FAQ Category: Knee

Ligamentous laxity has been linked with athletic injury. It’s commonly believed that knee hyperextension puts people at risk for anterior cruciate ligament (ACL) injury. There isn’t much to back that idea up. Only one study has been done in this area.

Researchers at the SUNY Upstate Medical University in New York reported on the effect of knee hyperextension and ACL injury. They looked at joint mobility among college athletes.
White men and women were included. They found both knee and elbow hyperextension were common among athletes who had noncontact ACL tears.

Women have more ACL injuries than men–even when both have generalized ligamentous laxity and hyperextended joints. So female gender is a risk factor, too.

Anterior cruciate ligament (ACL) repairs are often done using a piece of the patellar tendon in front of the knee as a graft to replace the torn tendon. After removing this piece of tendon and stitching the tendon back together, the surgeon makes sure the patellar tendon isn’t too tight.

If it’s too tight it pulls the kneecap (patella) down. When the patella is down too far, the condition is called patella baja. The opposite (patella up too high) is called patella alta.

You may be describing what’s called crepitus. This sound or feeling occurs when the back of the kneecap grates against the bone. This finding is more common before the ACL repair is done rather than afterwards.

Any snaps, clicks, crepitus, or joint sounds should be reported to the surgeon. The same goes for locking or giving way of the knee joint. Crepitus or similar sounds could occur when the extensor mechanism of the quadriceps muscle isn’t working quite right. This can occur when scar tissue forms or if the tendon has been shortened too much.

The doctor will be able to tell the difference between sounds caused by scar tissue and those caused by cartilage rubbing against bone. There may be some treatment that can help you. It’s not a normal sound and should be taken care of before it gets worse.

Repairing a ruptured anterior cruciate ligament (ACL) depends on ligament substitutes. Tissue from some other part of the body or from a donor is needed to take the place of the torn ACL.

Most often the graft tissue is taken from the patient’s hamstrings muscle or the patellar tendon. This is called an autograft.

When the hamstring is used, the harvested tissue is folded in half twice to make a stronger graft. When the patellar tendon is harvested, a small plug of bone is taken on both ends and used in the repair process.

Donor tissue from a cadaver is also possible. This is referred to as an allograft. It can be taken from the patellar tendon, hamstrings, or Achilles tendon.

Ligaments are not elastic like muscles. When they tear, it’s like a broken rubber band. It doesn’t grow back together. In order to fix a ruptured anterior cruciate ligament (ACL), surgeons take a piece of tendon tissue from some other place and transfer or graft it into place.

The two most common ACL repairs are done with a bone-patellar tendon-bone (BPTB) graft or a hamstring tendon (HT) graft. The patellar tendon is in front of the knee just below the kneecap. A small piece of bone is taken along with the tendon tissue.

The hamstring tendon is attached to the large muscle behind the thigh. The tendon is harvested and folded in half to increase the strength of the graft. The goal is to use a graft material that is easy to remove, gives a strong repair, and results in no problems afterwards. The long-term goal is to restore function and allow the patient to get back to a preinjury level of activity.

The doctor and/or the therapist may be using two tests of joint motion to look for joint laxity and joint stability. One is called the Lachman test. The other is the pivot-shift test.

Most of the time patient satisfaction and return to previous level of athletics or other daily activities are the most commonly used measures of success.

Does the knee or leg ever give way underneath you? Have you had to have a second or third operation after the ACL repair? Do you have any knee pain and/or swelling? Any of these problems may be a sign that the surgery hasn’t been a success.

In some physical therapy clinics. Special machines are available to test your strength through the available range of motion under different load levels. Expect to see gradual increase in strength over time as a measure of success.

It should but there are no guarantees. It may depend on the condition of the rest of your knee joint. Are the other ligaments okay? What about the cartilage? Are there any signs of advancing arthritis? How much strength do you have in the muscles around the knee joint? These are all important factors.

There are two popular ways to repair a torn anterior cruciate ligament (ACL). One of these methods called the bone-patellar tendon-bone graft has been shown to be 22 percent more stable. In other words, it’s less likely to give way because of joint laxity. The increased graft strength may come from the small piece of bone plug that’s used along with the tendon tissue to make the repair.

