News Category: Knee

It is well known now that the cartilage in the knee called the meniscus is very important to knee function. When torn or damaged, it is best to repair (instead of remove) the meniscus whenever possible. This is even more so for people under 20 years of age. Taking the meniscus out in a young athlete leaves the surfaces of the knee joint unprotected for many more years than in older adults.

Doctors are looking for ways to save the inner (central) part of the meniscus. This is an area where there is no blood supply to help with the healing process. Using animals and then humans, studies are being done to find ways to repair the meniscus and aid healing.

Dr. Frank Noyes from the Cincinnati Sports Medicine and Orthopaedic Center and his co-workers are studying this problem in a group of young athletes. Meniscal repairs in 71 knees of patients under 20 years old were followed for over four years. A special method of repairing the inner part of the meniscus was tried.

The results were good with 75 percent success. Only one in four patients (25 percent) had return of symptoms and a second operation. Some of these cases occurred because of a reinjury during sports activity. Before this study, the central meniscus would typically have been removed. With this new operation, surgeons are beginning to repair meniscal tears in young, active patients. This will help save knee function for many years to come.

Osteoarthritis of the knee is a common problem in the aging adult. It can begin to show up before 40 or as late as the eighties. The U. S. Food and Drug Administration has approved a new medical device for this problem. Viscosupplementation is the injection of a fluid made from rooster combs. This fluid is composed of hyaluronate and helps lubricate and protect the joint.

It can be used if the osteoarthritis is not severe and if the joint still has some of its normal fluid in it. Usually, a series of three injections is given. The most common use is to reduce knee pain, buy some time, and hopefully delay a surgery to implant a new knee joint.

Many trials have been done to show the safety of hyaluronate. Even so, there have been enough people with bad reactions that some doctors are questioning its use. The most common problem is pain or swelling where the shot was given. There is some evidence to suggest that these patients had a reaction to the rooster comb. Another possibility is that the injection had gotten contaminated as a result of the purification process.

These injections are being used as a new treatment for knee osteoarthritis. Pain and swelling at the site of the injection is a sign of tissue inflammation. Anyone who has a reaction to rooster comb should notify his or her doctor and determine an appropriate course of action.

Knee pain is well known to many athletes. It is also a common complaint in the general population. Pain with stair climbing, sitting too long, squatting, and kneeling is a sign of patellofemoral pain syndrome (PFPS). This problem occurs when the kneecap (patella) doesn’t slide up and down properly as the knee is straightened and bent.

The thigh muscle, called the quadriceps, moves the patella. This muscle is divided into four parts. Two of these, the vastus medialis obliquus and vastus lateralis, are the focus of many studies. The vastus medialis obliquus (VMO) is the section of muscle on the inside of the front of the thigh. The vastus lateralis (VL) is along the outer front thigh.

For many years, it was assumed that strengthening the VMO portion of the muscle would help PFPS. Yet some research showed this wasn’t true. Since then, many researchers have been studying the VMO in relation to knee problems. They are trying to find out when and how this muscle works. This may offer some help in finding better ways to treat knee pain from PFPS.

A new study from Australia shows that this muscle contracts differently depending on the movement. For example, when rising up on toes, people without problems from PFPS contract both the VMO and the VL at the same time. However, in people with PFPS, the VL contracts first–before the VMO. It was also noticed that when rising up on toes, there was a difference in how the calf muscle contracts. In people with PFPS, this muscle contracts later than for those without PFPS.

Timing of muscle contractions may depend on the task. Finding out how and when muscles around the knee and ankle work may help in the treatment of PFPS. Comparing muscle function in people with PFPS to those without PFPS is the current focus of new and helpful research.

Osteoarthritis of the knee affects walking more than any other disease in adults over 65. The medial part of the knee is hurt more than any other place. This is the joint area on the inside of the leg, closest to the other knee. The force from regular activities such as walking is often greatest at this point. 

