Focus on knee problems – includes related articles

Knees are remarkable mechanisms able to absorb six to eight times the body’s weight with every step, more when jumping or going up and down stairs. The rigour of spons added to everyday activities makes knees extra susceptible to damage.

Knees especially vulnerable to injury

The legs, particularly the knees, are the most injury-prone parts of the body. Knee injuries are the leading cause of Iong-term disability among athletes. A recent British study found that legs accounted for about 75 per cent of all sports injuries, one third of them knee disorders. Although most commonly due to sport, anyone an hurt their knees if they make an awkward movement or give lhe knee a hard blow. Women are especially susceptible because their wider pelvis tends to make them knock-kneed.

Besides the knock-kneed, those prone to knee problems are lhe flat-looted, whose leer “pronate” (turn inward) too much, those with somewhat unstable (“loose”) kneecaps and anyone who has imbalanced thigh muscles. Diagnosing knee injuries can be tricky, bul any sudden knee swelling usually signals trouble. Knee pain should ,ever be ignored or masked with medication. If symptoms persist. consult a sports physician, sports clinic, exercise or orthopedic specialist. Accurate diagnosis, preferably soon alter a knee injury, is essential for correct treatment. Any details noticed at the time – a pop or snap, and how soon swelling and disability appeared – can help determine what’s wrong.

Advice from sports medicine experts often helpful

Sports medicine specialists provide multi-disciplinary expertise likely to bring the best results in analyzing and remedying an activity-related knee (or other)injury. Sports medicine is a rapidly evolving field, perhaps more accurately called exercise medicine. Besides recognizing and treating exercise-related injuries, sports medicine teams suggest ways to prevent recurrence, assess fitness and advocate exercise as an integral part of wellness. Typically, a sports medicine team includes physicians, athletic therapists, orthopedic and neurological specialists, sport scientists, psychologists, perhaps also massage therapists, and physiotherapists – the rehabilitation experts. An essential part of any sports medicine team, not only do physiotherapists help to hasten recovery but they also educate people in ways to prevent recurrence.

One ardent jogger describes how a sports medicine team helped him to overcome patellofernoral syndrome or runner’s knee. “At first,” he relates, “the kneecap was painful only after vigorous exercise, hurting across the front (laterally), but later it remained sore between exercise bouts, finally being swollen and painful all the time.” Examination showed the knee malady to result from a combination of overuse and imbalanced thigh muscles.

The physician explained the roots of his knee problem: “the inner thigh muscle (vastus medialis) was weaker than the outer (vastus lateralis), pulling the kneecap out of alignment.”

Exercises learnt from a physiotherapist helped to strengthen and stretch the tight lateral thigh muscle. Together with tailormade orthotics or shoe inserts, worn all the time in all shoes, the problem soon cleared up, the pain vanishing in a few weeks.

Today’s simpler arthroscopic knee surgery

Knee injuries can now often be diagnosed and surgically corrected at the same time with arthroscopy, reserving the older, open-knee operations for ligament and reconstructive problems. Occasionally surgeons now replace entire damaged knees with arthroplasty (knee transplants) or with metal replacements. Arthroscopic surgery greatly reduces recovery time.

The arthroscope – a fibreoptic device – is useful for removing torn cartilage and for ligament repairs. It contains a light and magnifying lenses that relay a clear view of the knee’s interior spaces through a TV monitor and eyepiece. Tiny incisions are made in the knee to insert the arthroscope and inject saline (salt) solution. An accurate diagnosis and surgical correction are often undertaken at the same time, under local or general anesthetic. An arthroscope allows a thorough analysis of knee problems, can be used to diagnose ligament tears, see toughened surfaces and plan open-knee surgery. After arthroscopic surgery, the small incisions are taped or stitched, the knee bandaged, and a few hours after surgery the person can usually go home, preferably accompanied by a relative or friend who stands by until the after-effects of anesthetic wear off. Crutches may be needed to keep weight off the knee for a few days. Physiotherapy has become an indispensable part of post-surgical treatment, to strengthen the knee and promote recovery.

Following arthroscopy, the knee may feel slightly uncomfortable and a gurgling noise may be heard for a time when walking. After about four weeks or less of mild exercise, regular sports can often be resumed.

