FAQ Category: Knee

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.

Anterior Cruciate Ligament (ACL) injuries are a problem for many athletes in noncontact sports. Volleyball players are at increased risk because of the landing, turning, and pivoting required. Female athletes are up to eight times more likely to injure the ACL compared to male athletes.

Many studies have been done trying to find out the specific cause and ways to prevent ACL tears. Researchers have looked at weather conditions, playing surface, and footwear. They’ve examined hormonal differences between boys and girls. They’ve compared anatomy from head to toe as a possible reason for differences in the rates of ACL injuries between the sexes.

So far no single factor has been linked to ACL injuries. Bracing hasn’t been proven to prevent knee injuries either. Balance training and improving the joint’s sense of position seem to have the best record so far in preventing these types of knee injuries.

Studies focusing on improving balance and control of the knee throughout movement have reported positive results so far. Recently a new soccer training program was tried with girls ages 14 to 18.

They learned how to use deep hip and knee flexion instead of landing on a flat foot. They carried out a warm-up and exercise training program specific to the sport. Agility drills were geared toward soccer turns and pivots. They also practiced a multistep stop instead
of a single fast and forceful step.

All of this resulted in an 88 percent decrease in ACL injuries compared to a similar group who still did the traditional soccer warm-ups.

The program called Prevent Injury and Enhance Performance (PEP) included an instructional videotape. Basic-warm up activities along with stretching and strengthening activities are demonstrated. Proper technique during agility drills are also included.

Anterior cruciate ligament (ACL) tears are a common knee injury in athletes. Studies do show that female athletes are two to eight times more likely to injure the ACL in noncontact sports activities. Soccer, basketball, and volleyball players seem to be at greatest risk.

Researchers are studying the differences between male and female athletes doing the same sports activities. If they can find a specific cause for the problem, they may be able to prevent it from happening.

So far they’ve been able to show it’s not one single factor causing the problem. Differences in anatomy may be part of the picture, but it’s not the only factor.

It looks like specific strength training may be the answer. Stressing knee flexion on landing and balance training has been shown to reduce injuries in female athletes. It’s not a matter of keeping girls out of sports. It’s more a matter of finding ways to include them. Specific-sports training may be all they need to level the playing field.

There are many factors that could cause a failed treatment of this type. The exact shrinkage that takes place depends on how much heat is applied and for how long. Not enough heat may not shrink the collagen fibers. Too much heat can actually kill the tissue, a condition called heat necrosis.

The extent of the damage before treatment is important, too. For example larger tears are less likely to respond to this treatment and more likely to tear again. Smaller tears may respond better but studies show long-term results (five years later) aren’t successful. The collagen shrinkage doesn’t hold, and the ligament becomes lax again.

You may be better off having a surgical repair. There’s less chance for reinjury and degenerative changes in the joint. Talk to your surgeon about treatment options at this point in your recovery.

Studies show the long-term results depend on the amount of injury. If the tear is more than halfway through the ligament you have more than a 50 percent chance of further injury. The torn ligament can tear the rest of the way and you’ll have a complete tear.

The risks have been reported as follows:

Radiofrequency (RF) has been used to heat up the anterior cruciate ligament (ACL) in the knee. Results have been less than perfect. It seems to hold well for the first year, but after that the long-term failure rate (at five years) is high (85 percent).

Even with heat shrinkage the rehab time is about six months. Sports that include impact, cutting, and twisting are off limits for six months. Even if this got you back in the game again, it could end your career. Further injury and joint degeneration are common. Only about half of the athletes who have this treatment go back to sports at the same level again.

It’s probably best to follow the advise of your doctor and trainer. Also, it would be advisable not just to get back into the game but to preserve your knee for the rest of your life. That may not seem so important now, but you’ll be glad you did years later.

Not necessarily. Studies show that patients with the most severe disease and extreme symptoms have the best results. They get more pain relief and greater improvement in function than other patients.

In fact patients with a longer length of hospital stay and unstable health seem to have the best results overall. You may not really know the final outcome for up to 12 months. Sometimes it isn’t until a year out that the real results are known.

Lots of studies have been done on the results of total knee replacements (TKRs). Unfortunately, most surgeons focus on which operation works best and which implant has the fewest problems.

Very few studies look at the characteristics of patients. Does age make a difference? Do patients with rheumatoid arthritis do better or worse than patients with osteoarthritis? Does it matter if you’re overweight when you have the operation?

These are just a few of the questions patients raise when thinking about having a TKR. A recent review conducted by the University of Minnesota reported no evidence that age or type of arthritis was linked to results.

The biggest factor in success was how much pain the patient had before the operation. Those with the greatest pain had the best improvement in function.

Yes. Obesity has been linked to heart and lung complications from surgery. Surgeons like to do surgery. A patient should sit up and take notice when a doctor refuses to operate. Losing weight would be in your best interest for a good operative result.

Whether or not you need to lose weight for a good result with the knee replacement is still uncertain. It makes sense that less weight and less stress on the implant will mean it lasts longer.

But there’s really no data to show that being overweight means a worse result. This may not hold true for patients who are extremely overweight. Studies have not reported results for patients in this group.

People with patellofemoral pain syndrome (PFPS) often have knee pain and stiffness when climbing, going down stairs, or while squatting. Popping or stiffness after sitting with the knee bent is called the movie theatre sign.

Most of the symptoms of PFPS depend on the up and down movement of the kneecap and the pressure it places on the cartilage and bone underneath. Scientists aren’t sure what causes the stiffness. Symptoms go away when the person avoids any of these activities.

Changes in the joint, ligaments, and joint capsule may occur after a long period of pain. Messages of pain and stiffness may be sent to the brain sooner or more often than in the normal knee.