Pressure that goes from the ground upward through the foot to the knee is called ground force. A slight twist or rotation of force is called torque. Both pressure and torque are part of the problem. The medial joint space tends to get thin from these two forces repeated over and over. This, in turn, puts more pressure on the joint. A vicious cycle of ground force, joint torque, and damage starts.

One way to change this problem is to wear a wedge inside the shoe. This wedge is placed along the outside edge of the foot. It angles the foot outward five or 10 degrees. This moves the weight off the medial side of the knee and more toward the outside (lateral) joint surface.

A lateral wedge changes the way the patient walks and reduces joint pressure. The material of the insole also cushions the foot. The combined effects provide relief from knee pain. For some patients, the larger wedge (10 degrees) is uncomfortable. The foot feels cramped because of a lack of shoe depth to fit the wedge.

Treatment for knee osteoarthritis often includes weight loss, the use of an assistive device such as a cane, and knee bracing. A proven method is a wedge placed inside the shoe to change the force and pressure on the medial side of the knee. The reduced pain and torque on the knee may even slow down the arthritis.

The anterior cruciate ligament (ACL) in the knee is a commonly injured knee ligament. The usual treatment is to repair or replace the torn ACL. This can be done using a piece of “donor” ligament from the patient called an autograft. When the replacement tendon comes from another person, it is called an allograft.

Whenever possible, doctors like to use an autograft. Usually the donor site is the hamstring or patellar tendon. Sometimes, an autograft isn’t possible, and an allograft is needed. Unfortunately, the need for allografts is greater than the supply. For this reason, researchers are looking for another source of graft material that will work as well.

Scientists experimented with two allograft tendons (anterior and posterior tibialis) from the lower leg and ankle. They folded the donor tendon in half. This formed a single loop of replacement tendon. This single-loop was as strong or stronger than autograft tendon from the hamstring muscle.

Tibialis allografts to replace the ACL compare favorably with other grafts currently in use. They have the same structure, same amount of stiffness, and same strength. These may become a new source of donor tissue for a torn ACL.

Many people who have torn their anterior cruciate ligament (ACL) have surgery to repair the injured ligament. Since the ligament has been torn, donor tissue is needed to replace it. The donor piece may come from tendon taken from the patient. Usually, this comes from the injured leg, but it can come from the other leg. The graft site may be the tendon that goes to the kneecap or it may come from a leg muscle.

After surgery of any kind, problems can occur. ACL repair has its share of possible complications. There may be infection or poor wound healing. The donor tissue may not be strong enough to hold the joint together. In rare cases, the kneecap may even break. This is called a patellar fracture.

Patellar fractures occur in about one percent of all cases when the patellar tendon is used as the donor tissue. The number of patellar fractures has decreased as more and more ACL repairs are done. There isn’t a single cause of this fracture. In this study, eight people ended up with a patellar fracture either from blunt trauma or indirect injury. Three did not require additional surgery for the kneecap; five did.

Whatever the cause of patellar fractures, the final outcome when comparing other ACL patients isn’t changed. There are no differences between patients with and without patellar fracture when the patellar tendon is used as the donor graft. Both groups typically end up with good bone healing, full knee range of motion, and a stable joint.

Many athletes suffer knee injuries that damage the anterior cruciate ligament (ACL). The injury may weaken the ligament or tear it completely. In the case of an athlete with a tear, surgery is usually done. When the ligament is damaged but not torn a rehabilitation program may be advised.

Bracing is an important part of rehab for the ACL. A knee brace can protect the joint during some activities such as walking. It does not offer the same protection during sports activities. A brace can improve jumping, but does not increase running speed.

A knee brace can also improve how fast the hamstring muscle behind the knee reacts to movement. This muscle keeps the lower leg bone (called the tibia) from moving too far forward when the knee is straightened. In this way, the hamstring muscle protects the ACL by its quick reflex action.

When the muscles around the knee are fatigued from use, the hamstring reaction time is slowed down. This is true even with the brace on. Importantly, athletes should not rely on bracing to protect their knee during exercises or activities that fatigue the hamstring muscles.

