FAQ Category: Knee

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself. It is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

The procedure can be performed non-surgically when treating joint osteoarthritis or cartilage degeneration. Most non-surgical procedures can be done on an outpatient basis, usually in the office setting. Treatment with platelet-rich plasma is broken down into two steps: preparing the platelet-rich plasma for injection and then injection into the affected area.

First, blood is drawn from your arm and used to create the injected fluid. The blood is placed (in a test tube) in a machine called a centrifuge. The centrifuge spins the blood fast enough to separate it into layers based on weight. Heavier parts (e.g., red blood cells) stay on the bottom. Platelets and white blood cells spin out just above the red blood cell layer. Lighter particles (plasma without platelets or blood cells) make up the top layer in the test tube.

Once you have had your blood drawn, the sample is prepared right away. You can have the injection as quickly as 30 minutes later. The surgeon may use imaging such as fluoroscopy (real-time, 3-D X-rays) or dynamic musculoskeletal ultrasound to place the needle that delivers the PRP directly into the joint.

You will probably not be asleep or anesthetized unless the plasma is applied during a surgical procedure. When used on an outpatient basis for a nonsurgical treatment, a numbing agent like novacaine (e.g., lidocaine, marcaine) is used so that you don’t feel anything.

The post-operative program varies from surgeon to surgeon but often includes the use of local ice held on the knee for 20 minutes every two to three hours for a 24-hour period. Your doctor may suggest using Tylenol for pain relief but ibuprofen or other anti-inflammatories are not advised. That’s because the treatment is designed to set up an inflammatory response, so you don’t want to stop that process with medications.

You may be advised to tone down your level of activity and avoid vigorous use of the knee for at least 48 hours. Most surgeons allow their patients to put weight on the injected knee as tolerated (usually determined by pain levels).

You may see a physical therapist after this procedure to help you regain motion, strength, motor control, and function. There isn’t a known rehab protocol (standard program to follow) yet. Physical therapists are working with surgeons on a patient-by-patient basis to determine what might be best for each individual.

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. PRP refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

Using platelet-rich plasma to encourage tissue regeneration in the hyaline cartilage of the knee may be a new way to prevent or slow down the degenerative process that leads to osteoarthritis. Hyaline tissue is the type of cartilage that lines the inside of the knee joint.

The hyaline cartilage has many wonderful characteristics. It allows the knee joint to move without friction. It protects the bone underneath the cartilage from too much load and trauma. Hyaline cartilage also spreads out the forces placed on the knee joint during movement. But the one thing it does not have is a rich supply of blood. Injury or damage to the hyaline cartilage sets off a series of events that can lead to degeneration and osteoarthritis.

That’s where platelet-rich plasma comes in. It has been used for years after plastic surgery and surgery on the mouth, jaw, and neck. It seems to promote and speed up healing. Anywhere from two to six times the number of platelets with their growth factors are released into the injured area.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

In a recent study from the OASI Bioresearch Foundation in Milan, Italy, two groups of patients with osteoarthritis of the knee were given two injections of platelet-rich plasma (PRP). Conservative (nonoperative care) with anti-inflammatory medications had been tried for at least three months with no improvement in symptoms.

One group (25 patients) had previous surgery for the damaged knee cartilage (either a shaving procedure called debridement or a procedure called microfracture). Microfracture is the use of tiny holes drilled through the cartilage and bone to stimulate bleeding and healing. The other group (25 patients) did not have any knee surgery prior to the blood injection therapy.

Results for the two groups were compared by looking at pain, function, and quality of life. A variety of tests were used to collect information to measure these outcomes. All measures were taken before platelet-rich plasma injection (baseline), six months after the injections, and again one-year after injection therapy. Results were also compared between men and women to see if there was a sex-linked difference in treatment results.

They found no difference in results between the two groups or between the sexes. It seems everyone in the study benefitted and improved with this treatment approach. There was a positive effect of PRP in active patients with painful knee osteoarthritis. There were no differences between men and women and no adverse reactions or complications for anyone.

This study provides some evidence that using platelet-rich plasma (PRP) to stimulate the natural healing process and regenerate hyaline cartilage may be an acceptable way to treat the damaged hyaline joint cartilage you have. This is true even for patients (also like you) who have already had cartilage surgery (cartilage shaving or microfracture).

The authors point out that they used two PRP injections but there may be a more optimal number of injections required. Further research is needed to develop specific standardized treatment protocols. Likewise, studies are needed to find ways to predict how much PRP is needed for each type of tissue damage. Long-term studies (following patients for more than 12 months) are recommended.

