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Knee Injury and Knee Pain Relief Guide

Knee Arthroscopy

What is knee arthroscopy?

Knee arthroscopy is a surgical procedure used to visualize, diagnose, and treat various problems inside the knee joint. This is done through small incisions that allow the insertion of specialized instruments. The arthroscope is a pencil-sized tool that contains magnifying lenses and a fiber optic light. This is attached to a small camera that projects a clear image of the joint on a monitor, allowing your surgeon to see all the structures inside your knee.

Understanding your knee.

Your knee acts like a hinge joint connecting your thigh bone (femur) to your shin bone (tibia). Lining articular cartilage covers the ends of the bones and underside of the kneecap, and helps the joint glide smoothly. The meniscus is a horseshoe shaped pad of cartilage that functions as a cushion or shock absorber between the bones. Ligaments are rope like structures that hold the joint together and provide stability. There are 4 main ligaments in your knee, 2 outside the joint (medial and lateral collateral ligaments), and 2 inside the joint (anterior and posterior cruciate ligaments). The muscles around the knee provide strength and power, and also help stabilize the joint. Tendons are the specialized ends of the muscles that connect them to bones.

Why do I need arthroscopic surgery?

Arthroscopic knee surgery is used to treat a variety of common knee disorders, including meniscus cartilage tears, anterior cruciate ligament tears, articular cartilage wear, and patella problems.

How is arthroscopy performed?

Arthroscopy is typically performed in an outpatient surgery setting. The type of anesthesia used is up to the patient, surgeon, and anesthesiologist, but the procedures can often be done under local anesthesia. Two small incisions, each the size of a dime, are needed to insert the scope and any necessary instruments. The joint is filled with sterile fluid to improve visualization. Most procedures take less than one hour to perform. Partial weight bearing with crutches is recommended for the first few days after surgery, then walking as tolerated is allowed.

Elevation, icing, and anti-inflammatory medications will help decrease pain and swelling. The knee should be kept dry when showering for the first 3 days by placing a bag over the leg. After this, simply change the band-aids after bathing. Patients usually begin light exercise in 1 week.

Returning to full activities may take several weeks to several months depending on the procedure performed.

What are the benefits of arthroscopic surgery?

Benefits of arthroscopic surgery compared with older open surgical techniques include:
1. Minimal scars
2. No overnight hospital stay
3. Decreased pain and swelling
4. Improved motion
5. Quicker functional recovery
6. Fewer risks and complications

Risks and Complications

Complications from arthroscopic surgery are extremely rare, and include bleeding, infection, blood clots, nerve or blood vessel injury, and the need for further surgery. The most common reason patients experience some persistent discomfort after arthroscopic surgery is from underlying damage to the articular or lining cartilage of the joint (early arthritis).

Meniscus Tears

What is the Meniscus?

The meniscus is a horseshoe shaped structure in the knee that consists of fibrocartilage, a very tough but pliable material. The medial meniscus is located on the inside of the knee and the lateral meniscus is located on the outside of the knee. Together, they act primarily as shock absorbers and stabilizers in the knee joint. They also help nourish and protect the articular cartilage or lining cartilage of the joint.

How is the Meniscus Torn or Injured?

In young athletes, most injuries to the meniscus are the result of trauma. The menisci are especially vulnerable to injuries in which there is both compression and twisting applied across the knee. It is also common for the meniscus to be damaged in association with injuries to the anterior cruciate ligament.

In older patients, many meniscal tears are the result of trivial trauma, like twisting the knee, squatting, or through repetitive activities like running, which stresses the knee joint. These tears happen because the meniscus has a tendency to degenerate and weaken as part of the aging process. This degeneration often takes place in conjunction with early arthritic changes in the knee joint.

How Is A Meniscal Tear Diagnosed?

When a meniscus is torn, it will often produce pain, swelling and mechanical symptoms like catching, or locking in the knee joint. An injury to the meniscus can usually be diagnosed based upon the history that the patient provides, and a physical examination of the knee. Further diagnostic studies like an MRI scan, which provides a detailed image of the knee joint, may be required.

How Is A Meniscal Tear Treated?