The meniscus inside the knee is a protective piece of cartilage. Until the mid-1950s, doctors thought the meniscus was like the tonsils and appendix. Whenever the meniscus was torn or damaged, it was simply removed.

Today, after much study, the importance of the meniscus is known. It helps steady the knee joint during movement. It also absorbs shock during walking, running, jumping, and twisting.

Today, doctors try to save the meniscus when it is torn or damaged. Now they can do this without cutting the knee open. They use a tool called an arthroscope. This device allows the doctor to slide a thin instrument into the joint that has a tiny TV camera on the end. With the arthroscope, the doctor repairs the cartilage while watching a television screen.

There are many ways to make this repair using the arthroscope. A new “all-inside” repair can be done using arrows that eventually dissolve. This replaces the need for stitches or staples to make the repair. The arrows are threaded through the arthroscope and gently tapped to hold the torn meniscus in place. Usually one or two are needed, but up to six at a time may be used. They remain in place for six months and are gradually absorbed by the body after that.

Doctors have found a new way to repair a torn meniscus. Using an arthrscope to implant arrows decreases the time of the operation and reduces risk of damage to blood vessels and nerves in the area.

In the normal knee, a tear or rupture of the anterior cruciate ligament (ACL) doesn’t happen without a reason. Usually, the ligament is under a twisting (torsional) force. This happens most often during high-demand activities such as sports. The ACL is an important part of the knee. It should be repaired for any athlete who wants to return to competitive sports.

There are two ways to repair this ligament. Both involve taking a piece of tissue from some other part of the leg and using it to replace the torn ACL. The hamstring tendon is one possible donor graft. The patellar tendon is the other. Knowing if one is better than the other would be helpful for doctors.

A group of researchers in Australia divided patients with ACL tears into two groups. One group received the patellar tendon graft, while the other group got the hamstring tendon graft. Each patient was followed for five years. Many outcome measures were compared.

In the early rehabilitation after surgery, the hamstring group made the fastest progress. They left the hospital sooner, stopped using crutches sooner, and returned to work faster than the group with the patellar tendon graft. At two and five years, with one exception, there were no differences between these two groups.

Level of activity, range of motion, and number of graft failures or complications were the same for both donor sites. The one area of difference was the joint space. In the patients who received a patellar tendon graft, the joint space was narrower after five years. This is an early sign of arthritis. Researchers agree this finding must be studied longer before choosing the hamstring donor site over the patellar tendon for all cases.

The meniscus is an important part of the knee joint. Forming a pad on each side of the knee joint, the two “menisci” protect the knee. They help absorb the load and pressure of body weight and gravity. And they lubricate the joint.

When a meniscus is damaged or torn from injury or aging, doctors try to repair it. Sometimes, it has to be removed. Even then, doctors save as much of the meniscus as possible and remove only what must be taken out. If the entire meniscus is removed, it is possible for some people to have a meniscal transplant.

Doctors have worked hard to find ways to salvage the meniscus. They have found that it is possible to encourage healing around the meniscus. This is done by sculpting and shaping the edge of the meniscus on either side of the bone. Blood and new tissue move to that area to help the repair process.

They have also designed new surgical tools for the operation. Special needles are used to reach the middle section of the meniscus. Stitches (also called “sutures” that are absorbed into the body) and special T-shaped implants are used to repair the tear in one step. The implants don’t need any sutures to hold them in place. A small shaver is used to smooth the loose edges of larger tears. This can be done without damage to the bone underneath.

Researchers continue to look for ways to improve meniscal repair surgery. The goal is to save as much of this cartilage as possible. This will preserve the joint for a much longer time. The next step is to perfect the use of alternate tissues to replace a meniscus that has been completely destroyed or removed.

Doctors are rethinking the treatment of meniscal tears. The meniscus is a horseshoe-shaped piece of cartilage on both sides of the knee joint. It acts as a shock absorber and lubricates the joint. It also helps support the knee and keeps it steady and stable.