Talk to your surgeon about this treatment. See if you might be a good candidate for platelet-rich plasma injection. This is a relatively new procedure and not all surgeons are trained in this technique. You may have to seek a referral elsewhere if it looks like you might benefit from platelet-rich plasma injection and your surgeon does not provide this type of treatment.

Pigmented villonodular synovitis (PVNS) is a benign disease of the joint synovium. Benign in this case means that the condition is confined to the area of involvement. It doesn’t spread or travel to other parts of the body. It does not cause death but disability is possible. The synovium is the layer of soft tissue that lines the joint. It has a clear fluid that helps lubricate the joints.

Symptoms usually include joint swelling of a single joint (knee most often, hip, ankle, shoulder, elbow — in that order) with pain and loss of motion. Pain and loss of motion get worse as the disease progresses. X-rays often show lytic lesions (bone eaten away).

But lytic lesions of the bone can be caused by cancer so an MRI and biopsy are required to make an accurate diagnosis. In the case of pigmented villonodular synovitis (PVNS), MRI findings are clear. This is because the tissue contains iron deposits called hemosiderin and the MRI signals clearly show these lesions. Synovial fluid can also be tested to provide another diagnostic clue.

The final confirming diagnostic “test” is surgery to open the joint and remove the tissue, a procedure called synovectomy. With open incision, the surgeon can clearly see the condition. A yellow thickened synovial tissue is usually visible. Tissue samples are sent to the lab to provide an examination of the cells, called a histology report. The pathologic histology also helps confirm the diagnosis.

The underlying cause of PVNS remains unknown. There are so few cases reported that large studies aren’t possible. It seems to affect adults most often — usually between the ages of 20 and 40. Men and women seem to be affected equally.

No family pattern has been reported but there could be an unknown inherited factor contributing to this condition. At this point, there is more we don’t know about the condition that we know. If you start to develop joint pain of unknown cause with swelling and limited motion, don’t hesitate to see a physician for an examination and evaluation. Early diagnosis and treatment can help prevent painful loss of motion and long-term damage to the joint.

Allograft meniscus transplantation refers to the use of donor cartilage to replace what was removed from your knee. Since we don’t have any extra meniscus material anywhere else in the body to use, surgeons must rely on a donor bank for the graft material.

We’ve known for quite some time now that removing the meniscus leads to early degenerative arthritis of the knee. So whenever possible, the meniscus is preserved and stitched back in place to restore the natural anatomical structure of the knee. But sometimes it isn’t possible to save the meniscus. When it is removed, this type of transplantation is possible.

Surgeons are trying different surgical techniques and reporting on their results. They are looking for the least invasive, most successful approach that gives patients pain relief and improved knee function. The goal is to allow them to do exactly what you describe — whatever they want to whether that’s hopping, skipping, or chasing after a ball on the fairway.

A review of many studies shows a fairly high rate of what you are experiencing: extrusion of the graft. Extrusion of the graft refers to pushing of a part of the graft material out of the knee joint cavity. This extrusion was more common in grafts on the lateral side of the knee (the side away from the other knee). There does not appear to be any effect of this extrusion on pain or function — at least not in the short-term. Long-term studies may show a different result.

No one knows exactly why graft extrusion occurs. But it is commonly reported in all studies involving meniscal transplantations. Experts suggest a variety of possible reasons for this problem. The fact that the lateral side pushes out more often than the medial side (side closest to the other knee) suggests factors involving biomechanics and load distribution.

But it could be there are effects of surgical technique from putting too much tension on the sutures, using a graft that’s too large for the space (called “overstuffing”), or when the sutures do not reattach the graft at the anatomical location (where the meniscus normally inserts into the bone).

Since patients are usually asymptomatic (without symptoms), the usual approach is to wait-and-see what happens. Surgeons sometimes refer to this as “benign neglect.” In other words, they keep an eye on it and intervene only if it causes a problem. If you start to experience any unusual pain or symptoms anytime in the future, don’t hesitate to get back to your surgeon for a follow-up appointment. Until then, we hope you continue to enjoy the benefits this surgery has provided you with!

Meniscal transplantation is increasing in popularity and use. It is especially helpful for the person who has had to have the native meniscus removed due to severe damage. Without the protective, load bearing and distribution benefits of the mensicus, the knee can develop early painful and debilitating arthritis.

The procedure isn’t done on anyone. Patient selection is fairly important for a successful result. Patients are usually young (less than 55 years of age), not overweight, and in pain from the loss of the meniscus. Donor cartilage is used as the graft, a process called allograft transplantation.

Every surgeon has his or her own way of selecting the graft and putting it in place. Research shows that the best way to get optimal results with meniscal transplantation is to select the correct graft size for each patient, place the graft anatomically, and secure it in a way that promotes biologic healing.