Meniscus tears are usually treated with a minor outpatient surgery called an arthroscopy. Treatment involves either removal or repair of the torn fragment. The majority of tears are treated with excision of the loose pieces. This is called a partial meniscectomy. Only the torn portion is removed, leaving a stable rim. The decision to do a repair is based on many factors, including: location and pattern of the tear, age of the patient, and predictability of whether the injury will be able to heal. Most tears are not suitable for repair. In either case, the surgery is performed arthroscopically on an outpatient basis.

Most patients ask, "What is the benefit of removing the meniscus? Isn't it an important structure in my knee?" Clearly, the meniscus does play an important role in the human knee, but once torn and unable to be repaired, many of the beneficial effects of that structure are lost. Also, the torn meniscus can damage the articular cartilage of the knee leading to early arthritis. If a tear is causing pain and impaired function, removal of that tear is the treatment of choice.

Rehabilitation

Partial weight bearing with crutches is recommended for the first few days after surgery, then walking as tolerated is allowed. Elevation, icing, and anti-inflammatory medication will help decrease pain and swelling. The knee should be kept dry when showering for the first 3 days by placing a bag over the leg. After this, simply change the band-aids after bathing. Patients usually begin light exercise in 1 week. Return to full activities may take several weeks to several months. In the case of a meniscal repair, your surgeon may place additional restrictions on your activities to protect the healing meniscus for 3-6 months after surgery.

Risks and Complications

Complications from arthroscopic surgery are rare, and include bleeding, infection, (DVT) blood clots, nerve/arterial injury, stiffness, pain, and the need for additional surgery. The most common reason patients experience persistent discomfort after meniscal surgery is from underlying damage to the articular or lining cartilage of the joint (early arthritis).

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The Anterior Cruciate Ligament

The Knee Ligaments

A ligament is a structure that connects one bone to another. The four main ligaments that stabilize the knee joint are the medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL), and posterior cruciate ligament (PCL). The ACL is located near the center of the knee joint. It prevents the tibia (shin bone) from sliding forward and rotating on the femur (thigh bone).

Mechanism of Injury?

There are several ways of tearing your ACL. The most common is a non-contact twisting or pivoting maneuver. Another is a blow to the outside of the knee with the foot planted. Associated damage to the meniscus cartilage is not uncommon. Sometimes a pop can be heard at the time of injury. There can be a significant amount of pain, however this is variable. The person usually is unable to continue performing the activity that they were doing when the injury occurred. Swelling occurs within the first couple of hours. After several weeks, people are able to walk comfortably and may even be able to do light exercise, however any sporting activities may cause the knee to buckle and give way.

Diagnosis

An ACL tear is usually diagnosed with an accurate history and physical examination. The physical examination is less helpful in the acute setting with pain, swelling and guarding. Associated injuries may include additional ligament sprains, articular cartilage damage, and meniscal tears. X-rays help to determine if there are any fractures or underlying arthritis. A magnetic resonance imaging scan (MRI) is used to confirm the presence of an ACL tear and evaluate the knee for associated meniscal or ligamentous pathology. However, it often does not affect treatment recommendations and is ordered at the discretion of the treating physician.

Treatment Options

Treatment for an ACL tear is dependent on many factors, including age, activity level, associated injuries, and the desire to return to previous activities. Non-operative treatment includes physical therapy, bracing, and activity modification. Surgery is recommended for athletes, younger patients, those with associated injuries that require surgical management, and people who experience instability or giving way with daily activities. One of the main reasons to have surgery is to prevent further injury to the menisci and articular cartilage, which can lead to the development of arthritis.

Surgical Treatment

Surgery involves an arthroscopy to replace the torn ligament with a tendon. The tendons that are used to reconstruct the ligament are called grafts. The two main classes are autografts (ones own tissue) and allografts (from another persons body). The choice of autograft vs. allograft is dependent on many factors. Some of these factors include age, previous surgery, the availability of allografts, cosmetic appearance, and patient and surgeon preference. The most common tendon (autograft or allograft) used is the central third of the patella tendon with a small block of bone at each end. This is known as a bone-patellar tendon-bone graft. When an allograft is used it is first carefully screened for diseases and infection. The risk of disease transmission is very low, with no reported cases of AIDS or hepatitis using today's current testing standards. There is very little difference in the long-term outcome between autografts and allografts

During surgery, a routine arthroscopy is performed and a thorough inspection of the joint is carried out. Any associated cartilage damage (meniscus or articular cartilage) is addressed at this time. The findings during arthroscopy will help to determine the regimen after surgery and the expected long-term results.




