FAQ Category: Knee

Hamstring injuries are not uncommon in active adults. Athletes are especially prone to these types of injuries. Hamstring ruptures associated with zip line rides has not been reported in the literature. But there are studies involving athletes of all ages who injure their hamstring muscle as a result of falls, waterskiing, running or sprinting, soccer, football, hockey, in-line skating, dancing, tennis, and wrestling (to name a few). With your report, we can add zip line rides to the list.

There are three separate tendons that meld together at this site. For a complete rupture, all three tendons are torn. The rip or tear could be anywhere along the muscle. Tears at the ischial tuberosities are called proximal tears. Tears farther down toward the knee are referred to as distal hamstring tears. If it’s the tendon that is torn and the attachment is pulled away from the bone, it’s called an avulsion.

Treatment and recovery are based on several factors. First, how far from the bone did the tendon retract (pull away)? If the tendon only springs back a little bit (less than two centimeters), then conservative care may be all that’s needed. In these cases, surgery usually isn’t needed.

If the tendon pulls back more than that (and especially if it pulls a bit of bone along with it), then surgery is most likely needed. That’s because larger displacement of the tendon usually means more pain, weakness, and loss of function.

A second factor guiding treatment is how long ago was the injury? Chronic injuries (those that occurred more than a month ago) that are asymptomatic (no symptoms, no pain) can be treated conservatively (without surgery). But for the athlete with significant pain who can’t fully engage in his or her sport, surgery is indicated.

Without surgery, you can expect at least a six to eight week period of time for recovery. Depending on the location and severity of injury, recovery can be months up to two years or more. Patients must be careful not to restrain the tendon/muscle before complete healing has taken place. If together, you and your surgeon decide a conservative approach is best, then most likely you will be seeing a physical therapist to guide you through the process. Patient compliance (following your surgeon and therapist’s advice) are key to a good result.

Zip lines, bungee jumping, in-line skating, skiing and other similar activities with the grandkids might have to take a back seat for awhile. Your therapist will give you specific guidelines of what you can and can’t do doing rehab. But don’t worry, time with the grandkids won’t be on the “do not do” list!

Alignment or overuse problems of the knee structures is a common problem among athletes. Strain, irritation, and/or injury of the patellar tendon often produce pain, weakness, and swelling of the knee joint.

In the acute form of this problem, patellar tendonitis (also known as jumper’s knee) develops. When the condition goes on for more than three months (six months at the outside), it is considered a chronic problem. That’s when it becomes a tendinopathy (damaged tendon) and no longer a tendonitis (inflamed).

In the chronic phase of this condition, microtears in the tendon have failed to heal. Instead, poor blood supply leads to changes observed in the tendon-bone interface as well as in the fibrocartilage of the patella (knee cap). Ultrasound studies have also shown the formation of cyst-like cavities where the tendon attaches to the bone.

Nonoperative care is the first-line of treatment for this problem. The best approach (one that works for everyone every time) remains uncertain. Instead, the patient tries activity modification, rest, antiinflammatory medications, exercises, cold therapy, steroid injections, deep friction massage, or some combination of these approaches.

As for iontophoresis versus injection, there are studies supporting both forms of treatment. Iontophoresis is the use of a mild electrical current to push anti-inflammatory medicine through the skin to the inflamed or sore area. Steroid injection uses a needle to direct the medication directly to the problem area.

These conservative techniques seem to work best when applied early on in the condition and/or on patients with mild symptoms. These two techniques are not combined together (used at the same time) but they may each be combined with other approaches (e.g., activity modification , rest, manual therapy).

The best thing to do is work with your physician to identify the best form of treatment for you. If you do not get the expected results (pain relief, improved function), then try something else or some other combination of conservative care. If, after three to six months of trying various nonoperative approaches, then surgery may be the next step.

You might find the results of a recent European study of interest. They reported that recreational and professional athletes who continue to suffer pain and loss of knee function from patellar tendinopathy can benefit from surgery. Significant pain relief and return to full sports participation is possible.