Become knee-wise

For mild knee discomfort, ice, painkillers and modified movement may be enough, but persistent swelling or pain needs expert diagnosis. Avoiding sudden jolting movements and rough running surfaces can help to prevent knee injuries. Obesity adds pressure to the vulnerable knee joint, so weight reduction is a help. Learning the fundamentals of any chosen sport and being properly prepared, trained and equipped (with good footwear) can prevent taxing knee movements. While overuse harms the knee joint, properly done exercises are the salvation for weak knees. Knee damage can often be prevented by exercises that balance the thigh muscles, learnt from a qualified professional.

Exercises considered good for the knees include small (not deep) knee bends and straightening motions – done while in supination with most weight on the outside of the foot. Sports easy on the knees are: walking, swimming (flutter kicks, knees straight), skating, baseball, cross-country skiing and, depending upon the state of the knee, cycling (seat high, low gear, avoiding hills).

Preventive knee hygiene

* Choose activities to suit knee strength/capacity, remembering that sports especially “hard on the knees” are football, sprinting, soccer, rugby, hockey, squash, volleyball, basketball, downhill skiing, tennis and jogging – anything that pounds, jolts or twists the knees.

* Knee-friendly sports include swimming, skating, cycling, crosscountry skiing, baseball, walking.

* Knee-strengthening exercises should increase the flexibility and strength of the outer thigh (quadricep) muscle and balance its strength with its counterpart (hamstring) muscle. As the best quadricep-balancing routine, a University of Toronto sports physician suggests the Jenny McConnell Program. (See Australian Journal of Physiotherapy, 1986. volume 32, #4.)

* Get prompt expert medical attention for any knee injury, swelling, pain or morning stiffness.

* Use painkillers and anti-inflammatories sparingly for knee problems, never to hide or mask pain.

* Try to exercise with knees properly aligned.

* Wear knee protective equipment when recommended – for example, in hockey and when rollerbinding.

* Considers brace instead of surgery for an unstable patella (prone to dislocate) or knee ligament injuries. (For more on knee exercises, see Health News, June 1992 issue.)

Some common knee injuries

Acute knee injuries

* Torn menisci- the knee’s cartilaginous shock absorbers between the femur and tibia – can be due to a sudden, twisting movement (as in downhill skiing) or a blow to the knee. Tearing of the menisci may be accompanied by a “pop,” bringing immediate pain and swelling. Some meniscus tears respond well to “conservative therapy” with quadriceps-strengthening exercises. If symptoms persist, an MRI (Magnetic Resonance Imaging) test may be ordered and arthroscopic investigation or surgery to remove the torn cartilage. Although 30 per cent “settle” the rest ultimately need surgery.

* Medial collateral ligament tears (on the knee’s inner side) can occur from a collision or a violont blow, as in rugby, hockey and soccer, or from sudden wrenching or twisting. A pop may be heard at the time of injury and the knee feels loose. Afterwards, the person may go on with the activity – running, squash, tennis – only later developing pain and difficulty straightening the leg. Ice and gentle strengthening exercises are often enough for mild tears but sometimes a brace is advisable. Complete rupture may produce less pain or swelling but a more wobbly knee than partial tears. Surgery may be necessary to re-attach the torn ligament. Temporary immobilization in a cast or hinged brace usually works.

* Anterior cruciate ligament tears, the commonest of acute knee injuries – often misdiagnosed and mismanaged – usually occur through a violent pivoting or twisting movement. The knee may “pop” or feel as though it’s come apart even though it may not swell. About 30 per cent with this injury manage OK for daily activities but 70 per cent or more ultimately need surgical knee reconstruction for continuation of usual sports. Older people may simply need hamstring-strengthening exercises.

* Patellar dislocation, usually with a distinct “pop” as if “something gave way,” with sudden knee swelling, is a common problem, particularly in those with unstable kneecaps that “slip in and out of place,” perhaps because of a former injury. Treatment is ice, compression, crutches and, if severe or painful, a splint or cast, followed by gradual movement and then thigh muscle strengthening. (For subsequent dislocations, a cast is not generally required.)