Small tunnels are drilled in the tibia and femur at the original ACL attachment sites. The graft is then pulled in through the tibial tunnel and into the femoral tunnel to reconstruct the ACL. The bony plugs are secured using screws that wedge the bone blocks of the graft into the tunnels. This restores normal knee stability. The screws most often used today are made of a bio-absorbable material that dissolves over several years.

The procedure is usualy done on an outpatient basis. You should go home the same day. The knee is injected during surgery with a local anesthesia to reduce initial post-op pain. At home, a continuous passive motion (CPM) machine can be used to help bend your knee to prevent stiffness. A cold therapy pad is used to decrease pain and swelling. Prescriptions are given for pain medicine which can be taken as needed. Patients are typically seen in the office 1 week after surgery. Crutches are used as needed for ambulation for the first several weeks. Weight bearing as tolerated is allowed. Patients can usually return to light duty work after 1 week. Follow up is every other month for 8-12 months.

Rehabilitation

The rehabilitation program may be slightly different from patient to patient. Physical therapy begins 1 week after surgery in a supervised setting with trained therapists. The therapy is generally divided into three phases. The initial phase consists of controlling pain and swelling, as well as restoring motion to the knee. A light-strengthening program may also be initiated. This phase lasts about 6 weeks. The second phase consists of increasing muscle strength. Cycling, treadmill exercises, and light jogging can be advanced during this phase, which generally lasts 3-4 months. The final phase is a gradual return to previous activities. Full motion, strength of at least 85% of the other extremity, and absence of swelling are needed before return to sports is recommended. This generally occurs 5-8 months after surgery. It often takes 12 months before the patient does not feel like they had an operation. The surgeon and therapists monitor the patient's progress closely. Returning to activities too soon could cause persistent swelling or compromise graft healing and stability.

Outcomes

Complications are extremely rare, but can include anterior knee pain, loss of motion, infection, DVT, and graft failure. Most patients who aren't able to return to their previous level of activity usually have other associated injuries (extensive meniscal tears, cartilage damage, or associated ligament injury) that affect the ultimate surgical outcome.

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Osteoarthritis of the Knee

What is osteoarthritis?

There are many types of arthritis (osteoarthritis, post-traumatic, rheumatoid, etc). The most common form is osteoarthritis, also known as degenerative joint disease (DJD). While the exact cause is unknown, contributing factors include: previous injury, aging, misalignment, genetics, and obesity. Osteoarthritis is characterized by the breakdown of the articular cartilage, the firm whitish-colored rubbery protein material covering the ends of bones. It acts as a cushion and bearing surface between the bones, allowing them to glide smoothly over each other with almost zero friction. Osteoarthritis commonly affects large weight-bearing joints such as the hip and knee, but may affect any joint.

What are the symptoms of osteoarthritis?

The number one symptom of osteoarthritis of the knee is pain. The causes of pain in osteoarthritis include: irritation and pressure on the nerve endings in the bones, inflammation of the joint lining (synovitis), muscle tension and fatigue. The pain may progress from mild soreness and aching with movement to severe pain even during rest. The second symptom is loss of easy movement. As the lining cartilage wears away, the joints no longer glide smoothly. Eventually, the ends of the bones become rough and irregular, with resulting stiffness. This lack of mobility, in turn, often causes the muscles serving the knee to weaken, and overall body coordination suffers. Other symptoms common to osteoarthritis include grinding and "popping" sensations, joint swelling, and feelings of locking or giving way.

How is osteoarthritis diagnosed?

The diagnosis of osteoarthritis is usually made based upon the patient's medical history, physical examination, and X-ray findings. An MRI may be helpful in some cases to confirm the diagnosis and rule out any other conditions.