Sixty-four patients with patellar tendinopathy who did not get relief from their symptoms with conservative (nonoperative) care were included in the study. Alignment or overuse problems of the knee structures is a common problem among athletes. Strain, irritation, and/or injury of the patellar tendon often produce pain, weakness, and swelling of the knee joint.

Nonoperative care is the first-line of treatment for this problem. The best approach (one that works for everyone every time) remains uncertain. Instead, the patient tries activity modification, rest, antiinflammatory medications, exercises, cold therapy, steroid injections, deep friction massage, or some combination of these approaches.

When conservative care fails to improve things, the athlete may be directed to a surgical solution. Unfortunately, the best way to treat this problem surgically remains as much a mystery as the best nonoperative approach. The first decision regarding surgical treatment is whether the procedure should be done arthroscopically or with an open incision.

That’s where this study comes in. The 64 athletes were treated arthroscopically by one surgeon. One-third of the group was involved in professional sports (soccer, basketball, and volleyball). Those athletes involved in recreational sports were also engaged in jogging and tennis.

The technique used was debridement (shaving away) of abnormal tissue and removal of the lower pole (portion) of the patella. In particular, the surgeon removed an area of fat called the Hoffa fat pad. This layer of adipose (fat) tissue is located behind the patellar tendon. That’s the area where there is the most loss of blood flow. Shaving this tissue away helps stimulate a more natural healing process.

Despite concerns that arthroscopic surgery for patellar tendinopathy might not be the ideal choice, the majority of these patients had excellent mid-term and long-term results. Before and after testing showed significant improvements that lasted at least three years.

Some of the patients were followed for up to 10 years with the same continued good results. Best of all, half of the professional players were able to return to full sports play within three months of the surgery and there were no complications for anyone enrolled in the study.

You may not be a good candidate for this type of treatment. Ask your sports physician or team surgeon for an evaluation of your situation and the best recommendation for you.

We can see how a person might get this mistaken view of the term, so we’re glad you asked and happy to set the record straight. Twenty-five years ago, it was decided to create something now known as the rule of thirds describing ACL patients. The break down is as follows:

Perturbation activities is another way of saying balance training but specifically activities that challenge your balance (not just build up your ability to balance). For example, you may be given ways to practice standing or walking on unstable or uneven surfaces. Once you can do that without losing your balance, the program advances to more difficult tasks. You may be pushed off balance in various other ways.

In other words, your balance, alignment, and stability will be “perturbed” (disturbed) in one way or another. Studies show that when it comes to restoring normal stability and motor movement (called kinetics) of the knee, focusing on both strength training and perturbation yield much better results than just working on improving strength.

Using this type of rehab program for anterior cruciate ligament (ACL) tears helps retrain the muscles (reducing cocontraction) and restores more normal knee motion. Research has shown that patients with ligamentous laxity from damage caused by traumatic (often sports) injuries use a physiologic coping mechanism called cocontraction.

This is the simultaneous contraction of the muscles on both sides of a joint. In the case of the knee, that would be contraction of the hamstrings and quadriceps muscles at the same time. The overall effect of cocontraction is to increase stiffness of a joint that is too lax (or loose).

But does this training eliminate the need for surgery? The answer to this question remains unclear and points to the need for further study of this problem. Several groups around the world have started studying ACL injuries with this intent and focus. Their preliminary results show that as many as two-thirds of athletes with ACL injuries can obtain good knee function and return to sports with the rehab program just described. But the recovery period takes time and some athletes may still opt for surgery in hopes of a faster return-to-play.

In other words, there’s enough evidence to support a nonsurgical approach to ACL tears — even for athletes who intend to return to full sports participation. Combining strength training with perturbation is a key factor in getting good results with or without surgery.

You have a very clear understanding of the typical options offered young athletes with an anterior cruciate ligament (ACL) injury. There are pros and cons to both treatment choices. But some information from a recent (large) study at Kaiser Permanente might help.