The choice of graft material must be made on a case-by-case basis. It’s an educated decision based on the condition of your joint, your activity level, your goals, and the surgeon’s level of expertise.

Research data shows patients get relief from pain after a total knee replacement (TKR). But residual disability is common as you’ve noticed. Most patients get enough motion and strength back to do their daily tasks.

Recovery to pre-TKR levels just doesn’t happen for the average person. A year after the operation, most patients go up and down stairs at half the speed of healthy adults the same age. Squatting, gardening, and heavy housework often go by the wayside. Patients with TKRs walk slower and shorter distances than before the surgery.

Physical therapists are studying this problem. They hope to find ways to prevent or overcome these problems. A recent study from the University of Delaware suggests strengthening the quadriceps (thigh) muscle may be a key factor.

You and your friends are in the majority. Osteoarthritis (OA) is two and a half times more common than heart disease and six times more common than cancer. The incidence of both OA and cancer increase with age.

Since Americans are living longer with more active lifestyles, OA is expected to affect many more adults in the years ahead. An active lifestyle may be preventative for cancer. The odds are that cases of OA will continue to outnumber cancer in the near future.

Creatine helps the body build up muscle energy. More energy means better muscle contraction. Creatine monohydrate has been studied in boys with Duchenne’s muscular dystrophy. The results showed decreased bone breakdown. There may even be some increased bone mineral density when taking this supplement.

In another study creatine upplementation increased handgrip strength in boys with Duchenne’s. There’s one important finding from these studies. Improvement seems to occur when the body part in question is active. In the study with Duchenne’s only the arm strength in the dominant hand improved. Leg strength didn’t change in those boys who didn’t use their legs.

There are some side effects with creatine use. Weight gain, gas, and bloating are most common. Kidney stones can occur with high doses of creatine. Behavioral changes have also been reported.

No one knows the effect of taking creatine with other drugs or supplements. Check with your doctor before adding any new supplement.

Studies have shown that taking creatine supplements can help patients regain strength after surgery. However, a recent study of patients after total knee replacement didn’t reproduce these findings. In fact, knee and ankle strength went down 30 days after the
operation.

This study may be the first to point out the importance of physical activity and exercise when taking creatine. Movement and especially resistance to muscles seem to help the creatine get ransported into the muscles for active use.

Taking creatine supplements before and after joint replacement isn’t advised at this time. Talk to your doctor before taking any supplements. Some supplements shouldn’t be taken with other drugs or combined with anesthesia.

It’s true that the “no pain, no gain” thinking helps many athletes improve in many areas but it’s the enemy of anyone with patellofemoral pain (PFP). The goal is to reduce pain and improve function. The way to get there is with activities that don’t increase pain.

Research shows that putting load on a joint without overloading it is the way to go. Keeping the patient’s level of activity below what would trigger pain prevents tissue damage. Slow but steady progression of strength and flexibility are the keys to success in treating PFP.

First the therapist will help PFP patients find exercises that don’t cause pain. Icing and the use of pain relievers can help. Some patients need to start in a pool therapy program before attempting dry land training. More repetitions and more load can be added slowly so long as they don’t cause pain.

Patellar (kneecap) taping has been used with good results in many patients with patellofemoral pain (PFP). Decreased pain and increased function are the two main benefits of taping.

Studies have not been able to show a difference in alignment to explain why taping works. Some doctors think taping helps with the timing of muscle contractions. Patients with PFP have been shown to have abnormal contraction of the four parts that make up the quadriceps muscle.

Other parts of rehab may be equally important in the overall results. Strengthening the quadriceps muscle will help with activities like walking down the stairs. The quadriceps power is used in this activity to keep the knee from collapsing under the load.

Flexibility is important too. Poor flexibility may add to the load on the PF joint. Flexible muscles help absorb energy during loading activities. Joint proprioception or sense of position must be retrained, too.

So if you find your results are short-lived and you have to tape for more than six weeks, reconsider some of these other elements of rehab for PFP.

Many studies have been done to show before and after results with rehab for patellofemoral pain syndrome (PFPS). They look at the position of the kneecap (patella) in the groove where it tracks up and down. Some studies have found mild improvement after treatment. But other studies have shown that X-ray alignment was the same between the painful and pain free knees.