How is osteoarthritis treated?

Osteoarthritis is not a curable condition. The disease usually progresses slowly or worsens over many years. Therefore, treatment goals include decreasing pain, swelling, and inflammation, while increasing or maintaining joint function. To achieve these goals, a number of different treatments are used. Non-operative forms of treatment may include physical therapy, icing, activity modification, and bracing. Medications such as Tylenol ®, aspirin, or anti-inflammatories help decrease pain and swelling. An over-the-counter supplement containing glucosamine and chondroitin sulfate may be taken long-term to help alleviate symptoms and possibly slow progression of the disease. Cortisone injections into the joint may reduce acute symptoms for several months. Three or four steroid injections may be given per year, in each affected joint, without harm. Some relatively new injectable medications (Synvisc, Hyalgan, or Supartz) may help alleviate symptoms for 6 to 12 months in certain patients. These are administered by a series of 3 or 5 weekly injections, and may be repeated as needed.

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Osgood­ Schlatter Disease

What is Osgood-Schlatter Disease?

Osgood-Schlatter disease (also called "Jumper's Knee") is a common condition affecting girls around 10-12 years old and boys around 13-15 years old (but these ages vary). Osgood-Schlatter results from excessive traction on the soft growth plate at the front of the shin bone below the knee cap. This is the area where the large tendon connects the knee cap and thigh muscle to the shin bone.

This condition usually occurs in association with high levels of activity during a period of rapid growth. Activities that involve a great deal of running, jumping, starting and stopping usually aggravate the condition.

What are the Symptoms of Osgood Schlatter Disease?

Symptoms range from aching and soreness, to swelling, limping and giving way. Physical examination usually finds tenderness directly over the area of inflammation. X-rays are usually normal or may show some widening of the growth center at the front of the shin bone.

How is Osgood-Schlatter Disease Treated?

Treatment is focused on decreasing soreness as the condition is usually self-limiting (once the growth plate closes the symptoms will go away). However in some individuals, the symptoms may come and go throughout their growing years. Children with mild symptoms may wish to continue with some or all of their activities, while others may need to decrease activity levels for a short period of time. If a child prefers to cease activity because of pain, that decision should be supported by the parents.

Treatment includes rest, icing the affected area, and stretching the muscles on the front and back of the leg. Occasionally physical therapy may be suggested to help the child get started with the appropriate stretches and exercises.

In general, activities that cause pain should be avoided or decreased. "Active" rest is a term used to describe continued activity on a limited basis. If a child is comfortable remaining active, or has soreness after activity that goes away with stretching and icing (or overnight) ­ it is usually OK to continue with that amount of activity. However, if a child has increasing pain; pain that begins to affect play or activities; or other unusual symptoms (i.e. limping, swelling, inability to run or jump normally) ­ then cutting back on the activity level is important.

Home treatments include:

Icing the affected area 20 minutes at a time, as often as needed, but especially right after exercise. Stretching the muscles on the front and back of the leg after exercise and before icing.
Activity modifications ­ less running, jumping more biking and swimming.
Tylenol ®' or `Advil ®' type medicine may be used occasionally for soreness, but should not be used to allow a child to compete.

Range of Motion

1. Wall Slides (best to wear socks)

Lie on your back and bend your affected knee 90° with your foot flat against the wall. Slowly slide your foot down the wall by bending your knee as far as possible. Hold for 5-10 seconds and then slowly help raise the affected knee back using the healthy leg.

2. Passive Knee Flexion

Insert your foot through the loop of an exercise strap and lie on your stomach. Gently pull the strap handle until your knee is flexed to the point of tightness. Hold for 5-10 seconds and then relax.

3. Passive Knee Extension

Sit on the floor and fully extend your affected knee. Place a pillow under your ankle and a weight over your knee. Allow your knee to reach full extension by relaxing your muscles.

4. Prone Leg Hang

Lie on your stomach with a pillow under your affected knee (this can also be done by hanging your knee off the end of a bed). Allow your leg to hang freely. To assist in gaining full knee extension, a weight may be placed over your heel.