Kaiser Permanente is a large health care facility located across the United States in 35 medical centers and 431 medical offices. They serve more than 8.8 million members. They have a special registry for ACL patients called the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry. The information in this large database was used for this study. They included 1252 patients from three different locations under the care of 20 surgeons.

The information for each patient treated surgically to reconstruct a ruptured ACL was placed into the computer database. Information included patient demographics (age, occupation, sex, date-of-injury, date-of-surgery). The record for each patient also included type of soft tissue injury and results of surgical repair (repair rates).

By running various computer statistical programs, the authors were able to analyze and evaluate all 1252 patients. They found that delaying surgery (12 months or more) was linked to a greater risk of medial meniscus and joint cartilage injury. The delay was also likely to result in a reduced repair rate. The results of this Kaiser study are very similar to other smaller studies that showed a delay in time-to-surgery was linked with poorer outcomes.

This Kaiser study took a look at more than just time-to-surgery by comparing age and sex as additional possible risk factors for greater injury and decreased repair rates. What else did they find here? Younger patients were more likely to just suffer an ACL tear without other soft tissue injuries. Females made up more of the younger age group than males. Men tend to participate in active sports longer so injure themselves across a broader range of ages.

With this information in mind, talk with your orthopedic surgeon. Find out what (if any) risk factors you may have should you decide to delay surgery. Ask about a timeline (i.e., if you wait to have surgery, how long can you delay the decision)? Ask your surgeon for any activity guidelines to follow during this decision-making process. This may help prevent meniscal and cartilage lesions while you choose the right treatment approach for you.

That’s an interesting observation that might actually be true across the board. At least according to one large study from Kaiser Permanente, it looks like females make up more of the younger age group with anterior cruciate ligament (ACL) injuries.

This finding might reflect the fact that females tend to peak in sports participation earlier and at a younger age than males. Men tend to participate in active sports longer so they injure themselves across a broader range of ages.

The information for each patient in this study who was treated surgically to reconstruct a ruptured ACL was placed into the computer database. Information included patient demographics (age, occupation, sex, date-of-injury, date-of-surgery). The record for each patient also included type of soft tissue injury and results of surgical repair (repair rates).

Being male and older age were also risk factors for meniscal and cartilage injuries. Men were at greater risk of lateral meniscus injury and combined injuries (e.g., ACL tear plus meniscus AND cartilage damage).

The presence of combined injuries in males might also account for the higher number of patients who have surgery for this problem. It’s possible that women are able to recover sufficiently without surgery by following a rehab program. Studies are needed to confirm the differences between males and females pursuing surgery for ACL reconstruction.

Bone contusion or bruising may be an indication of the severity of the injury. It can be viewed on MRI as edema or swelling inside the bone where the bone marrow is located.

Bone contusion has long been suspected as part of knee injuries severe enough to rupture the anterior cruciate ligament (ACL). And recently, a study from South Korea has been able to verify this theory.

The discovery that bone contusion occurs during ACL ruptures was made by looking at MRIs of 81 patients who had an ACL injury that required surgery. Most of the people in the study were athletes engaged in their sport (soccer, basketball, baseball, volleyball) at the time of the injury. But there were a few who were involved in a fall or car accident. Everyone in the study had MRIs taken within six weeks of the injury.

The MRIs were essential in determining that there had been bone bruising. By taking a closer look at the MRIs in relation to the patients’ injuries, they were able to see how often bone contusions occurred. And, in fact, they found an 84 per cent rate of bone contusions in this group.

By breaking the data down further, they recorded 73 per cent of the bone contusions were located along the lateral side of the tibial plateau. The tibial plateau is the flat shelf of bone at the top of the tibia (shin bone). The tibial plateau forms the bottom half of the knee joint.

There were almost as many (68 per cent) of corresponding bone bruises along the lateral femoral condyle. The femoral condyle is the round end of the bottom of the femur. There is a lateral and a medial femoral condyle (one on each side of the femur). The femur forms the upper part of the knee joint.

