News Category: Knee

Knee pain from osteoarthritis (OA) is becoming more common every day. It is now the leading cause of disability in older adults. OA makes walking and stair climbing the most difficult tasks. Many studies have been done on the forces placed on the arthritic knee during walking. Researchers are now turning their attention to stair climbing.

Going up and down stairs is more demanding than level walking. Greater muscle strength and control are needed. OA is often linked with weak muscles. Pain causes the affected person to move less often. This sets up a cycle of pain, loss of motion, weakness, and more pain–and ultimately less activity. Weak muscles get tired easily. Weak and tired muscles don’t contract quickly or on time. All of these factors make stair climbing difficult.

The knee joint takes a greater force going down stairs. Patients with OA bend the knee less when going down stairs. This loads the joint because the muscles are slow to contract to protect the joint. If the thigh muscle doesn’t contract in time during stair descent, the knee doesn’t absorb shock as well. The puts a much bigger load on the joint and can make arthritis worse.

Having good control of the muscles is important in knee OA. It gives full motion to the joint and reduces the load. Finding out when the muscles aren’t contracting properly may help prevent arthritic changes. This is the focus of research by physical therapists, so they can better prescribe exercises to keep knee arthritis from getting worse.

Osteoarthritis of the knee often causes a loss of motion. This is often because bone spurs form along the front of the joint and block movement. This causes pain in the front of the knee and an inability to fully straighten the knee.

If the loss of motion is less than 10 degrees, a simple surgery to remove the bone spurs may be all that’s needed. This operation is called arthroscopic debridement. The doctor inserts a slender device, called an arthroscope, into the joint. It has a tiny TV camera on the end that displays a view of the joint on a TV screen.

During the debridement procedure, the doctor scrapes away bone spurs and smooths the joint surface. The goal is to increase motion, decrease pain, and increase function. It may also prevent the need for more extensive surgery later.

Debridement should be done sooner rather than later. Patients who wait more than five years and who have lost more than 10 degrees of knee extension are poor candidates for this operation. Often, the result isn’t as good, and more surgery is needed. Those with early symptoms (less than one year) and minimal loss of motion (less than 10 degrees) generally regain full knee extension and keep it.

Joint cartilage, the smooth lining that covers joints, doesn’t register pain. But when cartilage in the knee joint is damaged, it can put painful pressure on the bone below (called subchondral bone). This can cause painful swelling.

It’s not easy to repair joint cartilage. Patients often lose joint function. Osteoarthritis and disability can be the end result of this condition. New methods of regaining or restoring knee cartilage are being studied.

Doctors in Sweden and Norway combined efforts to describe damage to the knee joint. They did this by filling out a form after every surgery done with an arthroscope. The arthroscope is a slender device with a tiny TV camera on the end. It can be inserted into the joint so the doctor can look inside.

One thousand knees were examined this way. The location, size, and depth of the damage were recorded. Doctors also measured knee motion, swelling, and other areas of damage or disease. The hope is to find out which patients should have surgery to repair the damaged cartilage.

Defects in the joint knee cartilage are common. Some are caused by trauma and injury. Others occur after years of wear and tear. Younger patients tend to have moderate-sized areas of damage. Larger defects come from repeated minor injuries to the joint surface, along with the effects of aging.

Smaller areas of damage respond better to treatment. Patients younger than 45 years have the best results with surgery. The upper limit of age for a successful operation seems to be around 50 years. Results are best in all ages if the repair is made within three weeks of injury.

Surgery is often needed to repair a torn anterior cruciate ligament (ACL) in the knee. Doctors have more and more choices now when doing this surgery.

One option is to take a piece of bone and tendon from the patellar tendon (below the kneecap) to replace the torn ACL. The second option uses graft tissue from a donor rather from the patient. A third option is to take a piece of the hamstring muscle as the graft tissue.

A new and fourth method has been in use since 1996. This is the bone-quadriceps tendon (BQT) graft. In the BQT procedure, the torn ligament is replaced by taking part of the top of the kneecap and its attached tendon. The tendon in this case is the quadriceps tendon.