Stretching Exercises

5. Calf Stretch

Face a wall and stand with your rear leg straight and your front leg slightly bent. With you heels on the floor, lean towards the wall until the calf muscle in your rear leg is tight. Be sure not to bounce and hold the position for 10 seconds and then relax.

6. Groin Stretch

Sit on the floor and put your feet together. Use your elbows to firmly push your knees outward. Hold for 10 seconds and then relax.

7. Hamstring Stretch

Insert your foot through the loop of an exercise strap and lie on your back. While keeping your affected knee straight, pull the strap handle until your leg is tight. Hold for 5-10 seconds and relax. Repeat.

Strengthening Exercises

8. Quad Set

Sit on the floor with your legs straight out in front of you. While keeping your toes pulled back towards you, tighten your thigh muscles. Hold for 5-10 seconds and then relax.

9. Straight Leg Raises

Lie on your back and bend your healthy knee. Straighten the affected knee (place a weight on or around your foot or ankle for more resistance) and tighten the thigh muscle. Slowly lift the leg as high as the healthy knee. Bring the leg down slowly down to the floor.

10. Toe Raises

Face a wall and spread your feet shoulder width apart. Stand up on your toes as much as possible. Hold for 5-10 seconds and then relax.

11. Calf Strengthening

Sit on the floor and insert your foot through the loop of an exercise strap. Point your toes away from you while holding the end of the strap.

12. Short Arc Knee Extensions

Lie on your back and bend your healthy knee. Place a pillow under your affected knee (place a weight on or around your foot or ankle for more resistance). Tighten your thigh muscles and lift your heel off the ground without lifting your knee off the pillow. Keep your knee straight and hold for 5-10 seconds. Slowly lower your foot to the floor.

13. Resistive Knee Extension

Connect an exercise strap to your ankle and to a wall or stationary object. Sit in a chair, facing away from the wall or stationary object, and bend your knees 90°. Place a pillow under your affected knee and straighten your leg.

14. Hamstring Strengthening

Connect an exercise strap to your ankle and to a wall or stationary object. Sit in a chair, facing towards the wall or stationary object, and straighten your affected knee. Flex your knee and bend it to 90º.

15. Hip Flexion

Connect an exercise strap to your ankle and to a wall or stationary object. Stand up straight, facing away from the wall or stationary object, and use a chair to balance yourself. Raise your affected leg up, making sure to keep it straight. Lower it back to the starting position.

16. Hip Extension

Connect an exercise strap to your ankle and to a wall or stationary object. Stand up straight, facing towards the wall or stationary object, and use a chair to balance yourself. Raise your affected leg backwards, making sure to keep it straight. Lower it back to the starting position.

17. Hip Adduction

Connect an exercise strap to your ankle and to a wall or stationary object. Stand up straight, facing sideways to the wall or stationary object, and use a chair to balance yourself. Pull the affected leg across in front of the healthy leg, making sure it is kept straight. Return it back to the starting position.

18. Hip Abduction

Connect an exercise strap to your ankle and to a wall or stationary object. Stand up straight, facing sideways to the wall or stationary object, and use a chair to balance yourself. Pull the affected leg away from the wall or stationary object, making sure it is kept straight. Return it back to the starting position.

Functional Exercises

19. Squat to "Knees Cover Toes"

Stand with your feet shoulder width apart. Keeping your feet straight, bend your knees until they barely cover your toes when you look down. Make sure to keep your weight mostly on your heels and your back straight. Return to a standing position so your knees are almost straight, but not "locked".

20. Squats with Resistance (2 Legs)

Place both feet on the center of an exercise strap. Hold the handles at your sides until the strap is taut. Squat down and bend your knees 90º. Hold for one count and to a standing position.

21. Squats with Resistance (1 Leg)

Place one foot on the center of an exercise strap. Hold the handles at your sides until the strap is taut. Squat down and bend your affected knee 90º. Hold for one count and to a standing position.

22. Heel Touchdowns

Stand with the affected leg on a phonebook or step and let the healthy leg hang off with toes pointing upward. Bend the affected leg and touch the floor with the heel on your healthy leg. A chair may be used for balance.

23. Single Leg Balance

Balance on your affected leg only for 5-10 seconds.