In a smaller number of cases, there was bruising along the medial femoral condyle (24 per cent) and on the medial tibial plateau (26 per cent). Bruises along both the femoral and tibial sides of the joint on the same side (medial or lateral) are called kissing bone contusions.

The surgeons were also able to identify how many patients had meniscal injuries (and what type) at the time of the arthroscopic surgery. About half of the group had some type of meniscal injury. They compared how many patients with bone contusions also had a torn or damaged medial or lateral meniscus. The greater the bone contusions, the more the meniscal injuries.

Bone contusions aren’t treated directly. But they are a sign of a more severe injury. And they serve as a signal to the orthopedic surgeon. Now the surgeon knows to look for associated knee injuries. The additional injuries likely involve the meniscus and ligaments. Finding and assessing these injuries will guide the surgeon in making all the necessary repairs during surgery.

You may be referring to a mechanism called contrecoup. It’s a bit like a neck whiplash injury where the head is thrown forward, then backward, then forward again. The force of the accident is enough to accelerate the head in one direction. Then there is a rebound or movement in the opposite direction as the head whips back. The head movement decelerates (slows down) as the head comes back to a neutral position.

With anterior cruciate ligament (ACL) injuries of the knee there is a similar back and forth shifting as a result of the force placed on the knee. When the injury occurs, the foot is planted firmly on the ground while the person (often an athlete) is moving in a different direction. The intensity and speed of the event shifts the weight over the knee.

The femur (thigh bone) rotates and the resulting shear force ruptures the ACL. The contrecoup mechanism describes the motion in the knee as the joint complex shifts back to compensate for the first pivot-shift during the initial injury. Like a whiplash injury with three directions (forward-back-forward), there can be a side-to-side-to-side shift in the knee before movement stops. This would be called a coup-contrecoup shift.

The reason this mechanism is important is that it brings with it the potential for injury to other parts of the knee besides the ACL. For example, bone contusion has been documented with MRIs in association with a contrecoup shift.

A lateral force on the knee intense enough to rupture the ACL is often enough to damage other aspects of the knee as well. A recent study showed how bone contusions (bruising) occur much more often than ever realized. With minimal force, there may be no bone contusion. With moderate force, the lateral side of the joint is affected first. And with severe force, there is enough energy behind the event to bruise the bone on both sides (medial and lateral).

This makes sense if we remember the contrecoup mechanism. The initial injury damages one side of the joint. The knee shifts (rupturing the ACL) then shifts back (bruising the bone and tearing the medial collateral ligament). With enough force on the either side, the meniscus can be torn as well.

It’s very similar to a whiplash injury of the neck but instead of forward and back acceleration and deceleration, it’s more of a side-to-side shift in one direction then shift back followed by a final shift.

The use of patellar resurfacing has come under scrutiny many times over the years without a clear consensus about what to do. Resurfacing the patella involves shaving and smoothing the cartilage and bone along the back of the patella. Then the surface is covered with an implant made of metal, polyethylene (plastic), or a combination of both metal and polyethylene. Many surgeons favor the all-polyethylene backing as a result of studies that have shown there are fewer problems with it.

One of the reasons surgeons try to address the question of “to do” or “not to do” patellar resurfacing is related to the overall results of knee replacements. Studies show a 90 per cent survival rate of the implant. That’s great but it doesn’t say anything about how the patient is doing.

Other studies report a large number of patients have ongoing knee pain and loss of function despite the new knee. Quality of life is then affected. Could it be that something so simple as to resurface the knee cap could change that dynamic?

A recent study was done in England to see if patellar resurfacing made any real difference. It was part of a larger study investigating the results of using four different total knee replacements. The larger study is called the Knee Arthroplasty Trial (KAT).

With over 1700 patients enrolled in the KAT study, this may be the largest research project looking at patellar resurfacing. Half the patients got a knee replacement with patellar resurfacing while the other half received the knee implant but did not have the patella resurfaced.