Once that hurdle has been completed, the rehab piece becomes the focus of attention. At first, you will probably be in a full extension (no knee flexion or bending allowed) knee brace. Immobilizing the knee like this allows healing to take place without disrupting the graft.

You may be placed in a device called a continuous passive motion or CPM machine. The machine can be preset to allow only a certain amount of knee motion. The machine passively moves your knee by bending and straightening it several times each day.

In this way, the joint can stay fluid and without stiffening up but without the use of the muscles that could pull on the graft. The machine is adjusted to allow more motion as time goes by. According to reports of protocols typically used, you should have 90 degrees of passive knee flexion by the end of two weeks. Passive means the machine is moving you. You are not actively moving the knee yourself.

You will be instructed in all these things by a physical therapist. The therapist will also show you how to perform isometric muscle contractions. These exercises are started right away after surgery. Isometric means you will contract the muscles without moving the knee. The two most common exercises to start with are quadriceps setting and straight leg raises.

When the surgeon removes the external stitches, you can begin a pool therapy program. Again, the therapist will guide you through what you can do in the pool. With the elimination of gravity and the force/load of your body weight, you will be allowed to do many things in the pool that are not yet allowed on dry land.

After the first month, you will be instructed to start moving the knee yourself. At this point, more vigorous muscle contractions are added to the program. This is all done gradually but with the goal in mind of reaching full motion by the end of six weeks after the surgery. You’ll probably be using crutches in the first six weeks.

At first, you won’t be allowed to even put the foot down on the surgical side. At four weeks post-op, you will be allowed to gradually put a little weight on the foot, then increase weight-bearing bit by bit. By the end of six weeks, you should be able to put full weight on the leg without using crutches.

If you are involved in sports or other strenuous physical activity, you’ll have to put these on hold for at least four months. Full contact sports are not recommended for a full eight months and then only if the therapist has progressed you through a sports-readiness program. Strength and motion testing will be done to confirm your readiness for return-to-sports.

What we have described is a general outline of what you might expect in the coming weeks to months. Each surgeon has his or her own protocol. For optimum results, it is always advised to carefully and closely follow what your surgeon recommends.

There are several soft tissue structures in the knee that can cause pain and swelling with minor trauma in someone over the age of 50. The type of symptoms you describe could come from a ligamentous strain or meniscal tear. Only an evaluation with a medical doctor will give you an accurate diagnosis. And that would be important because early treatment is usually the best way to achieve optimal outcomes.

We can tell you that the history given for meniscal tears in older adults is often described just as you put it. Something that seems as minor as a kneeling or a squatting position puts enough force and load on the aging cartilage that it tears more easily than in a younger adult.

Tears in the meniscus in patients under 30 years old usually occur as a result of a fairly forceful twisting injury. In the younger age group, meniscal tears are more likely to be caused by a sport activity.

Symptoms of knee aching, tenderness, swelling, and/or sensation of the knee locking are other common reports associated with meniscal tears in all age groups. You’ll need an examination and possible some imaging studies to know for sure. Sometimes the surgeon will recommend an arthroscopic examination to confirm the diagnosis.

The meniscus is a commonly injured structure in the knee and this injury can occur in any age group. For quite some time now, surgeons have been able to repair torn or damaged menisci (menisci is plural for meniscus) using minimally invasive arthroscopic techniques.

Ten years ago, a new arthroscopic approach called the all-inside method was introduced. There are several benefits to this technique. 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 (an inside-out technique). Healing time is shorter.

Like all surgical procedures, there can be complications. And with this particular approach, (all-inside arthroscopy) there can be local soft tissue irritation with knee swelling. The implants used as sutures for the all-inside repair (arrows, screws, staples, or sutures) can pull out and shift position (called migration). You may be feeling the prominence of a suture anchor.

Those devices used to stabilize the torn meniscus can work themselves out of place and even put pressure on nearby nerves or blood vessels. It’s best to make an appointment with your surgeon and get back in for a follow-up evaluation. Whatever is causing the problem can be identified and taken care of before it progresses any further.

Girls and women seem to be at greater risk for anterior cruciate ligament (ACL) than their male counterparts. Women playing basketball and soccer are much more likely to injure their ACLs than men playing these same sports at the same level. Much research has gone into trying to understand the risk factors in order to prevent this potentially disabling injury.

Some studies have attempted to see if females are more likely to injure their knees at a particular time in the menstrual cycle. There are some reports that ACL tears are more likely at three points in the menstrual cycle: the preovulatory phase, follicular phase, and menstrual phase. Each of these phases has different changes in the type and levels of hormones circulating in the blood.