In the past, injury to the meniscus usually required surgery to remove it. Today’s doctors know how important it is to save the meniscus whenever possible. The decision to treat a meniscal tear is more complicated now. The doctor must look at the patient’s anatomy and the injury itself to decide on the best treatment.

Most meniscus tears are one of two types. A healthy meniscus can tear from trauma to the knee. And in older adults, tears in an aging, damaged meniscus can occur from normal forces. In either case, damage to nearby ligaments often occurs along with the meniscal tear. If more than one structure is torn, surgery to repair the damage is more likely to be needed.

The exact method of repair depends on the size, location, and direction of the tear. Most surgery for the meniscus is done on an outpatient basis. The doctor uses an arthroscope to see inside the joint. This slender tool is inserted into the knee joint. There is a tiny TV camera on the end that allows the doctor to see the meniscus and make repairs.

Not all meniscal tears need to be repaired. Some don’t cause symptoms or problems and can be left alone. They may even heal on their own. For tears that do need repair, a wide variety of surgical methods may be used. The exact surgery depends on the knee structure and type of tear present.

The lower leg has two bones: the tibia and the fibula. The tibia is the larger bone, sometimes called the “shin bone.” The shin portion is also called the tibial shaft. Fractures of the shaft often heal with an angle. In the past, these fractures were treated with a cast, but now surgery is used. Surgery results in less angulation.

Doctors at a large hospital in England studied 164 cases of tibial fracture from over 30 years ago. All had been treated with a cast. The doctors X-rayed all the patients and remeasured the angle of the healed bone. These findings were compared with patients’ current status.

The long-term outcome after a tibial shaft fracture was good for most of the patients. There were mild symptoms of knee and ankle pain and arthritis. However, these were not caused by the previous fracture. In a small number of patients, fracture in the upper part of the tibia (closer to the knee) resulted in more wear and tear on the knee joint.

A 30-year study of the alignment of the tibia after fracture and treatment has been reported. Changing treatment from casting to surgery for tibial fractures may not have been needed. Patients from more than 30 years ago, who were treated with casting, didn’t end up with more arthritis because of poor alignment after healing.

This information tells doctors two things. Tibial shaft fractures may not need to be treated with surgery. Casting may be all that is needed. And change in the angle of the tibia doesn’t lead to arthritis. Arthritis appears to be caused by other factors after this injury.

X-rays are often used to identify problems in the knee and other joints. A new measurement has been introduced to help doctors evaluate knee X-rays. The measurement is called anteroposterior patellar-tilt angle. It records the angle between the top of the kneecap (patella) and the thighbone (femur).

By studying X-rays of cadavers (human bodies preserved for study), doctors have found that this angle is best observed when X-rays are taken with the knee slightly bent (30 degrees). The measurement is reliable. This means that different doctors come up with the same results.

The measurement is useful because it shows a difference between normal and problem knees. Patellar-tilt angle is less in knees that have tendinitis. Notably, even when patients only have symptoms in one knee, the angle is reduced in both knees. Doctors think that a smaller tilt between knee and thighbone puts more stress on the patellar tendon in the knee. This makes it more likely that knee pain and tenderness may develop over time. Why tendinitis sometimes shows up in one knee and not the other when both have a reduced angle is unclear.

An easy new measurement for evaluating knee X-rays has been introduced. The measurement is reproducible and may help identify who is at risk for some types of knee tendinitis.

When the anterior cruciate ligament (ACL) in the knee is torn or injured, surgery may be needed to repair it. There are many different ways to do this operation. One is to take a piece of the hamstring tendon from behind the knee and use it in place of the torn ligament. The spot where the tendon is taken is called the “donor site.”

Some researchers say this is a good idea with no problems. Others are sure the hamstring muscle loses strength when the tendon is used as a donor site. The main function of the hamstrings is to bend the knee (knee flexion). If this treatment method affects the muscle function, there should be a change in knee flexion.