Overuse knee problems

* Runner’s knee, or patellofemoral syndrome, the commonest knee complaint, is signalled by a noisy “clicking” when the knee is bent and straightened, pain behind the kneecap on descending stairs, prolonged car driving or sitting in a theatre. Discomfort builds gradually. Bending the knee is difficult and causes pain across and on both sides of the knee. It’s due to failure of the knee tissues from abnormal or excess stress on the joint, often because of “lateral tracking” (sideways movement) of the patella. This overuse knee problem is particularly common in runners and people who have poorly balanced quadricep muscles. Other causes are flat feet, wide hips, knock-knees or a tight iliotibial band. In patellofemoral syndrome, the kneecap’s normally smooth inner surface may become rough.

Treatment of patellofemoral syndrome aims to improve pateIlar tracking (alignment). The muscles which control the kneecap must be strengthened, making sure to equalize quadricep muscle strength. (Learn the proper exercises from a professional.) Orthotics (shoe inserts) help to realign the foot if it pronates (turns or slopes inwards) too much. People with this problem should initially choose sports with a limited range of knee motion. Doing warm-ups to stretch the hamstrings and calf muscles before exercising helps to avoid runner’s knee. When experiencing pain, runners should stop, then modifytraining routines (run less fast, less far and less frequently), opting for a cushioned surface and avoiding hills.

* Jumper’s knee or patellar tendinitis, another common overuse problem, results from excessive force on landing, as in basketball, volleyball, squash, sprinting and other activities that pound the knee. Small tears in the tendon’s attachment to the patella cause swelling. Pain is felt at the bottom of the kneecap (where the pateilar tendon attaches to the bone). The best treatment is simulated jumping movements (squats and knee straightening), slowly at first, then more quickly, gradually adding weight, to stretch and strengthen the quadricep and calf muscles. Properly cushioned footwear and knee supports help to prevent the condition.

* Osgood-Schlatter’s disease, not strictly a knee disease, is an adolescent version of Jumper’s knee with inflammation of the area where the pateilar tendon joins the lower leg bone. It’s a problem exclusive to rapidly growing teenagers, especially those who are active or athletically-inclined. A painful little bump forms below the kneecap. Modified movement (and occasionally leg splinting) are the remedies, resuming usual activities once pain subsides. Teenagers should avoid sports that require excessive squatting, bending or jumping and do regular stretching exercises. They will outgrow the pain but the bump will remain.

* Prepatellar bursa, sometimes called “carpet layer’s knee, “with swelling in front of or on top of the kneecap, can be due to a hard blow on the kneecap but is usually an overuse or compression problem due to continual kneeling or repeated falls on the knees. Ice, anti-inflammatory drugs, an elastic wrapping and moderate movement are usually the best treatment. Obviously, kneeling should be avoided ! * Loose bodies are pieces of cartilage (or bone chips) in the knee joint (sometimes called “joint mice” as they wriggle off when grasped), common in athletes, often due to trauma (e.g., joint dislocation). The loose chips can be felt through the skin. The chips can become wedged between the knee bones causing the knees to catch, lock or give way with accompanying pain and swelling, or the chips occasionally hide in the joint crevices. If the condition persists, the loose chips must come out to avoid chewing up the knee joint. Removal via an arthroscope is easy to do, given today’s sophisticated surgical techniques.

* Baker’s cyst is a protrusion of the knee joint lining felt as a lump at the back of the knee, often a complication of osteoarthritis or trauma, causing fluid build*up. The ankle or calf may also swell. While rest usually allows the knee to settle, if symptoms persist, surgery is an option.

* Iliotibial band syndrome (pain at the sides of the knee) with an over-tighttendon and/or muscle is often due to excessive running. Ice, massage and stretching exercises, and perhaps reduced running, are the remedy.

* Pes Anserine syndrome, also known as “swimmer’s” or “breaststroker’s knee”- due to excessive egg-beater or whipping kicks – produces tendinitis (inflammation) on the inside of the knee. It is often relieved by stretching exercises.

* Knee joint sudace degeneration due to wear and tear on the cartilage can be helped by modified activity or perhaps a debridement – simple, same day arthroscopic surgery – to shave off the rough surface and lavage out loose bits of tissue. Knee strengthening exercises should follow.

COPYRIGHT 1992 Strategic Inc. Communications Ltd.

COPYRIGHT 2004 Gale Group

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