ACL repair with BQT grafts have some definite advantages. There is less pain and fewer problems for workers or athletes who use the kneeling position. This graft is thicker and helps fill the tunnel in the bone made during the operation. The BQT also offers an alternative method of repair when one of the first three options is used and fails.

BQT grafts used for ACL repairs have been in use since 1996. These thicker grafts are of excellent quality. The author of this report believes patients have fewer problems after surgery and can safely take part in an aggressive rehab program afterwards.

The good news is that torn ligaments in the knee can be surgically repaired. The bad news is that sometimes these repairs fail. In the case of the anterior cruciate ligament (ACL) of the knee, a piece of tendon is usually taken from another part of the knee and grafted in place. If the graft doesn’t take, or if it gets torn, another operation is needed.

Many studies have shown that the ACL doesn’t heal well by itself. This is especially true when it has been completely ruptured in an accident or injury. There are many possible reasons for this poor healing response. The ACL doesn’t have a strong blood supply, and the cells that make up this ligament don’t have a good repair process.

But what happens when a tendon is grafted in place of the torn ligament, and then the tendon gets torn? Can it repair itself? One case report suggests this may be possible. A 19-year-old woman with a torn ACL from a soccer injury had a tendon graft repair. Four years after the repair, she injured her knee again while playing soccer.

After the second injury, doctors couldn’t find signs of an unstable knee. However, an MRI showed that the graft was ruptured. Surgery to repair the graft injury was planned but was delayed for seven weeks. When the doctor looked inside the joint during surgery, the graft had healed itself. The knee was stable, and the woman returned to sports after a brief rehab program.

This case is important because it points out that this kind of healing is possible. Finding out what conditions and factors support healing is the next step. Graft rupture with only a small amount of knee instability should be observed for a time before the next operation. Healing may take place without another surgery.

You’ve probably heard the old saying, “If it’s not broke, don’t fix it.” But what if it’s half-broke? For example, damage to the knee joint from arthritis may only affect a portion of the joint. Is it really necessary to replace the entire joint?

Some doctors don’t think so. New materials and techniques now make it possible to replace one side of the knee joint. This is called a unicompartmental knee arthroplasty (UKA). It can be done on either the inner half or outer half of the joint. Doctors try to preserve as much of the natural knee joint as possible. They also want the knee replacement parts to survive 10 years or more.

New research shows that using a UKA in the “right” patient has excellent results. The 10-year survival rate of the implant is 94 percent. Only a small number of knees must be revised with a second surgery during the first 10 years.

Which patients are best selected for this method of treatment? The best choice includes those with damage in one compartment only. Cartilage on the other side must be in good shape. A total knee replacement is advised when there is a great loss of cartilage on both sides of the knee. Cartilage must also be healthy in the patellofemoral joint. This is where the kneecap (patella) meets the upper leg bone (femur).

It isn’t always necessary to have a complete knee joint replacement. Treatment is possible for joint damage on one side only. The results are favorable for most patients. A simple revision can be made years later to replace the liner of the implant if it becomes worn.

Surgical treatment for degenerative arthritis of the knee has a long history. In the 1940s, doctors started removing bone spurs, torn cartilage, and loose fragments in the joint. A new device, called an arthroscope, changed treatment in the 1970s.

The arthroscope allows doctors to look inside the knee. A slender hand-held tool with a tiny TV camera on the end is inserted into the joint. With this tool, doctors don’t have to make a large cut to repair damage inside the joint. Over the last 30 years, doctors have refined the use of the arthroscope. It’s been used for many joint conditions and problems.

Many studies have been done using arthroscopic surgery for knee joint arthritis. Doctors are still unsure if arthroscopic methods of treatment work for this condition. They’ve used it for procedures to scrape the joint smooth and flush it clean. The meniscus can also be removed using the arthroscope.