Results were compared between the two groups using pain, motion, and function as the main measures. There are several tests that give objective data to compare. The authors used the Oxford Knee Score, the Short-Form-12, and the EuroQoL 5D. They also looked at costs and compared the number of patients in both groups who had to have a revision (second) surgery.

After all the data was in and the number crunching was done, there was no difference between the two groups. After five years, presence of pain, pain levels, and the quality of life based on knee function were about the same for all patients in both groups.

The large number of patients involved in the study help support this idea that there is no obvious benefit of patellar resurfacing at the time of the knee replacement procedure. Surgeons may want to reserve patellar resurfacing for patients who continue to experience knee pain after knee replacement. Resurfacing the patella is a simple revision procedure that can be done later if needed.

Total knee replacements have been proven to last at least 15 years. But survival of the implant and knee function are too different things. And many total knee patients report persistent knee pain and loss of function despite the new knee.

Surgeons are exploring the reasons for this dilemma and looking for ways to improve results. One of those ways is to resurface the patella (knee cap) as part of the knee replacement procedure.

Resurfacing the patella involves shaving and smoothing the cartilage and bone along the back of the patella. Then the surface is covered with an implant made of metal, polyethylene (plastic), or a combination of both metal and polyethylene. Many surgeons favor the all-polyethylene backing as a result of studies that have shown there are fewer problems with it.

We can share with you some information from a large study done comparing total knee replacement with and without patellar resurfacing. In particular, the results of the study addressed late patellar resurfacing (meaning as a revision surgery like you are considering).

They found that patellar resurfacing at the time of the total knee replacement doesn’t yield any better results than putting in an implant without touching the patella. For those who had persistent pain and went back for a second surgery, patellar resurfacing was advised.

Patients who had revision surgery to perform a patellar resurfacing reported a gradual improvement in painful symptoms. Along with pain relief came improved function. But overall, the group never reached a level of improvement equal to patients who had a total knee replacement without residual knee pain. At the very least, you should know patellar resurfacing can help but complete pain relief is not guaranteed.

Athletes aren’t the only ones to develop knee pain from a condition called patellofemoral pain syndrome (PFPS). Many people of all ages in the general public develop this problem, too. It sounds like your daughter has joined in as well!

The patella, or kneecap, can be a source of knee pain when it fails to function properly. Alignment or overuse problems of the patella can lead to wear and tear of the cartilage behind the patella.

This produces pain, weakness, and swelling of the knee joint. Several different problems can affect the patella and the groove it slides through in the knee joint. Patellofemoral pain syndrome is one of them.

A brief review of knee anatomy may help you understand this problem better. The patella (kneecap) is unique in that it is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscle, to the lower leg bone.

Tightening up the quadriceps muscles places a pull on the tendons of the quadriceps mechanism. This action causes the knee to straighten. The patella acts like a fulcrum to increase the force of the quadriceps muscles.

The underside of the patella is covered with articular cartilage, the smooth, slippery covering found on joint surfaces. This covering helps the patella glide (or track) in a special groove made by the thighbone, or femur. This groove is called the femoral groove.

Two muscles of the thigh attach to the patella and help control its position in the femoral groove as the leg straightens. These muscles are the vastus medialis obliquus (VMO) and the vastus lateralis (VL). The VMO runs along the inside of the thigh, and the VL lies along the outside of the thigh. If the timing between these two muscles is off, the patella may be pulled off track.

What causes this muscular imbalance? That’s been the focus of many, many studies. In a recent study, researchers found that the cross-sectional area of the VMO was smaller at the patellar level in the patients diagnosed with patellofemoral pain syndrome (PFPS). In fact, the entire quadriceps muscle was smaller in the PFPS group when measured at the midthigh level.

But these findings don’t answer the question: which came first — the PFPS or the change in muscle size? Maybe people born with a smaller vastus medialis obliquus (VMO) are more likely to develop PFPS. Or maybe the pain of PFPS leads to inactivity and the muscle begins to waste away and get smaller.