Since each normal menstrual cycle is approximately a month long, there may be a connection to the moon cycles. We are unaware of any scientific studies to prove or disprove this connection. Scientists have discovered receptor sites on the anterior cruciate ligament (ACL) for hormones such as estrogen and progesterone. Just the presence of these places for hormones to attach to cells suggests hormones may influence ligaments. But what the connection is or exactly how these hormones affect the ACL is a big unknown right now.

As a member of a professional ball team, you likely have a group of health care professionals at your disposal such as an orthopedic surgeon, physical therapist, and/or athletic trainer. Any of these foks may be able to give you some good counsel and direction. They can examine you closely and directly, which is something we cannot do.

We understand that sometimes players don’t want to reveal the extent of their delay in recovery. So they don’t seek the help, services, and guidance that’s close at hand. But we encourage you to do just that. In the meantime, we can offer some thoughts that might help give you the perspective you are looking for.

Ten months post-ACL surgery may be too soon to expect full recovery. Although it’s true that some athletes are back on the court or field in six months’ time, this is the exception rather than the rule. A 12-month (or more) return-to-sport is much more common.

There can be other factors to consider. For example, were other soft tissue structures in the knee injured at the time of the ACL rupture? Damage to the articular cartilage lining the joint surface or a meniscal tear can contribute to delays in healing.

The surgeon who performed the ACL reconstruction knows all that was done and can give you a better idea what to expect and why. At 10-months post-op, there is still much that can be done in rehab to reduce pain, increased motion and strength, and improve function. Don’t hold back in bringing these issues to the attention of your surgeon and rehab team. Getting on top of the problem now can help ensure getting back into the game sooner than later.

Long-term studies do show that a knee with an anterior cruciate ligament (ACL) repair or reconstruction is at risk for early arthritis. In fact, studies show patients with an ACL rupture (rupture means torn completely through) eventually develop knee osteoarthritis (OA) a full 15 years sooner than adults the same age without this type of knee injury.

Surgery to reconstruct a ruptured ACL is usually done to spare the knee joint further damage. Without an intact ACL, the tibia (lower leg bone) slides forward under the femur (thigh bone). This excess joint motion can cause wear and tear that a stable joint would not be subjected to.

Many times, a force strong enough to cause a complete rupture of the ACL is enough to damage other soft tissues in the knee such as the joint cartilage or the meniscus. Without these additional protective structures, the joint is at increased risk for degenerative changes leading to arthritis. Preventing this early development of osteoarthritis (OA) is another reason surgeons recommend surgery when the ACL is ruptured.

Surgeons do consider whether the surgery itself may be a risk factor for later osteoarthritis (OA). And beyond that — whether the type of surgery performed is a risk factor for OA. The two major types of ACL reconstruction involve taking a piece of donor graft tissue from some other area of the same patient’s knee and using it to replace the torn ligament. The two most common donor sites are the hamstring tendon (behind the knee) and the patellar tendon from the front of the knee.

In a recent study from the Australian Institute of Musculoskeletal Research, degenerative changes in the knee after ACL reconstructive surgery were investigated. The researchers limited their research to patients who had a bone-patellar tendon-bone (BPB) autograft. As you know from your own procedure, autograft refers to the fact that the donor tissue is the patient’s own graft material.

The results of previous studies have indicated that osteoarthritis may occur more often after bone-patellar tendon-bone (BTB) grafting. The authors questioned this finding and suggest there are other risk factors potentially associated with poor outcomes following BTB reconstruction.

To explore this idea further, they followed 114 of their own patients who had the BTB procedure. Follow-up was considered long-term with an average time of 13 years. X-rays were used to identify and rate severity of arthritic degenerative changes throughout the follow-up period. Whenever possible, X-rays of the uninvolved knee were used as the control group since that leg had not been subjected to surgery.

Tests of knee motion, strength, and function were also used to assess changes over time. They found that one-third of the group developed abnormal to severely abnormal arthritis changes. This rate of 33 per cent was higher than the 12.8 per cent rate of knee osteoarthritis in the general population. In other words, the injured knee was significantly more likely to show signs of osteoarthritis compared with the nonoperative side.

After analyzing all the data, there were several risk factors identified for osteoarthritis after BTB grafting. These included: 1) injury to the first layer of bone under the articular cartilage of the knee joint (chondral bone), 2) a previous knee surgery, and 3) not returning to sports. Previous knee surgeries reported in this group included arthroscopic exam, meniscus cartilage repair or removal, and/or removal of a bone tumor.

The authors concluded that there is indeed a higher rate of degenerative joint changes after bone-patellar tendon-bone (BTB) grafting for rupture of the anterior cruciate ligament (ACL). Whether or not a different reconstructive technique would have the same effect was not determined in this study. But a number of other risk factors may be the real key to the early development of arthritis observed in this patient group.

