scientists have also found greater forward slippage of the tibia (lower leg bone) during sudden stops or stop-jumps. The shear force during the landing phase of these activities may cause the ACL to tear. The ACL is one of two ligaments that cross inside
the knee joint. It keeps the tibia from slipping too far forward.

Two new bits of news have been added to the data bank of information on ACL tears in women. First, it’s been found that women have more coronal plane motion in the knee compared to men. This means there’s more forward slippage naturally. A second new finding is the role of balance on knee joint stability.

Each new study brings us closer to finding ways to prevent ACL injuries. This information is also being used to study which exercises are best for retraining after injury to this
ligament.

Hyaluronate injections into the knee are used to restore the lubrication in the joint. It helps make the joint fluid more slippery. In some cases, it can increase the amount of lubricating fluid. The result is better joint function and less pain. It may even slow
down the loss of fluid.

A recent study from Taiwan compared 30 arthritic knees against 30 normal knees. The arthritic knees were injected for five days. Walking pattern and force through the joint from the ground up were measured and compared between the two groups.

The hyaluronate resulted in changes for the arthritic knees right away. There was less force through the joint. The patients could walk better and more easily. The changes lasted at least six months.

This treatment method works best for patients with mild to moderate osteoarthritis. There must be some joint space still present on X-rays. Patients with joint infection or implant are not good candidates for these injections.