Scientists in Japan are studying this problem in adult recreational athletes. They used a CT (computed tomography) scanner to measure the size of the tendon after a piece was removed. They found that there is enough muscle wasting to affect muscle strength. However, overall strength is not lost because the rest of the hamstring muscle takes over for the weakened area. Even the portion of muscle where the tendon was removed works harder to make up for the loss.

A large amount of muscle wasting does occur in a small number of people who have this kind of ACL repair. It only affects athletes involved in sports that require deep knee flexion. This may include judo, wrestling, and gymnastics. These athletes may want to choose a different method of repair for ACL tears. This could include use of the tendon below the kneecap (patellar tendon) or an allograft, replacement material stored in a tissue bank. Leaving the hamstring tendon untouched may help maximize performance after surgery for athletes in these types of sports.

It’s hard enough when one knee is injured, but imagine having both knees out of order. Life gets tricky. So does treatment. Most people with knee problems from anterior cruciate ligament (ACL) tears use a rehab program or surgery to get better. These cases get complicated when a second or third injury affects both knees.

In patients like these, doctors look at all the options. They try and decide which treatment works best for each patient. Symptoms such as pain, loss of motion, and weakness help guide the decision. Treatment may take place in stages. First, exercise and rehab are tried. If these don’t work, surgery becomes an option. If surgery is done on one knee first and then the other knee, it is called a staged procedure.

There are many different ways to do this surgery. A piece of tendon from the left knee can be used to repair the right knee. Or the replacement tendon could come from the same knee. It may come from one of two places around the knee: the tendon to the kneecap or the tendon to the hamstring muscle in back of the knee. Another option is to use a piece of tendon donated by someone else (called an allograft).

All of these choices must be looked at carefully. There are good things and bad things about each one. For example, when an allograft is used, a second incision for a “donor site” is not needed.
for the patient. This prevents problems such as infection or poor healing at the donor site. However, there can still be infection, disease, or loss of blood supply when the donated tendon is in place.

In the case of one 28-year old woman, surgery was needed despite a strong rehab program to strengthen both knees. Her knees were weak and unable to support her. The doctors did surgery on the weaker (left) leg first. They used a piece of tendon from the right knee to reconstruct the left ACL.

Six months later, the second stage was done with ACL surgery on the right knee. Again, the doctors took a tendon from the opposite (left) knee to repair the right ACL. A rehab program before and after both surgeries was followed with very good results in both knees. The patient was able to exercise regularly without knee braces.

When knee osteoarthritis (OA) hits and antiinflammatories don’t cut the pain, what can you do? There are a variety of treatment options including using a cane, a shoe wedge, exercise, and surgery. Another strategy is to use a special type of brace, one that is getting a closer look these days in the treatment of knee OA.

Knee OA most often affects the inside section (closest to the other knee) of the joint. This is called the medial compartment. During normal walking, forces from the ground below and body weight above tend to shift to this area of the knee.

When the medial compartment of the knee is worn down from OA, daily loading in this part of the joint takes an even greater toll. All this results in a harmful cycle. Loading builds pressure on the knee, which shifts more weight to the inside of the joint; this leads to even more joint destruction, followed by more loading on the knee.

A special “unloading” brace helps take pressure off the inside part of the knee joint. And it shares the load placed on the medial compartment. This type of brace works best when it is placed at an eight-degree angle. This angle is used to correct the varus, or “bow-legged” position of the knee by lining up the joint. This can reduce knee pain from osteoarthritis, while improving knee health and function for the years ahead.

What determines the result of knee surgery? Is it how well the body heals? Is it how well the patient can get around? Researchers say it’s something called the health locus of control.

This refers to the patient’s beliefs about themselves and others. They may believe that other people (doctors, therapists, trainers) control what happens. Some patients think that the final result is left to fate, luck, or chance. These people have an external locus of control. Others hold to the belief that their own actions decide the outcome. This is an internal health locus.

Researchers used a group of patients who had surgery to repair the anterior cruciate ligament of the knee as study models. They found that patients who believed their outcome after surgery was under the control of others had a poorer result. Those patients who thought fate, luck, or chance were responsible for their result had the same reduced result with more pain, less function, and more limitations. Patients who believed that their own actions and attitudes made the difference had less pain, could do more, and weren’t as limited.