A recent study at the University of Illinois found that subjects with PFPS may be misinterpreting their pain as stiffness. Future treatment of PFPS may be centered on pain relief in order to decrease the sensation of stiffness.

There’s actually been some research to suggest that the pain of patellofemoral pain syndrome (PFPS) is misinterpreted as stiffness. There isn’t any real mechanical stiffness
at all.

A study comparing patients who had PFPS with normal subjects showed no difference in the actual amount of mechanical stiffness present. Mechanical stiffness was defined as resistance of a body part to changes in shape or position.

The joint capsule, muscles, tendons, skin, and ligaments around the joint affect mechanical stiffness in the knee. Since there was no link between mechanical stiffness and pain, it was suggested that patients think the sensation of pain is stiffness.

Treating the pain may reduce stiffness. More study is needed to sort this all out.

Snapping or popping with a change in position is often caused by the tendon moving over the bone underneath it. Flexibility may have something to do with this.

Tendons move more freely in flexible people. Those with tight muscles and tendons have fewer (or no) episodes of popping because the tendon doesn’t slide as much. It’s more tightly bound to the connective tissue above and bone underneath.

Joint popping may occur for a variety of reasons. In some cases there isn’t enough natural lubricant inside the joint to make joint motion smooth and noise-free. Muscle tension and spasm can also put stress on the joint forcing the natural lubricant to thin and changing the natural alignment. The result is the snapping, popping, or crackling often heard.

Cracking or popping the knuckles often produces a single pop that can’t be done again for awhile. Pulling on the joint or distracting it changes the pressure in the joint. With distraction gas in the joint fluid forms bubbles making it easier for the surfaces to move apart making a popping sound.

There are several benefits to this type of surgery. First of all, only a few small puncture holes are needed to slip the surgical tools into the joint. No large scars are needed. The back of the knee doesn’t have to be opened to tie the sutures. Healing time is shorter.

There’s less risk of damaging nerves or blood vessels with arthroscopy. The risk of infection is also less. The disadvantages may be just coming to light.

The first long-term studies are being reported. After about 10 years of using special devices that allow for an all-inside or all-arthroscopic repair, it’s clear that the repair is incomplete for many patients. A second operation may be needed to repair or remove the re-injured meniscus.

The meniscus arrows were one of the early devices that allowed surgeons to repair adamaged meniscus without outside sutures. They are still used by some doctors but this may be changing.

A recent study from the University of Virginia followed patients for over six years. Each one had an ACL repair along with a repair of the meniscus in the same knee. The meniscal arrow was used to close the gap caused by the tear but broke down after three years.

Patients who had a “good” result with a “successful” repair started having symptoms again between three and four years after the operation. They found an incomplete healing of the meniscal tear in all cases.

For now it looks like the standard sutures may be needed for a good long-term result.

More studies are underway to find a way to repair a torn meniscus with minimally invasive
surgery.

Incomplete healing of a torn mensicus is usually found by having a second arthroscopy.

The surgeon makes one or more puncture holes in the skin and inserts a long, thin needle called a cannula into the joint.

Tiny tools can be passed through the cannula including a miniature TV camera to take a look inside the joint. What the surgeon sees as an incomplete healing of meniscal tears is a cleft or gap at the site of the tear. It may go down 10 to 50 percent of the thickness of the meniscus.

A gap of more than 50 percent is a nonhealed repair. A second operation is often needed in such cases.

Simply put he’s having trouble straightening his knee all the way or with full strength.

This is a common problem with ACL repairs using the patellar-tendon graft.

A small piece of tendon from below the kneecap along with a piece of bone on either side
of it can be harvested and used to replace the torn ACL. The quadriceps muscle along the
front of the thigh straightens the knee. It’s attached to the patellar tendon. Removing a
piece of the tendon can disrupt the way the muscle pulls.

This problem is usually taken care of with a good rehab program. The fact that your son
is aware of the deficit is a good sign that his rehab team is working on it.

If you are satisfied with the results then you have nothing to regret or wonder about.

Researchers agree the two methods have equally good results. There may be complications
from time to time. These differ between the two types of repair.

The hamstring graft is a little nicer looking cosmetically. It gives a strong graft fixation early on. The hamstring may not be able to tolerate motion right away.

The patellar graft seems to help athletes get back into high-level action more often.

There are still some problems with kneeling and quadriceps muscle weakness after a patellar tendon graft.

Overall patients report satisfaction with function and results after either type of graft repair.

The two ways to repair and anterior cruciate ligament (ACL) tear both involve a tendon graft. The first takes a piece of bone on either side of the patellar tendon along with a piece of the tendon itself. The second uses a graft from the hamstring muscle, which is then folded over to make it stronger.

Ask your surgeon what he or she advises. Sometimes it’s just a matter of personal preference. Some surgeons use one method more often than the other. In some cases the kind of tear is best repaired one way over another.

The patellar tendon graft gives a firm fixation for athletes who have to get back to their sport faster. The hamstring graft delays return to play but allows for a faster overall rehab program. Sometimes there are problems kneeling with the patellar tendon
graft.

According to a recent review of the studies done so far, both methods have equally good results.

Many people with ganglion cysts are never aware of them and they cause no problems. In a small number of patients, tenderness along the joint line or pain with movement may bring this to their attention.

The tibiofibular joint is just below the knee. The two bones of the lower leg (tibia and fibula) meet at this joint. A ganglion cyst in this area can cause mild discomfort or pain along the outside of the knee.

However, it can also put pressure on the peroneal nerve to the foot. This can lead to a condition called foot drop. The nerve damage can be permanent. Ganglion cysts may invade and damage the bone. Many doctors adopt a “wait-and-see” approach to this problem. At the earliest sign of problems, surgery is advised.