The most significant contributing risk factor seems to be the presence of chondral damage at the time of the initial injury. This association may be explained by microscopic damage to bone cells. This damage is made worse when surgery is delayed and the patients continue to walk on that leg with a change in normal knee joint biomechanics. Meniscus damage also contributes to changes in the load bearing on the joint leading to osteoarthritis. The use of a bone-patellar tendon-bone graft may not be the main predictor of early degenerative bone disease.

The forceful and repeated actions of sports can strain the immature surface of the knee joint in children and teens. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off. When this condition occurs in this age group, it is called juvenile osteochondritis dissecans (JOCD).

JOCD can also occur in children and adolescents with no known cause. The condition can be stable and without symptoms but more often there is knee pain and/or tenderness around the joint. Mild swelling may be present but more often than not, there is no swelling. With stable lesions, motion is normal. Loss of knee motion is more common with unstable lesions.

An OCD lesion is unstable when a piece of cartilage or cartilage and bone breaks loose and is free to float around inside the joint. How does this happen? The articular (joint surface) cartilage in children is newly formed. It can’t handle the type of forces placed on it with repetitive activity.

The subchondral bone (under the articular cartilage) takes the brunt of the stress. A portion of the bone may eventually weaken, and possibly even crack. When the bone is damaged, the tiny blood supply going to the area is somehow blocked. Without blood supply, the small area of bone dies. This type of cell death is called avascular necrosis. (Avascular means without blood, and necrosis means death).

The crack may begin to separate. Eventually, the small piece of dead bone may break loose. This produces a separation between the articular cartilage and the subchondral bone, which is the condition called OCD. If the dead piece of bone comes completely detached, it becomes a loose body that is free to float around inside the joint. And that is how an OCD lesion becomes unstable.

In the absence of a specific injury, the child may at first feel bothersome knee discomfort only while playing sports or during physical activity. The soreness generally goes away quickly when the leg is rested. Over time, however, the joint pain worsens, is hard to pinpoint, and may linger after using the leg. The knee may feel stiff, and it may not completely straighten out.

In advanced (unstable) cases of OCD, the patient may notice that the joint grinds (called crepitus). The knee may catch, or even lock up occasionally. These sensations may mean that a loose body is floating around inside the joint. The joint may also feel warm and swollen, and the muscles around the elbow may appear to have shrunk (atrophied).

Patients with this problem may need to stop their usual sport or physical activities. This gives the joint a chance to rest so that healing can begin. The doctor may prescribe anti-inflammatory medicine to help reduce pain and swelling.

Patients are usually shown how to apply ice to the area. When sport activities are resumed, ice treatments should be used after activity. Ice treatments are simple to do. Place a wet towel on the knee. Then lay an ice pack or bag of frozen vegetables or bag of crushed ice over the elbow for 10 to 15 minutes.

The doctor may also suggest working with a physical therapist. Physical therapists might use ice, heat, or ultrasound to control inflammation and pain. As symptoms ease, the physical therapist works on flexibility, strength, and muscle balance in the knee and leg. Therapists also work with athletes to help them improve their form in ways that reduce strain on the affected joint during sports.

In severe cases, patients may need to wear a splint for several weeks before starting motion exercises. As symptoms ease and movement improves, a guided program of strengthening and sport training begins. Some patients may need surgery if the joint continues to lock up, if it won’t straighten out, or if pain continues even after a period of rest and physical therapy.

Your experience is very similar to patients in a recent study from Spain. Surgeons in Spain evaluated 306 patients with knee osteoarthritis receiving a knee replacement. Two groups of patients were compared. The first group received physical therapy and started a rehab program within 24 hours of the knee replacement surgery. The second group (with an equal number of patients) began the same rehab program 48 to 72 hours after the replacement procedure.

Patients in both groups were treated in the same hospital by the same physical therapist following the same exercise program. The therapist used a mobilization program, exercises, breathing, and posture instruction. The program was advanced as quickly as possible based on each patient’s performance and tolerance.

Outcomes were measured in terms of knee motion, level of pain, and muscle strength (quadriceps muscles along the front of the thigh and hamstring muscles along the back of the thigh). Function was also assessed using activities of daily living, balance, and walking as the benchmarks.

Patients who started therapy right away stayed in the hospital (on average) of two fewer days compared to the group who received delayed physical therapy. The early group also got their balance and normal walking pattern back faster compared with the group who started rehab later.

According to this study, getting patients up and moving after total knee replacement is the best medicine. The longer the delays and the more days in the hospital, the slower the recovery and the greater the costs associated with the procedure. Physical therapy to initiate therapy as early as possible is recommended — both for the patient’s benefit and for a cost-savings measure.