For now we know that there is atrophy of the VMO in patients with patellofemoral pain syndrome. This is new information that hasn’t been published before. And since we know the VMO is important in stabilizing the patella during knee motion, it seems logical that the smaller size of this portion of the quadriceps could be a key to directing prevention and treatment. Understanding the cause and effect of VMO size and PFPS will be the focus of future studies.

Osteonecrosis (death of bone) after arthroscopic surgery has been reported in the medical literature. But as you have discovered for yourself, it’s very rare. It’s estimated that about two out of every 50 patients having any type of arthroscopic surgery may develop this condition. That’s a rate of about four per cent.

The next question is always, what causes this to happen? We don’t know the answer to that just yet. It appears that the medial femoral condyle is affected most often. That’s the large round knob of bone at the end of your thigh bone (femur). Medial means it’s on the side closest to the other knee.

Different theories have been put forth as possible reasons why this condition develops after arthroscopic surgery. Some experts suggest it depends on the type of arthroscopic tools used (laser probe, radiofrequency, mechanical instruments).

Others believe there’s been some damage done to the cartilage, meniscus, or subchondral bone (first layer of bone underneath the joint cartilage). This is called occult pathology meaning it is unseen. Tiny fractures of the subchondral bone disrupt the bone leaving it vulnerable to damage resulting in blood loss and eventually osteonecrosis.

No matter what causes knee osteonecrosis, the goal of treatment is always the same — prevent bone destruction and collapse. The patient is given medications for pain and inflammation and put on weight-bearing restrictions.

If conservative (nonoperative care) fails, then joint-preserving techniques may be attempted (bone grafting, microdrilling, mosaicplasty). If despite all efforts, the condition deteriorates and there is severe joint destruction, then joint replacement (unilateral or total knee) is the final step.

Osteonecrosis of the knee is a condition where a portion of the femur (thigh bone) loses its blood supply, dies, and collapses. Another term used for osteonecrosis is avascular necrosis. The term avascular means that a loss of blood supply to the area is the cause of the problem and necrosis means death.

This condition can affect other joints as well (e.g., hip, shoulder). When the knee is involved, the problem usually occurs on the medial femoral condyle — that’s the large round knob of bone (called a condyle) at the bottom of the femur. The medial condyle is affected most often. That’s the side closest to the other knee.

There are three separate types of knee osteonecrosis. Each one is associated with different causes. In the case of spontaneous osteonecrosis, as the name suggests — it just happens without warning or known cause.

There probably is an underlying cause but we just don’t know what it is yet. For example, some experts think that a mini-fracture of the layer of bone just under the knee cartilage (called the subchondral layer) may later become osteonecrotic.

Separately, there has been some suspicion that osteopenia (decreased bone density prior to developing osteoporosis) is also part of the initial process in spontaneous osteonecrosis. If it turns out that either of these conditions leads to osteonecrosis then this type of osteonecrosis won’t be called spontaneous any longer.

There is no evidence that this condition (no matter what causes it) is hereditary or contagious. Spontaneous osteonecrosis is the most likely to respond to conservative (nonoperative) treatment.

If the lesion does not improve and get smaller with nonsurgical management in the first three months after diagnosis, then the surgeon may scrape the bone clean of any dead cells and give the joint a chance to heal. Transferring bone cells from a healthy part of the joint to the osteonecrotic section is another treatment option for spontaneous osteonecrosis. This procedure is called mosaicplasty.

There are other surgical procedures available for the treatment of severe spontaneous osteonecrosis (e.g., joint replacement). But that’s farther down the road for anyone just diagnosed with the problem. With early diagnosis, it’s highly likely that your family member will have a good result with conservative treatment.

The step-down test is used to test the knee in anyone with a healthy knee or with knee pain to determine level of function. It mimics stepping down stairs, which is often very painful for someone with patellofemoral pain syndrome (PFPS).

The test is done by standing with the leg to be tested on a standard height stair (usually 20-cm or five inches). You lower your body enough to touch the heel of the opposite leg on the floor in front of the step. Then you straighten back up and repeat.

