Knee

Chondromalacia / Patello-Femoral Pain / Anterior Knee Pain

This term is most often associated with the knee, but can also be associated with any joint that has articular cartilage. "Chondromalacia" is a Latin word meaning "cartilage softening" . "Chondromalacia" is a surgical determination, not a clinical one. Two common types of cartilage are: hyaline/articular and fibrocartilage. The former is a glistening, near friction-free surface that covers the ends of bones, allowing for smooth movement. The latter is a tougher type of cartilage, like the meniscus of the knee, which helps in stabilizing the joint. Chondromalacia is graded from I to IV, the latter implicating "bone on bone" wearing. A recent study (1) proved that one can have as much as a Grade III wearing without pain. So, pain is variable. The source of chondromalacia pain (2) is not the articular cartilage itself, but the thinning of it, which transfers loads onto the underlying subchondral bone, which is pain-sensitive.

Patello-Femoral pain is the most common of knee problems. This involves the joint between the knee cap(patella) and the thigh bone(femur). It is chronic, but usually only episodically painful. There is often no one trauma associated with it, just a sense of discomfort with fluctuations of pain over time. It is often associated with sub-optimal biomechanics around the knee cap and lower limb, but not always. When biomechanics are good, but there is PF pain, this may be due to a predisposition towards soft articular cartilage, which is poorly understood. Direct trauma to the knee cap can instigate PF pain and softening of the cartilage over time. Biomechanics are unalterable conservatively, but can be influenced by selective muscle stretching and strengthening exercises around the knee, pelvis, hip and foot. This helps to reduce the abnormal vector forces influencing the patella.
PF Pain is characterized by a poorly localized, deep aching under the patella, which often refers towards the front and inner aspects of the knee. Aggravating factors are: prolonged sitting, descending/ascending stairs or hills, and squatting. There is only rarely very mild swelling.
The treatment of PF Pain is conservative. This means seeking the advice of a Physical Therapist who will identify selective exercises to optimize lower limb mechanics. McConnell PF taping may also be indicated. Occasionally, modalities such as Ultrasound and Biofeedback may be helpful. The prescribed exercises are a life-long commitment, like brushing your teeth.
If conservative care of PF Pain fails, and the pain is significant, then the advice of a surgeon should be sought. But surgery is the last resort.
Other conditions such as patellar subluxation(partial dislocation) or dislocation often cause PF pain.

Meniscus

The menisci are fibrocartilage discs between the two main bones of the leg (upper femur ; lower tibia). They act as cushions and load-transmitting bearings. The mensici are commony injured. The usual cause is a twist on a weight-bearing leg. It can become degenerative over time. The episodic pain is often focal along the joint line and associated with any pivoting movement or squatting. Swelling is usually minimal. If pain persists, it often leads to weakness of the quads, the main front thigh muscle, which in turn may lead to other problems over time. The key to treatment is preservation of range of motion and strength of the knee. If the tear is along the rim of the meniscus, there is a chance it may heal back down on its own, without surgery. If not, consulting a surgeon may be necessary to determine if an arthroscope is needed to stitch the tear or remove the torn segment of meniscus. Intensive Physical Therapy is usually needed post-operatively.

Knee Ligaments

There are many ligaments in the knee, all interlacing to provide stability. Ligaments are discrete bands of tissue whose function is to connect bones together. They have no contractile power - they are simply cables. The four most important are the ACL (anterior cruciate ligament), the MCL (medial collateral ligament), the PCL (posterior cruciate ligament) and the LCL(lateral collateral ligament). Ligament strains are graded as I, II, and III, with I being a mild strain without rupture and III being a full tear.
The ACL is commonly injured during sports, usually from some form of twisting on a planted foot or with jumping. There is often a distinct "pop" followed by discrete swelling. There may be a sense of the knee giving way thereafter. The ACL does not heal back together. If there is a partial tear with no other injury, surgery is not usually indicated, just intensive rehab. If no meniscus is torn along with the ACL, ACL reconstruction is an option, not a given. It depends on your lifestyle. However, if you play high torque sports or your job involves torque, it is seriously considered. If you are sedentery, ACL reconstruction is an option, unless there are episodes of the knee "giving out" during activities of daily living. It is known that some ACL-deficient knees learn to "cope" well with just regular strengthening and agility exercises, and avoiding torque situations. Running, swimming and cycling, the "pure" sports, involve much less twisting and pivoting, so ACL reconstruction is an option only in these athletic people. If the meniscus is torn as well as the ACL, surgery is usually required.
ACL reconstruction is a major surgery and its rehab arduous. You will likely not be able to return to a "desk" job for about two weeks, and if your job is physical, it may not be for months. Depending on your surgeon's protocol, your return to high-torque sports will be about 6-12 months. You will be instructed to consult a Physical Therapist within 1-2 weeks of your sulrgery. The therapist will guide every aspect of your rehab, with initial emphasis on regaining range of motion(ROM) as quickly as possible in the days following your surgery. Thereafter, strength and then agility, balance and coordination are essential. Access to a gym is optimal if you plan to return to sports. Concommitant meniscus repair may lengthen rehab time.
The MCL, on the inner side of the knee, is also commonly injured in a fall or twist. It generally heals by itself and as long as it is not subjected to "stretch" during the healing phase, it should eventually regain its role as the main stabilizer of the inner aspect of the knee. There is usually appreciable pain, swelling, loss of ROM and muscle weakness. A temporary brace may be indicated. It is critical to preserve full motion of the knee during the healing phase or there could be permanent loss. Consulting a Physical Therapist will help you with the appropriate exercises. In isolated MCL tears, rarely is surgery indicated.
The LCL is on the outer side of the knee, and is not commonly injured. It is often associated with other knee injury.
The PCL is also not commonly injured and is not readily diagnosed by ER or primary care physicians. It criss-crosses the ACL dead-center in the knee. When torn, it does not heal. The usual injury is a severe blow to the front of the knee or shin. In the non-athletic person, the treatment is very rarely surgical, as one can function quite well without it. Maintaining a very strong quads(front thigh) muscle is critical to counteracting the loss of the PCL. PCL reconstruction is, at present, not as advanced as ACL reconstruction is, but advances are happening quickly. When combined with other knee injury, reconstruction may be indicated. Rehab with a Physical Therapist is recommended, for the rehab is intense as well.