Congratulations! Your experience certainly sounds like it mimicked what was reported in this study. Not everyone can do this but for those who can, it is well worth the effort!

Studies show that fewer days in the hospital after a total knee replacement usually means lower costs. And one way to accomplish that is to begin physical therapy within the first 24 hours after surgery. Many surgeons are going in this direction. Your mother’s surgeon may have written orders for physical therapy to begin immediately.

As a member of the rehab team, the therapist may be following a prescribed protocol based on best-evidence available from studies. Getting patients up and moving after total knee replacement is considered the best postoperative approach.

The longer the delays and the more days in the hospital, the slower the recovery and the greater the costs associated with the procedure. Physical therapy to initiate therapy as early as possible is recommended — both for the patient’s benefit and for a cost-savings measure.

But as anyone working patients who have had a total knee replacement knows, not all patients are created equally. There are some who are ready and eager for an exercise program and immediate activity (on day one after surgery).

But there are others who are very slow to move the leg and get out of bed much less make themselves contract muscles and flex and bend the knee. Sometimes the pain (or perception of pain) is just too great in their minds to move smoothly or often.

There are other risk factors that might work against some patients following knee replacement surgery. For example, the patient’s state of mind (i.e., mental health) is an important factor. Depression, low self-esteem, anxiety, and fear can interfere with rehab progress.

Getting started and progressing quickly through the program can be a major challenge for some people after a knee replacement. The type of implant used, the way it fits (or doesn’t fit) inside the joint, and even specific surgical technique can result in postoperative complications and problems, including failure of the implant.

Your mother may actually surprise you and herself by complying with this young man who does seem to know what he is doing. Unless you think your mother is in some kind of physical danger, it may be best to take a back seat for a bit and see how this works itself out. Your mother may even do better if family members aren’t present. If no one is there to offer sympathy or a way out, she may just step up and surprise everyone, including herself!

Your attitude is completely understandable. It is discouraging to play your heart out only to end up on the bench due to an unfortunate incident. Some people in the medical field say there are no such things as “accidents.” There are always reasons why people get sick or are injured. And this idea may be very true when it comes to ruptures of the anterior cruciate ligament (ACL) of the knee.

Sure it’s easy to say the ligament ruptured when the athlete was tackled and another player landed on that leg. Or when the basketball player’s foot was planted on the floor and she got knocked over while trying to pivot and shoot.

But the truth is these events happen many, many times to other athletes who don’t end up with an injury. So we try to accept what has happened and make the best of it — maybe even learn a few things we had not expected along the way.

But there are other reasons to buck up and get busy with rehab and recovery. Studies show there can be long-term consequences such as reinjury or joint arthritis developing years later. A good rehab program can help you avoid some of these unpleasant possibilities.

The therapist can help you reduce neuromuscular risk factors contributing to injuries such as posture, landing biomechanics, ground reaction forces, core stability, trunk displacement, and proprioceptive repositioning error. Changes in movement patterns from any one of these factors increase the strain on the ACL and seem to be contributing to the increased risk of ACL injuries.

With proper training and good body mechanics, athletes can be protected from new injuries or avoid reinjury of the same area. Knee geometry cannot be changed but improving muscle strength, motor control, and neuromuscular coordination could make a difference. And many athletes with ACL ruptures are able to return to full participation in the sports of their choosing. You may yet want to take advantage of this aspect of rehab as well.

As you have found out the hard way, anterior cruciate ligament (ACL) injuries are more common than athletes would like and can be very disabling. They can take a long time to heal and rehab. An injury forceful enough to rupture a ligament like the ACL can also cause damage to other soft tissues in the knee making recovery an even greater challenge.

For an overview, it may be helpful to recognize that there are many identified causes of ACL injuries. Most are multifactorial meaning there is more than one factor increasing the risk of ACL injury. Two broad categories for these risk factors are: intrinsic risk factors and extrinsic factors.

Anything intrinsic refers to the patient or affected individual. Intrinsic risk factors potentially contributing to ACL injuries include sex (male or female), hormones, genetic factors, and anatomy. Females are at greater risk than males for ACL injuries for a combination of reasons including anatomy and hormone shifts. Previous injury(ies) to the leg (especially the knee) is also an important risk factor.

Anatomical and neuromuscular features play a big role in ACL injuries. Variables such as knee geometry, alignment, and joint laxity are half the problem. Knee geometry refers to three specific measures of shape, depth, and angle that have been linked with ACL injuries. These include decreased intercondylar femoral notch size, decreased depth of concavity of the medial tibial plateau, and increased slope of the tibial plateaus. No doubt you will come across these in your research.