The test was standardized in 2002 for testing with healthy adults and compared with patients who have patellofemoral pain syndrome (PFPS). A normal, healthy adult can perform an average of 18 repetitions of this step-down activity. People with PFPS test out at around an average of 14 repetitions.

Other studies that have repeated this test with female athletes who have PFPS have reported an average of 15 plus or minus seven repetitions before rehab. That means there was a range from eight to 22 repetitions within the group. After an eight-week long strengthening program, the athletes were able to perform 21 plus or minus five repetitions (range of 16 to 26).

You can also check with the therapist who did the testing and see if this matches with the test he or she was using. Your therapist will know what goal to set for you based on several factors such as current strength of hip and knee muscles, type of sports activity, activity level you plan to engage in, and level of strength needed for both.

We’ve known for a long time that a weak, impaired, or imbalanced quadriceps muscle is a risk factor for patellofemoral pain syndrome (PFPS). But recent studies have shown what you have found out — that weak hip muscles (external rotators and abductors) are directly linked with PFPS.

The question of order for exercises is a good one — and one that is being studied. In fact, a group of physical therapists, athletic trainers, and sports physicians at the University of Kentucky Musculoskeletal Lab have just finished comparing results between two exercise programs designed specifically for patellofemoral pain syndrome.

They compared the results of hip strengthening exercises performed by one group of athletes with PFPS to a second group of similar athletes who did a quadriceps strengthening program instead.

All the participants in both groups were female. That was intentional because patellofemoral pain syndrome affects women twice as often as men in the general population and four times as often among athletes. They carefully screened participants so that everyone had the same symptoms and clinical presentation.

Results were measured using a couple of different outcomes. Pain intensity was one measure. Strength of hip and knee muscles was a second measurement used for comparison. They used a special handheld device called a dynamometer to test the muscles.

A third way to measure results was a test for functional strength. This test involved stepping down on one leg from a step, touching the heel to the floor, then returning back up to the step. The unit of measure used for comparison was the number of times each athlete could step down and back up in 30 seconds.

Each athlete performed flexibility exercises (performing each stretch three times for 30 seconds each) before doing strengthening exercises. Then they did their program of (quad or hip) exercises three times a week. During one of those three times, they were supervised by a physical therapist or athletic trainer. The other two sessions were done at home on their own.

There were two phases of the rehab program. Phase one (flexibility and strengthening as described) lasted four weeks. Everyone was retested at that point before progressing to phase two. Phase two consisted of weight-bearing resistance exercises, balance exercises, and a continuation of either the hip or quadriceps strengthening (the same exercise program done in phase one). Following phase two (four weeks), retesting was conducted and the results reported.

Here’s what they found. Everyone in both groups gained in strength. Athletes in the hip strengthening group had less pain during the first four weeks compared with the knee group. The step-down test improved significantly for everyone in both groups.

They concluded that performing isolated hip strengthening helps decrease patellofemoral pain in female athletes faster than doing a traditional quadriceps strengthening program. This is just one piece of the puzzle.

Further research is needed to investigate the use of strengthening exercises as part of the rehab program for patellofemoral pain syndrome (PFPS). The goal should be to find the most efficient approach to the problem of pain and loss of function using exercises to rehab hip and/or knee muscles.

The just-in-case factor is one practice in sports that is hotly debated. Should I wear a knee brace “just-in-case” I might injure my knee? This question arises any time an athlete participates in a contact sport with the potential for traumatic injuries. Add high speeds and difficult terrain in the dangerous and intense sport of off-road biking and you may find yourself reaching for that brace, too.

But does a knee brace really protect you or anyone else participating in sports like motocross (MX)? That’s the question raised (and answered) in a recent study. The information comes from a survey placed on the Internet and completed by over 2,000 off-road motorcycle riders.

Data was collected for one-year. Participants in track, off-road, motocross (MX), and other types of riding from around the world responded. Riders were asked about injuries (type, severity, frequency), riding hours, and use of prophylactic (preventive) knee bracing. The results were compared between riders who wore a brace just-in-case and those who did not.