IlioTibial Band(ITB) Syndrome

ITB syndrome is a common athletic injury. The ITB is a taut band of connective tissue that starts at the hip and runs along the outer thigh and inserts at the outer knee. The pain may be at the hip but more commonly at the knee. It is characterized by a very sharp pain at the outer knee, often associated with downhill running/stairs. There is often no pain at rest. Friction results as the ITB rubs back and forth over a projection of the femur at the outer knee. Many biomechanical factors predispose to this condition. These need to be analyzed by a Physical Therapist who will initiate selective stretches and strengythening exercises to minimize their abnormal influence. Soft tissue mobilization and modalities(such as Ultrasound) may be helpful. Once the pain is resolved, one must keep doing the exercises on a regular basis to prevent recurrence.

Patellar Tendonitis

Please refer to Tendinitis for general information. Patellar tendonitis more likely involves a micro-degeneration process of the quads tendon below the patella(knee cap). It is often associated with jumping sports or repetitive knee activities. The diagnosis is clinical. Rarely is MRI needed and only if conservative treatement fails to eliminate the pain, and surgery(very rarely) is being considered. Treatment comprises identifying and eliminating the causative factors. Then, performing selective exercises and icing over a consistent period of several weeks will hopefully help. A Physical Therapist should be consulted if pain persists.

Patellar Subluxation and Dislocation

Due to multifactorial reasons, some patellae (knee caps) are prone to either partially dislocate (sublux) off the femur (thigh bone) in an outward direction or fully do so episodically. After such an event, the patella usually snaps back into place spontaneously. Less commonly, a traumatic incident can dislocate a non-predisposed patella. Some biomechanical factors may be involved: a somewhat flat patella undersurface gliding on a shallow groove on the femur; inward rotation of the femur which places the patella in a position to outwardly sublux/dislocate; weak quads or gluts muscles; and hypermobility ("double-jointed"). Since one cannot alter one's own skeletal makeup, it is crucial to emphasize what can be influenced: soft tissue. Optimizing the quads and gluts; selective stretching to decrease the pull of tissue on the outer side of the patella; and McConnell Patello-Femoral taping are important among othertreatment principles. It is important to seek the advice of a physical therapist to help develop an Independent Exercise Program. Like any other chronic condition, one must remain diligent with these exercises throughout life, just like brushing teeth.

Total Joint Arthroplasty or Replacement: Osteoarthritis

The most common joint replacements are the hip and knee. More shoulders are being done now as well. As humans live longer, our joints wear down. Of the over one hundred types of arthritides, the most prevalent is OA: osteoarthritis - the degenerative form. How much joints wear down is not well understood, since even young people can have arthritis and old people may have very little. In other words, inherent predispositions for joint degradation is probably a factor, added to the "microtrauma" of living over decades, and of course joint trauma itself. Besides living longer, humans are working and "playing" longer and harder. Increasing incidence of obesity adds yet another complication.
If conservative treatment (rehabilitation, medication, lifestyle modification...) does not control the pain and the pain is intractable - affecting daily living - an orthopedic surgeon may suggest joint replacement. This is a very significant and final surgery, with a long and arduous rehab. Since the joint is replaced, pain that used to stem from the arthritic joint is reduced. Incision and swelling pain abates over a time.
In the case of the knee, the the single most important aspect of rehab is regaining as much range of motion (ROM) as quickly as possible. Most critical is the ability to straighten the knee fully. If it doesn't, one will walk with a bent knee, which can affect your gait, hip or back. Depending on the type of prostheses, a minimal goal for bending the knee is 120 degrees, which would allow the descending of stairs without limping. Concurrently, intensive muscle strengthening is emphasized, the quads (front thigh muscle) being the most important. Normalizing gait is stressed immediately. The end result should allow for resumption of full normal activities of daily life. Some sports are not recommended, as this will wear down the prosthesis. Discussing realistic goals before surgery is important. A total knee is not a normal knee. What is predominantly gained from this surgery is pain relief. Revision of primary Total Knees is not a solution without significant risks, as the base of bone into which the prostheses sits is diminished with each revision. Choosing your sports carefully post-op will ensure longevity of the prosthesis. Cycling, hiking and swimming are gentle on the joint, yet can be done at a intensive level ensuring maintenance of good muscular, aerobic and functional levels.

Osgood Schlatter condition

This benign condition in teenagers is transient. Histologically, tiny microfractures exist at the tibial tubercle, where the knee cap(patella) tendon attaches to the lower shin bone. It is more often seen in boys and in athletes in the running or jumping sports. It is self-limiting, lasting 2-3 years. A sudden growth spurt is often involved, when bone grows at a faster rate than the tissue attached to it, causing stress on the bone. Pain and swelling ensues. Treatment involves discontinuing the offending activity, icing and possibly a patellar strap. Gradually stretching the quadriceps muscle and its (patellar)tendon carefully is necessary. Very rarely is surgery indicated.

Reference:
Am Fam Physician. 2006 Mar 15;73(6):1014-22