Orthopedic Solutions for Common Knee Problems Linda A. Martin, MD, MPH Waverly Health Center Orthopedic Clinic

The Knee • ~19.8 million visits were made to physicians’ offices in 2012 because of a knee problem (Centers for Disease Control and Prevention) • It is the most common reason for visiting orthopedic surgeons • The knee is the largest joint in the body, and one of the most easily injured

Anatomy The knee is comprised of: – Lower end of the thighbone (femur) – Upper end of the shinbone (tibia) – Kneecap (patella) – Ligaments • ACL, PCL, MCL, LCL – Cartilage • meniscus, hyaline cartilage

Bursae • A number of bursae are located around the knee to reduce friction during knee movements

Common Knee Problems • Kneecap (prepatellar) bursitis • Runner’s knee (patellofemoral pain) • Meniscal tears • Anterior Cruciate Ligament (ACL) tears • Osteoarthritis

Kneecap (Prepatellar) Bursitis • Plumbers, carpet layers and others who spend a lot of time on their knees, often experience swelling in the front of the knee. • This constant friction irritates a small lubricating sac (bursa) located in front of the patella.

Kneecap (Prepatellar) Bursitis Symptoms: – Pain with activity, not usually at night – Rapid swelling on the front of the kneecap – Tender and warm to touch

Kneecap (Prepatellar) Bursitis Treatment: – Rest – Apply ice at regular intervals – Elevation – Anti-inflammatory medication (aspirin or ibuprofen) – Aspiration – Surgical excision

Kneecap (Prepatellar) Bursitis Prevention: – Wear kneepads if you work on your knees or participate in high-risk sports such as football, basketball or wrestling – Rest your knees regularly by stopping to stretch your legs – Ice/elevate knees after a workout

Runner’s Knee (Patellofemoral Pain) “Runner’s knee” is a term used to refer to a number of medical conditions that cause pain around the front of the knee – Anterior knee pain syndrome – Patellofemoral malalignment – Chondromalacia patella

Symptoms of Runner’s Knee (Patellofemoral Pain) Dull, aching pain under or around the anterior aspect of the kneecap: • Going up or down stairs • Kneeling • Squatting • Sitting with the knee bent for long periods of time

Treatment of Runner’s Knee (Patellofemoral Pain) – – – – –

Rest Ice Compression Elevation Nonsteroidal anti-inflammatory medications – Physical Therapy

Prevention of Runner’s Knee (Patellofemoral Pain) – Good general conditioning • warm-up – Stretching – Increase training gradually • Avoid sudden changes in intensity of exercises – Use proper running gear • Running shoes with good shock absorption – Use proper running form • Lean forward and keep the knees bent • Never run straight down a steep hill, walk or run in a zigzag pattern

Meniscal Tears One of the most injured parts of the knee, the meniscus, is a wedge-like rubbery cushion that helps the knee joint carry weight, glide and turn in many directions.

Meniscal Tears • Athletes may tear the meniscus by twisting the knee, pivoting, cutting or decelerating • Older people can injure the meniscus without any trauma, as the cartilage weakens and wears thin over time, setting the stage for a degenerative tear

Symptoms of Meniscal Tears – Stiffness – Tenderness in the joint line – Swelling – Giving way and/or locking

Diagnosis of Meniscal Tears – Physical examination – MRI

Treatment of Meniscal Tears – – – – –

Rest Ice Compression Elevation Anti-inflammatory medications

Surgical Treatment of Meniscal Tears – Arthroscopic debridement or repair

Meniscal Tears

Meniscal Tears (cont)

Meniscal Tears (cont)

ACL Tears • The anterior cruciate ligament (ACL), prevents the shinbone from sliding forward beneath the thighbone • The ACL can be injured in many ways: – – – – –

Changing direction rapidly Slowing down when running Landing from a jump Hyperextension of the knee Direct contact, such as in a football tackle

ACL Tears Normal anatomy Anterior cruciate ligament

Patella

Hyperextension

Femur Anterior cruciate ligament tears

Tibia Fibula

Illustration reproduced with permission from The Body Almanac, Rosemont, IL American Academy of Orthopaedic Surgeons, 2003

Femur slips

Symptoms of ACL Tears – You may not feel pain immediately – May hear a popping noise and feel your knee give out from under you – Within 2 to 12 hrs the knee will swell and you will feel pain with weight-bearing

ACL Tears Diagnosis: – Physical Examination • Lachman test - knee flexed ~30 degrees

ACL Tears • Diagnosis – MRI

ACL Tears Treatment: – Partial tear • May or may not require surgical treatment – Complete tear • May require reconstruction – Uses a strip of tendon, usually from the patient’s knee, that is passed through the inside of the joint and secured to the thighbone and shinbone

ACL Tears

Natural History of ACL Deficiency • (Hawkins, 1986) series of 40 isolated ACL injuries – 86% were unable to return to sports and experienced symptoms of giving way

• (Kannus, 1988) 8-yr f/u of 90 pts placed in an aggressive rehab program – >1/2 required a surgical procedure for either instability, meniscal lesions, or loose bodies

Natural History of ACL Deficiency • (Sherman, 1991) 6-yr f/u – Medial tibial osteophytes, tibial spine osteophytes, and patellar osteophytes were observed in 36% of patients

ACL Treatment • Nonoperative – Low demand patients – less instability • Operative – higher demand, active patients – more instability

Osteoarthritis • The covering on the ends of bones gradually wears away • Risk factors: – Usually develops after many years of use and generally affects people who are middleaged and older – Obesity – Injury to a joint – Family history of osteoarthritis

Osteoarthritis Symptoms: – Pain and inflammation – Stiffness – “Sticking” and weakness

Osteoarthritis Early Treatment: – Lifestyle modifications – Medications •Oral anti-inflammatory medications •Cortisone injections •Glucosamine (stimulates formation and repair of articular cartilage) •Chondroitin sulfate (prevents cartilage from degrading) •Viscosupplementation (a series of injections designed to change the character of the joint fluid) – Physical Therapy

Osteoarthritis Surgery: – Arthroscopy – Joint fusion – Joint replacement

Conclusion/Tips • Moderate physical activity lessens joint pain and improves flexibility and function • Always take time to warm up and stretch before physical activity – Cold muscles are more prone to injury • Invest in good equipment, including the proper shoes for your sport • Stop doing high impact activities and start doing smooth, low impact activities that are easier on the joint

Questions?