Neuromuscular risk factors include posture, landing biomechanics, ground reaction forces, core stability, trunk displacement, and active proprioceptive repositioning error. Changes in movement patterns from any one of these factors increase the strain on the ACL and seem to be contributing to the increased risk of ACL injuries. Your coach and/or athletic trainer will help define and describe these factors to you.

Extrinsic refers to something outside the body such as the type of playing surface or equipment in use. Sometimes weather and field condition contribute to increasing the risk of any injury including ACL tears or ruptures.

The benefit of research projects like the one you are working on is in being able to counsel athletes wisely and develop effective prevention strategies. Injuries like ACL ruptures can end an athlete’s career — or at least sideline the player for a season or more. There is a future risk of knee osteoarthritis that must be considered as well.

With proper training and good body mechanics, even athletes with nonmodifiable anatomic risk factors may be protected from such injuries. Knee geometry cannot be changed but balanced muscle strength, motor control, and neuromuscular coordination could make a difference.

Exercise programs aimed at these areas during different stages of growth and development may help. Further research is needed to fully understand all ACL risk factors and find appropriate prevention strategies. The role of skeletal and muscular maturation versus conditioning must be evaluated as well. If you get started with this basic information, it won’t be difficult to expand and fill in the details. Good luck!

There is some truth to the notion that surgeons like to wait to replace joints as long as possible knowing that the implants have a limited lifespan. It used to be implants were good for 10 to 15 years so anyone younger than 65 was definitely not a good candidate for knee joint replacements.

But things are slowly changing for several reasons. First, with the help fo surgeons and research scientists, implant manufacturers have improved the designs and provided many helpful features. The result has been longer lasting implants with fewer complications.

For example, there are fewer damaging infections. Better bone-gripping surfaces help hold the implant firmly in the bone. This means fewer implant sink down into the bone or come loose — both scenarios often required revision (second) surgeries.

Studies show that surgeons have expanded the indications for knee replacements. This means that surgeons are finding greater uses for knee replacements than just severe osteoarthritis in older adults. For example, sports-related injuries early in life have been shown to develop later into joint arthritis when folks like you are in their 40s and 50s.

This might account for the increasing numbers of knee replacements in the 45 to 65 age bracket. In fact, the number of knee replacements in adults ages 45 to 65 tripled in the last 10 years. Over 40 per cent (41 per cent) of the adults getting knee replacements are between the ages of 45 and 65. The rest are over 65.

So don’t assume you aren’t a good candidate for this type of treatment approach. Seek out an orthopedic surgeon and at least have an examination and evaluation. Find out what treatments (conservative and/or surgical) that might be recommended and available for you.

Researchers at Brigham and Women’s Hospital in Boston, Massachusetts may have some information that will help. Using national data from inpatient (hospital) reports, they presented the following U.S. statistics:

The number of knee replacements in adults ages 45 to 65 has tripled in the last 10 years.

There’s still no clear-cut, single answer to what type of graft should be used for anterior cruciate ligament (ACL) reconstruction. Each one has its advantages and disadvantages. A recent review of studies published on graft choices may offer some insight.

Before launching into all their findings, it might help others reading this to understand there are allografts and autografts. Allografts refer to tissue from a donor bank. The major disadvantage of an allograft is the body’s tendency to reject tissue it considers “foreign” or “nonself.”

But the advantages are great in that the patient does not suffer pain or infection at the donor site. There is a faster healing time with only one wound to heal. And for some people for whom appearances are important, one less scar is worth the risk of using someone else’s tissue for the procedure.

Autografts refer to tissue harvested from the patient. There are three places the autograft (donor) tissue usually comes from: 1) bone-patellar tendon-bone (BPTB), 2) hamstring tendon, and 3) quadriceps tendon. As you might guess from what has been said so far, the donor site can cause a more painful response than even the primary surgical site.

Patients who have tendon harvested from the front of the knee (two of the three options) can end up with pain along the front of the knee. The painful symptoms can be severe enough to keep them from being able to bend the knee fully or kneel down. That may not sound like much of a problem until you can no longer bend down to tie your shoe, tend a garden, play with grandchildren, or slide into home plate for an athlete.

To help compare each technique used from study to study, the authors of this study used seven basic measures. These included knee stability, leg strength, function, return-to-sports, patient satisfaction, complications, and cost. Here’s what they found to help answer your question.

When it comes to post-operative knee joint stability (joint “give”, laxity, or looseness versus tightness of the joint) it looks like there’s no difference between allografts and autografts. The primary difference is in terms of rupture rate. Improper preparation of allografts (e.g., sterilization, drying) can result in more graft ruptures years later compared with autografts.