Other arthroscopic treatment for the arthritic knee includes repair of torn cartilage. The arthroscope has made it possible to use laser and radiofrequency energy to treat the knee. Through it all, the goals of surgical treatment haven’t changed in all these years. The purpose of treatment is still to decrease pain and improve function.

Doctors report that arthroscopic surgery is very helpful for the treatment of many knee problems. However, it isn’t a cure-all for everything. Local treatment doesn’t prevent the arthritis from getting worse. It can only delay major operations like joint replacements by months to years. Doctors agree that more studies are needed to find the best uses of arthroscopic surgery for the arthritic knee.

When a teenager injures the anterior cruciate ligament (ACL) of the knee, is it the same as in adult? Do they need surgery right away? What happens if treatment is delayed?

These and other questions are unknown at this time. It’s not even known yet how many teenagers injure their ACL each year. It does seem to be more common all the time. Doctors and parents would like to know if surgery is needed for this problem and how soon it should be done. The concern is that without treatment, other injuries might occur. For example, in adults, a torn ACL can lead to damage in the meniscus or other ligaments in the knee.

Doctors at several hospitals in Boston report the results of treatment for ACL injury in teenagers. All patients were between 10 and 14 years old. The injuries were the result of an accident or sports activity. Two-thirds had other injuries along with the ACL tear. Most of these were tears of the meniscus.

The meniscus is the pad of cartilage inside the knee joint. There is one meniscus on the inner (medial) half of the joint and one on the outer (lateral) half. When surgery to repair the damaged ACL is delayed, more medial meniscal tears occur. Without surgery to repair this, the joint starts to break down.

Surgery to repair damaged meniscus and ligaments in the adolescent knee is not standard. Doctors say that this is another area of debate for them when treating these patients. Each patient requires a slightly different approach based on the damage. The bone is not fully matured, and this affects the treatment. Sometimes, the meniscus can be repaired. At other times, it must be removed, either partially or completely.

The first study to report patterns of injury in teenagers with ACL tears has been published. As suspected, teens are not different from adults when it comes to ACL tears. Many teens tear the meniscus along with the ACL. Early treatment to repair the meniscus can save it, preventing future damage to the joint.

Ever hear of PFPS? Sounds like someone whispering to get your attention. Patellofemoral pain syndrome (PFPS) is anything but a whisper coming from the knee. Pain around or under the kneecap gets patients’ attention loudly and clearly. Climbing stairs, sitting for long periods, squatting, and kneeling are especially painful activities.

PFPS is somewhat of a mystery. Actual problems or disease are rarely found. It may be caused by the kneecap (patella) getting off track as it goes up and down during knee motion. Recent studies show that it might be a problem with muscle control rather than muscle strength.

The leg straightens and the patella moves up when the quadriceps muscle is contracted. This large muscle of the upper thigh is divided into four parts. Two of those sections are most important for knee extension. These are the vastus medialis oblique (VMO) and the vastus lateralis (VL).

Physical therapists are working hard to find ways to treat PFPS. Their focus is to retrain the muscles to contract with the correct timing. This is called muscle reeducation. Treatment includes taping the patella and doing exercises with biofeedback. This is called the McConnell Program.

Two groups of PFPS patients were included in the study. One group received the McConnell-based program, while the second group was the placebo group. Each group was treated once a week for six weeks. Home exercises without biofeedback were also done daily. The placebo group received “dummy” treatment.

Physical therapy improved patient’s pain and function. According to this study, muscle control can be changed with retraining biofeedback. The placebo group showed no change in symptoms or function.

It’s not clear which part of the treatment made the difference. Did the taping change the timing of the contracting muscles? Or did using biofeedback decrease the pain, so the muscles could then function normally? More research is needed to study each treatment step one by one.

Jumper’s knee is a common problem among athletes. It involves inflamed tendons attaching to the patella, or kneecap. The pain is usually felt in the patellar tendon where it connects at the bottom of the kneecap. Jumper’s knee most often occurs in athletic young adults. It forces many young athletes to give up their sports. But what happens then? Do their knees ever fully recover?