They found that fewer injuries were reported by riders who wore preventive braces. Riders who didn’t wear a brace were more likely to injure their anterior cruciate ligament (ACL), the meniscus (cartilage) in the knee, or their medial collateral ligament (MCL).

By taking pressure off the ACL, these knee braces do seem to be making a difference in the number and severity of knee injuries. In fact, riders who do not wear a knee brace are twice as likely to suffer knee injuries compared with those who do wear the brace. That conclusion confirms the importance of prophylactic (“just-in-case”) bracing for riders engaged in any of these off-road biking events.

When it comes to wearing braces prophylactically (as a preventive measure) during sports activities, things have changed quite a bit over the years. Sports enthusiasts in this area have gone from wondering if it’s really worth it to wear a brace to prevent knee injuries to recommending them routinely.

As a result, manufacturers have come out with many off-the-shelf as well as custom-made knee braces designed just for off-road biking. In fact, changes in design and specificity of prophylactic knee braces have been made for participants in other sports as well.

The wide variety of knee braces available actually makes it difficult (if not impossible) to compare them and find out which one works best. Studies done so far have shown that all of the braces reduce the strain on the knee by at least 20 to 30 per cent. In fact, riders who do not wear a knee brace are twice as likely to suffer knee injuries compared with those who do wear the brace.

Experts suggest the effect is probably more than the 30 per cent strain reduction tested so far. Braces on the market today clearly have greater protective effect than the ones available 20 years ago.

Wearing any of them is likely to be effective. The risk of injury will be reduced when using the knee as a pivot coming around a corner at a high rate of speed or when landing with the knee over extended after a high-speed jump. That alone would be worth the price of purchase.

There are three ways to measure long-term success or results from meniscal repairs. First is the patient’s own report. Is the knee stiff or painful? Can you move the knee joint through its full motions?

Are there any activities (e.g., squatting, climbing stairs, running) that are limited by your knee? Do you have full strength on that side? And how is your standing balance on that side compared with the uninjured side?

Second, the surgeon looks at imaging studies such as X-rays, MRIs, and arthrograms to see the size and shape of the joint space (distance between the two bones that make up the knee joint).

Any narrowing (especially on the side of the injury) of the joint space may be a warning flag of future joint degeneration leading to arthritis. These imaging studies also provide an idea of the condition of the surrounding soft tissues.

And the most reliable test of all: a repeat arthroscopic examination. Taking a look inside the knee joint using a special instrument called an arthroscope is referred to as a second-look arthroscopy.

Surgeons don’t routinely perform second-look arthroscopic examinations. They are invasive and costly compared to the other types of evaluation. But when formal studies are done, this kind of follow-up is really necessary to get examine the full extent of healing and recovery.

This type of meniscal tear occurs most often when traumatic force is generated that is strong enough to rupture the anterior cruciate ligament (ACL) inside the knee. Along with the ACL tear, a posterior lateral meniscus root (PLMR) tear such as you are describing occurs.

The standard procedure with meniscal tears is to repair them (rather than leave them alone to heal on their own or removing them). But posterior lateral meniscal root (PLMR) tears are handled a bit differently.

PLMR tears are difficult to repair. There are nerves and blood vessels close by that could be injured during a repair procedure. Because of the location of the posterior lateral meniscus, the risk of further cartilage damage or damage to the opposing bone (femoral condyle) is high just trying to get the arthroscopic instruments into the area.

For these reasons, until there is clear evidence that PLMR tears should be routinely repaired, surgeons leave them alone. PLMR repair should be done only when it is clear that leaving the PLMR tear will yield a worse result than fixing it. It sounds like that’s how your case was handled.

The knee stiffness could be coming from something else and should be checked out. Bring it to your physician’s attention at your earliest convenience. It’s probably best not to put it off indefinitely. With most orthopedic problems, early diagnosis and intervention usually yield better long-term results.