In fact patients with severe joint changes on X-ray may get better with treatment while patients with mild changes don’t.

What researchers have found is that patients who get better have improved muscle strength and flexibility. They used a combination of rest, ice, and activity to get better. Exercises to restore normal timing of contraction seemed to help. Rehab to improve joint position sense called proprioception is also important.

Patellar replacement called patellar resurfacing may extend the life of the implant. It has been shown to reduce knee pain after surgery. It can also improve function after total knee replacement (TKR).

There seems to be a higher rate of reoperation for patients with patellar resurfacing. Some doctors think resurfacing should be saved for patients with rheumatoid arthritis or severe pain after surgery. A large or thick patella can also keep a patient from having the patella resurfaced.

Overweight patients and those who have had many knee operations are also not advised to have patellar resurfacing done.

Many trials have a small number of patients. This can make it difficult to see differences between two treatment options.

Some studies go longer than others. The length of time can make it impossible to compare results over time.

Other factors can get in the way of making comparisons. Type of implant used, general health before surgery, and amount of soft tissue cut during the operation can affect the results.

Ask your mother’s orthopedic surgeon for his or her advice. He or she may be able to give you some insights to help with the decision. There may be some specific reasons why your mother should have one type over another.

Kneecap replacement is called patellar resurfacing. Most of today’s new patellae are made of plastic (polyethylene). Metal backed implants have been used but the metal debris caused problems in the joint.

Plastic backed kneecaps can still wear out or wear unevenly over time. They can be very difficult to remove and replace years later. The biggest plus to patellar resurfacing is the decrease in knee pain after surgery. Chronic knee pain is more common when the kneecap isn’t replaced.

Problems can occur if the kneecap isn’t replaced and the blood supply is cut off during surgery. The bone can actually die, a condition called osteonecrosis. This doesn’t happen very often. It’s more likely to occur when large amounts of soft tissue must be cut or released.

If the muscles around the knee are out of balance, the patella may not move up and down as it should. Tracking problems can occur in both kinds of patellae. More and more studies support the use of resurfaced patellae. Long-term studies (more than five years) may offer extra information in years to come.

A little bit of both. While it’s true surgeons are hesitant to replace a “young” knee, joint replacements in adults ages 45 to 64 has risen by 10 percent in the past 10 years. Rates of hip and knee implants are the highest in adults between ages 65 and 84.

Surgeons are still concerned about the revision rate for adults having joint replacements at a young age. Enough bone is removed and changes made in the joint structure the first time that a second replacement can be risky. Since the average life of an implant is 10 to 15 years, it’s a safe bet that a 45-year old will likely need at least one more joint implant before age 80.

There are surgeons who will replace a joint in a 45-year old under the right circumstances. Most agree it’s best to keep active, maintain your strength, and wait.

Technology in terms of the implants and the surgery is changing so fast it’s hard to predict. From what we can see so far, it looks like joint replacement will be as common for the Baby Boomers in the 21st century as taking out the tonsils was in the 20th century.

Another trend might be getting joint implants at a younger age. Partial replacements will be a popular way to prevent uneven wear and tear from continuing once the joint starts to break down. Scientists are also looking for ways to regenerate joint tissue to avoid replacement altogether. Stem cells may play a key role in that research.

Hopefully the next generation will remain active with lower rates of obesity and arthritis. This might help them avoid joint problems in the older decades. Better care of joint injuries during the younger years will also make a difference. For example in the knee, cartilage tears meant removing the entire meniscus. This led to more joint damage later. With repairs of these injuries rather than removal, the future looks much better for injured athletes. They may be able to avoid joint replacements.

The real record is in how many more people are having joint replacements each year compared to the previous year. In the past 10 years the number of total hip replacements has doubled. The number of total knee replacements has tripled.

People who study statistics and report trends agree this is a fast growing upward trend. The increase in obesity and osteoarthritis seem to be behind the big push. New implants
and improved technology have also been a factor in the increased numbers.

Researchers expect to see this growth continue at least for a while. Not only that but as more and more people have their first joint replacement, the number of revisions will go up, too. Either problems will develop and the implant will have to be repaired or replaced–or younger adults getting implants will wear them out and need new ones.