This study tracked down athletes with jumper’s knee 15 years after their injuries. They were compared to athletes who had never had knee problems. More than 50 percent of the athletes with jumper’s knee had quit their sports because of their knee problems, compared to only seven percent of the other athletes. And the athletes with jumper’s knee still had significantly more knee pain during activities such as climbing stairs and jumping.

On the positive side, the injured athletes reported the same ability to work and exercise as the uninjured group. The symptoms of jumper’s knee may be long-lasting, but they tend to be mild.

Many older adults with arthritic knees suffer pain and loss of function. The effort of walking and climbing stairs can be an agony. A swollen joint with loss of motion can be the painful result of this condition.

Many people have an increased angle where the thighbone connects to the leg bone to form the knee joint. Instead of being a straight line, the bones make a slight angle. This is called varus. If the angle is large enough, the patient looks bow-legged. With varus of the knee, there is increased pressure along the inner edge of the joint.

Over time, the joint lining thins out and wears down to the bone. The bone surface can become worn and polished. This is called eburnation. Surgery may be needed. Surgery can straighten the knee angle, restore the cartilage, and improve function.

Correcting the angle of the knee unloads the joint, especially the inside or medial compartment. This operation is called a tibial osteotomy. By correcting the joint deformity, pressure is taken off the cartilage. A proper joint angle actually allows the cartilage to regrow, a process called regeneration.

Dislocation of the knee has always been thought of as a rare injury. But with more people taking part in sports and more car accidents, the number of knee dislocations is going up. In this injury, both main ligaments inside the knee joint are torn completely. Usually, there are other injuries as well. Other injuries might include damage to other knee ligaments, stretched nerves, or ruptured blood vessels.

The best treatment for a dislocated knee remains unknown. Some doctors insist that surgery is required. Others try a program of exercise and rehabilitation first. In some cases, the leg is immobilized in a cast or special device that holds the knee in place while it heals. This device is called an external fixator.

A group of doctors in Germany looked at the records of 89 patients who had a dislocated knee. Data from treatment and follow-up was collected for 25 years. Type of treatment (surgery versus no surgery) and other factors were studied.

It turns out that patients who had surgery for this injury had the best outcome. The results were even better when the surgery was done within two weeks of the injury. The younger patients had the best motion and function after treatment. Sports injuries did better than car accidents. This is probably because injuries in car accidents occur with higher energy and force than sports injuries.

Studying treatment results for knee dislocations isn’t easy. The number of cases is too small. But the best results do seem to come with surgical treatment followed by a rehabilitation program. According to these authors, the ideal time for surgery is three to five days after the injury. Waiting up to two weeks is acceptable.

Most conservative treatments for joint pain seem to be based on good old common sense, but they aren’t always based on science. The treatments might work just fine, yet there may not be any solid research to back them up.

This is the case in treating patellofemoral pain. Patellofemoral pain is often felt behind the kneecap (the patella). Patellofemoral pain mainly occurs during activities such as climbing stairs, squatting, running, and kneeling. Patellofemoral pain is very common, especially in athletes.

No one really understands what causes the pain. There may be several different causes. But no matter what the cause, the standard treatment is physical therapy to strengthen and stretch the tissues around the kneecap. But does physical therapy really work better than the simple effects of time? So far there has been no strong research to prove it.

These researchers in Australia looked at 67 people who had patellofemoral pain. All the patients were younger than 40, and they all had symptoms for more than one month. The researchers divided them into two groups. The treatment group was given standard physical therapy treatment once a week for six weeks. This group worked on strengthening and stretching specific areas around the knee. They also taped their knees to help hold the kneecap in place and did daily exercises at home. The second group was the placebo group. They got false taping, fake ultrasound treatments, and rubbed a nonmedicinal gel on their knees.

After six weeks, the treatment group showed much more improvement in their pain and function. The conclusion was clear: standard physical therapy is an effective treatment for patellofemoral pain. In this case, common sense was backed by science.