Before surgery, it may be a good idea to do an attitude check. A positive internal drive, rather than reliance on other people, luck, or chance may be all it takes to have a better result.

What do knee pain, loss of motion, and decreased muscle strength have in common? They’re all symptoms of knee osteoarthritis. Osteoarthritis (OA) is a condition of joint and bone damage. Knee OA is found in many people over age 65.

Exercises to reduce pain and improve strength and motion seem to help with knee OA. Physical therapists are always looking for new and better exercises to use.

Knee OA causes some of the same problems as knee ligament injuries. For example, patients may feel that the knee will “give way” or buckle during daily activities. They may also feel that the knee joint is “slipping.”

Physical therapists tried using an exercise program for ligament injury to help a patient with OA. A 73-year-old woman with mild knee OA in both legs agreed to try this program. The program worked on two things: balance and agility. Agility is the ability to move quickly and easily. This helps the knee handle sudden changes in direction and twisting movements. Balance helps keep the knee steady when pushed off center.

Balance and agility can help protect osteoarthritic knees. Some exercises used for athletes after knee ligament injury can be used with older people who have mild knee OA. To adapt the exercises for knee OA, physical therapists make them less intense and avoid putting too much load on arthritic knees. This program can help older people keep active with less pain and more function.

In the United States, 200,000 knees are replaced with artificial joints each year. This operation is called total knee replacement, or TKR. Most often, one knee is replaced at a time. For people with severe arthritis in both knees, it is possible to have both joints replaced at the same time. This is called bilateral TKR.

Until now, researchers have studied single knee replacements. Information about motion, strength, and function has been collected. The data have been compared for different methods of surgery, types of knee joints, and methods of rehabilitation.

The first study of knee strength after bilateral TKR has been reported. Physical therapists measured strength in both legs before bilateral TKR. Strength was measured again 30 and 60 days after TKR. (This is the earliest that strength has been measured after single or bilateral TKR.) After surgery, all patients took part in a physical therapy program three times a week for eight weeks.

Strength dropped quite a bit in the first 30 days after surgery. However, both legs were equal in strength and motion. The greatest improvement in strength happened 30 to 60 days after surgery. Since both knees were treated at the same time, there was no “good” or “bad” knee, and patients couldn’t favor the “good” knee during recovery. Patients used both knees equally.

The first month after TKR is the most important time to build muscle strength. At 30 days, the legs are much weaker than before surgery. With continued exercise, strength improves in the second month. Future studies will look at balance and function during the first 60 days after TKR. This will help physical therapists improve on existing exercise programs.

When it comes to anterior cruciate ligament (ACL) injuries, football is a high-risk sport. In fact, the risk of ACL injury may be 10 times higher in football than in other sports. Although knee injuries are common in football, no one has specifically analyzed these injuries at the professional level.

Researchers tracked knee injuries in the National Football League (NFL) over a five-year period. During this time, knee injuries accounted for 20 percent of all injuries. ACL injuries made 16 percent of  knee injuries. Based on these results, football has about the same risk of ACL injury as skiing.

Offensive and defensive linemen had the most ACL injuries. However, the risk of ACL injury was greatest for running backs. Injuries were more common during games than during practice. The only exception to this was during the preseason months of July and August. Practice may be more intense during these months.

During games, most ACL injuries happened in the second and third quarters. ACL injuries happened at roughly the same rate on artificial surfaces (AstroTurf) and grass.

For linemen and quarterbacks, most NFL team doctors recommended surgery soon after ACL injury. For kickers and punters, more doctors tried a wait-and-see approach. This was especially true if the injury affected the kicking leg. Most doctors used tissue from the player’s kneecap (patellar tendon) to repair the ACL.

In general, players returned to sport six to nine months after surgery. Although ACL injuries can be season-enders for NFL players, most players are able to get back into the game.