Concerning muscle strength. There is agreement among studies that quadriceps strength seems to be equal among the various autografts. The hamstring muscle group is more likely to lag behind in recovering full strength, especially for patients who have a hamstring autograft.

Return of overall function seems to be equal among all graft types. But return-to-sports varies widely. The majority of patients (75 per cent) get back to playing but not all return to their preinjury level of participation. Some athletes have to gear down to a lower intensity level of activity while others change the sports activity altogether.

One more area of concern and comparison is complications (e.g., pain, infection, graft failure or rupture). Most patients expect a certain amount of pain right after surgery. But when pain lasts months-to-years later, this symptom becomes a complication. Kneeling pain persists more often with patellar donor grafts. Other long-term annoying symptoms at the harvest site can include numbness, tenderness, or irritation.

Results also showed that infection rates are not higher with allografts. Disease transmission from allograft (donor) tissue (e.g., hepatitis, HIV) occurs in less than one out of every 1.6 million patients.

Finally, graft failure or rupture is more likely occur when there is significant joint laxity (looseness) after surgery. Another significant risk factor is return to sports that require sudden turns or changes in direction (pivoting), sidestepping, and jumping. Studies show that younger, more active patients are the most likely to experience ruptures with an allograft.

In the end, patient satisfaction is rated high (in the 90 percentile) no matter what type of graft is used.

This is a very good question and one that physical therapists and surgeons are beginning to address more directly. Let’s start with exploring what is normal knee motion? The standard range for knee motion is from zero (full knee extension) to about 135 (full knee flexion). Some people like yourself naturally have knee extension beyond zero. That condition is called hyperextension.

Restoring knee extension to zero after ACL surgery in someone who has five or 10 degrees of extra extension (or flexion) in the other knee isn’t going to feel “normal.” In most patients, there is a tendency to start favoring the involved knee by putting less weight on it and shifting over to the uninvolved leg. This can create problems of its own. Rehab must continue until both knees have equal amounts of motion. This of course assumes the other knee has not been injured or altered from normal.

With proper measuring, the therapist can identify even small (three to five degree) losses of motion early on. This is important while the graft tissue is still remodeling in order to regain full motion. Waiting too long can result in a stiff, painful, and weak knee. Studies show that small losses of either knee flexion or extension can lead to knee osteoarthritis. This is especially true when there is any damage to the cartilage.

Knee extension is restored first, and then knee flexion. When knee motion on the operative side equals motion on the uninvolved side, then the patient progresses to the next stage of strengthening and motor control. Athletes will advance even further in order to complete exercises that will specifically prepare them for the kind of movements (e.g., pivoting, jumping/landing, switching directions quickly) needed to compete in sports.

There’s one other reason to work toward symmetry (equal amounts of knee motion from side-to-side) and that’s to prevent the development of osteoarthritis. The long-term studies that are available showed a significant increase in the number of patients with loss of knee motion who developed abnormal joint findings as seen on X-rays.

Such changes were observed as early as five years after ACL surgery in patients who had loss of knee motion. On the flip side, patients with known cartilage damage but who maintained normal knee motion were much less likely to develop knee osteoarthritis.

It would probably be a good idea to voice your concerns to both your surgeon and your therapist. Listen to their perspectives and advice and work with your therapist to adjust your rehab program accordingly.

It is agreed and well understood by surgeons and therapists that following surgery to repair or reconstruct a torn or ruptured anterior cruciate ligament (ACL), it is vitally important to restore normal knee range-of-motion. It may be helpful for you to understand a bit more about why this is so important.

Studies show that small losses of either knee flexion or extension can lead to knee osteoarthritis. This is especially true when there is any damage to the cartilage. And restoring and maintaining knee motion is one thing patients can do to possibly prevent (or at least delay) osteoarthritis from developing.

With proper measuring, the therapist can identify even small (three to five degree) losses of motion early on. This is important while the graft tissue is still remodeling in order to regain full motion. Waiting too long can result in a stiff, painful, and weak knee.

Long-term studies following patients who have had ACL surgery show a significant increase in the number of patients with loss of knee motion who develop abnormal joint findings as seen on X-rays. Such changes were observed as early as five years after ACL surgery in patients who had loss of knee motion. On the flip side, patients with known cartilage damage but who maintained normal knee motion were much less likely to develop knee osteoarthritis.

If you and your therapist are having some personality conflicts you may want to ask to be assigned to a different therapist. But it sounds like your therapist is working in consultation with the surgeon following priciples of best practice in this area.

Letting your therapist know you are doing your best and asking some questions about his or her thinking in your case might be a helpful place to start. We can at least assure you that a progressive rehab program aimed at quickly restoring normal knee motion following ACL surgery is extremely important.