Reconstruction of the anterior cruciate ligament (ACL) of the knee is a fairly common surgery. Sometimes patients, most often athletes, have torn the ACL in both knees. In these cases, it is not always clear how to proceed. Should the surgeon rebuild both ACLs in one surgery? Or should the surgeon do two surgeries at different times?

These authors compared the outcomes of 28 patients who had two separate ACL reconstruction surgeries (unilateral reconstruction) to 28 patients who had two ACL reconstructions at the same time (bilateral reconstruction). The average age of both groups was about 30. The authors followed them for two to five years after surgery. Both groups had the same type of surgery, and they all followed the same rehabilitation program.

The authors found no difference in the outcomes between the two groups. Patients were about equal in their ability to function and return to work and sports. Both groups regained strength in both legs. There was also no difference in pain after surgery. The group who had bilateral construction didn’t use any more pain medication in the hospital than the unilateral group. This finding surprised the authors. They expected that a surgery that involved both legs would cause more pain.

There are benefits to doing both ACL reconstructions at the same time. Costs are lower because there is only one operating room fee, one hospital stay, and one period of rehabilitation. The patient only has to go through surgery and rehab once. This means less time away from jobs and activities. The authors conclude that bilateral ACL reconstruction is a safe, effective, and economical option for many patients.

Lots of studies show that strengthening exercises can help older adults with knee osteoarthritis (OA). But what kind of exercises work best? This study looked at 102 people with knee OA who were not exercising.

At the beginning of the study, participants were timed in going up and down a flight of stairs and in laying down and getting up off the floor. The subjects were then divided into three groups. One group used large elastic bands to do dynamic resistance training, which moves the legs through the range of motion. Another group used the bands for isometric resistance training on the legs. Isometric training involves pulling or pushing against the resistance of the bands without moving the joints. Both groups of exercisers followed a set program. They exercised three times a week for 16 weeks. A control group did no exercises during this time period.

The researchers then repeated the timed tests. People in both exercise groups had gotten faster at both tests. They also reported less pain afterwards. Both types of training with elastic bands seems to be an effective way to help people with knee OA improve daily function.

When the pain of arthritis doesn’t go away, replacing the problem joint may be an option. For the knee, the procedure to implant a new joint is called total knee arthroplasty (TKA). For most patients, TKA gives pain-free motion and return of function.

For a small number of patients, the result isn’t good. Painful swelling and loss of function can make them wish they’d never had the procedure. These patients can be helped. The doctor must make a careful search to find the cause of the problem before correcting it. There are many possible causes for a painful TKA.

Problems from inside the knee may be the cause of painful symptoms. Recent changes in the design of the joint implant have helped solve some of these problems. Infection and bleeding are the first two things the doctor looks for. This can be assessed using laboratory test results.

Scar tissue and pinching of the joint lining can cause a painful, stiff knee. This can be found using an arthroscope. The scope is a slender device with a tiny TV camera on the end. It is inserted into the joint. The doctor looks for uneven wear of the joint, loose pieces of tissue, or other changes within the joint. The problem can be found and treated with this single procedure.

Sometimes a painful TKA is caused by something outside the knee joint. This could be from hamstring or quadricep tendinitis. There could be a small break in one of the bones called a stress fracture. Again, improved knee joint implants have helped decrease these problems.

Finally, a painful TKA could be coming from other places. For example, the hip or a herniated disc in the back can send pain messages to the knee. Disease affecting blood flow to lower part of  the body can also cause leg and knee pain. Patients who are depressed or anxious have a greater chance of knee problems after TKA.

Total knee replacements for arthritis are a great answer for 95 percent of all patients. For those patients who end up with a painful, stiff knee after joint replacement, doctors must search carefully for the cause before treating. This can be something inside the joint, outside the joint, or unrelated to the joint altogether.

Sometimes knee joint replacements fail. There can be loosening of the implant, fractures of the bone, or lingering knee pain. The implant may have to be removed and replaced with another one. Each knee joint replacement has three main parts. There’s an upper piece called the femoral component. The lower half is called the tibial component. The third part is the kneecap or patellar component.

What if the implant has failed and there’s nothing wrong with the patellar component? Does the patellar part have to be removed and replaced, too? Doctors at four centers in Philadelphia, Baltimore, and Boston studied this question. No one really knows how long these components last, but the old saying, “If it isn’t broke, don’t fix it,” might be good advice in these cases.

The records of all patients in these centers who had a total knee revision were reviewed. Only patients whose patellar part was left untouched during the revision surgery were included. The researchers found that if the kneecap was in the right place and not loose, there was no reason to remove and replace it.

The authors of this study also report that any failures of the patellar component may be caused by something else. They found that the method used to sterilize this part makes a difference. This process takes place at the manufacturing plant when the implant is made.

According to these findings, doctors should contact the manufacturer before removing or replacing the patella. The method of sterilization should be determined before a second operation. If gamma sterilization in air is the method used, then the authors suggest that the patellar component be replaced. Otherwise, the authors advise doctors to leave it alone.

When faced with a difficult medical decision you might ask, “Doctor, what would you do?” In the case of repairing the anterior cruciate ligament (ACL) of the knee, doctors may have an answer to this question. Presently, there are two different ways to repair a torn ACL. Both methods have good and bad points.

Since the final result seems to be the same, comfort may be the deciding factor. One method removes tissue from the front of the knee to transplant it to the other knee. This is called a patellar tendon graft. The donor site where the tissue was taken is commonly painful. Kneeling or walking on the knees is often painful and even impossible for some people.

This is a big problem for patients who have to be on their knees a lot — for example, carpet layers, house cleaners, gardeners, construction workers, and mothers with small children. Thankfully, there are other ways to do this operation.

Donor tissue can be taken from the hamstring tendon along the inside edge of the knee. There’s less pain after the operation when the hamstring graft is used. Range of motion, strength, and function are also just as good two years after the operation with this method. For this reason, some doctors are recommending the hamstring tendon graft over the patellar tendon graft for ACL repairs.

There’s new hope for those who suffer knee pain. If damage to the cartilage is your problem, this procedure may be for you. Doctors report more than 5,000 cases of cartilage cell transplantation. You can be your own donor, too.

The first operations of this type were done in 1994. Since that time, methods have improved. Doctors no longer have to cut the knee open to insert the cartilage. Now, they can use an arthroscope to complete the operation. The arthroscope is a slender instrument with a tiny TV camera on the end. It allows the surgeon to see inside the joint and perform the operation.

Once inside the joint, the surface is cleared of any torn or loose cartilage. The bone is shaped and prepared for the transplant. Cartilage cells called chondrocytes are mixed with a gel. The mixture is spread on a small piece of material called a fleece. The fleece is anchored down to the bone with stitches. The stitches are absorbed by the body and don’t have to be removed.

This new arthroscopic method of implanting cartilage has fewer problems than the open approach. Doctors report that with careful rehab, the patient won’t lose knee motion. There are fewer and smaller scars with arthroscopic surgery. Best of all, patients have less pain after the operation.

Patients with various knee problems may benefit by having an arthroscopic examination of the knee. In an arthroscopic exam, the doctor inserts a slender instrument with a tiny TV camera on the end into the joint. This allows the doctor to look inside the joint and assess the problem.

The operation doesn’t require any large cuts or incisions. Two or three small puncture holes are all that are needed. Even so, patients tend to have quite a bit of discomfort afterward. The knee may swell and feel hot from inflammation. This can cause limited knee motion.

A new dressing called a pain wrap is being used to control pain after an arthroscopic exam. The pain wrap is placed around the knee and removed only to do exercises. The dressing is changed every other day. All dressings are removed after a week.

In this study, the pain wrap decreased patients’ pain. However, it didn’t change how much pain medication patients took. The joint had less swelling and the skin temperature was cooler with the pain wrap compared to patients who didn’t receive the wrap. Knee range of motion was the same in the two groups.

More studies are needed to compare the pain wrap with other post-operative methods of treatment.