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C. Thomas Vangsness, Jr., M.D.

ORTHOPAEDIC SURGEON

What are some reasons or causes for knee pain?


KNEE MENISCUS (MEDIAL AND LATERAL)


A. The meniscus is a tough fibrocartilage structure and can be injured with twisting, stopping, and turning motions of the knee. Meniscus tears are usually traumatic in origin. However, as we age, hydration decreases in this tissue and tears can happen with twisting motions that pinch and tear or shear the meniscus between the end of the femur and the tibia bone.

A. Symptoms of a damaged meniscus are pain and catching, clicking, or locking during certain twisting knee activities. These mechanical sensations are very commonly felt by the patient. The knee can also have swelling.

A. Generally, meniscus tears do not heal because they have a poor blood supply. However, they can occasionally become asymptomatic.

A. Treatment options are generally conservative and nonoperative as long as the pains aren’t too strong. Persistent pain and/or mechanical symptoms will require an arthroscopic procedure to trim out these mechanical tears or occasionally sew and repair the meniscus tear in the younger (<40) patient.

A. Persistent pain and mechanical symptoms that cannot be relieved by rest, anti-inflammatory medicines or physical therapy indicate a need for surgical intervention.

A. Surgery for the common meniscus tear is an outpatient arthroscopic surgical procedure. A couple of portals (holes) are made in the knee so that an arthroscope and the trimming instrument(s) can be inserted. Often a motorized or radiofrequency (electro-thermal) device is used to help trim and contour the torn area of the meniscus to create a smooth surface.

A. I start by having patients use crutches after surgery. You can stop using crutches over the next couple of days as you feel comfortable. Your recovery from meniscus surgery is really the recovery from the arthroscopic portals made into your skin. These small holes (portals) can cause pain and swelling. As they heal, the motion and function of your knee will improve. Recovery can be anywhere from 3-6 weeks depending on the inflammation encountered after the surgery and the amount of tissue damage found at the time of arthroscopy. You can drive within days and return to work within a few days. Sport activity can take 3-6 weeks.

A. If pain or mechanical symptoms (locking, clicking, instability) are not present, a meniscus tear can be treated acutely with rest, elevation, ice, compression. Additionally, physical therapy can be issued to work on quadriceps, hamstrings, and gluteal muscle strengthening. By participating in low impact activities, such as swimming, and bicycling, less forces will be transmitted across the knee.

A. Meniscus tears are often a result of a traumatic episode, such as a fall, twist, jump, etc. Pain, and swelling are common symptoms. Meniscus tears can be associated with the knee locking, clicking, or feeling unstable. Acutely the RICE protocol can be used, (Rest, Icing, Compression, Elevation). Over the counter anti-inflammatory medications such as ibuprofen or naprosyn can help pain management. Contact your primary care provider or orthopaedic surgeon to get your knee examined. Physical exam combined w/ MRI can accurately diagnosis meniscus injuries. Treatment options include conservative management or arthroscopic surgery. Arthroscopic surgery can be performed to repair or remove the damaged meniscus.


ANTERIOR CRUCIATE LIGAMENT (ACL)


A. The anterior cruciate ligament is generally torn in a noncontact situation where excessive forces are placed on the knee and the tibia is twisted under the femur causing a complete rupture (tear) of the ACL. This commonly is seen with twisting, stopping, turning sports such as football, volleyball, basketball, skiing, and soccer. It can also happen in contact sports with a blow to the knee.

A. Symptoms with a damaged ACL will be pain, swelling and a feeling of instability. Often times the knee can buckle underneath you and “give way.” If twisting, stopping, turning sports are attempted with a torn ACL, these buckling and “giving way” episodes will recur – a “trick knee.”

A. The ACL does not heal on it’s own and younger patients (< 40), who wish to participate in twisting, stopping, turning sports need to have this fixed (an ACL reconstruction). Repetitive “giving way” episodes of the knee with an anterior cruciate tear can harm the articular cartilage surface of the femur and tibia, and possibly tear the meniscus. These additional associated injuries can lead to painful arthritis in the future.

A. Nonoperative treatment options include avoiding any twisting, stopping or turning activities. A brace can be prescribed. Generally, an anterior cruciate ligament reconstruction is undertaken to stabilize the knee and prevent excessive motion and repetitive “giving away” episodes which can harm the meniscus and the articular cartilage.

A. You should have surgery if you want to play twisting, stopping, turning sports or if you have continued “giving way” episodes in your everyday activities. Another reason for surgery would be to stabilize the knee, which minimizes further damage to the articular cartilage or meniscus.

A. The damaged ACL cannot be sewn back together as it will not heal. A torn ACL will require a reconstructive procedure using transplantable tendons from your body (autografts) such as the hamstring, bone-patella-tendon-bone (BTB) or quadriceps tendons, to reconstruct this torn ligament. Allograft (tissue bank cadaver tissue) tissue is often used with less pain to you and earlier return to function. Both autograft and allograft tendons are acceptable to use for ACL reconstructions.

A. Recovery from an ACL reconstruction involves intelligent work with a physical therapist and a good home exercise program. Cycling and range of motion exercises are important. Strengthening of the quadriceps and the hamstring muscles along with sports specific and balancing exercises are important for knee recovery and developing skills for future sport activities. I can guide you through a good physical therapy program and protect your knee during the several months of rehabilitation. Simple goals after surgery are jogging at 3 months and return to sports between 6-9 months.


PATELLA (PATELLO FEMORAL PAIN – CHONDROMALCIA)


A. There are great forces transmitted across and through the patella as we walk and climb stairs everyday. The patella can get injured with a traumatic event such as a dashboard injury (knee jammed into the dash) in a car accident or falling directly onto the knee cap. Often times the patella can become painful with repetitive overuse.

A. Symptoms are swelling about the knee, and pain while going up and down stairs.

A. Generally, this pain can go away and heal on it’s own. Body mechanics and control of the femur from above with your hip muscles are important. Stretching and strengthening the quadriceps and hamstring muscles are also important.

A. Treatment options are always conservative with a smart course of physical therapy as well as stretching and strengthening all the limbs of the lower extremity. Core stability is important. Hip exercises are important to control the femur… Generally surgery is rarely needed.

A. Surgery may be needed if the pain persists over many months, the knee cap repetitively dislocates or there’s a fracture involved.

A. Surgery about the knee cap can be controversial with no exact reason when to operate or consensus about the type of procedure that should be done.

A. Rehabilitation after surgery depends on what was done in surgery. There are many different problematic and controversial surgical procedures for the knee cap. Return to work can occur within the week. You may encounter difficulty going up and down stairs for several weeks depending on the exact problem with the knee cap. This is also true with returning to sports activities.


ARTHRITIS


A. Arthritis is a breakdown of the articular cartilage covering the ends of bones – a degenerative process over time, similar to the thinning of your tire treads with use. There are many causes of arthritis. There are an estimated 30-40 million Americans with arthritis; most of these tears are due to degenerative arthritis (osteoarthritis). There are 2-3 million Americans with inflammatory rheumatoid arthritis. Trauma to the knee is one of the major reasons for arthritis in the younger individual. Arthritis most often increases as we age.

A. Symptoms of arthritis are stiffness, pain, and swelling of the joint. Morning stiffness is very common.

A. Treatment options include weight reduction and good (cushioned) shoe wear. Further conservative measures include taking over the counter Tylenol or anti-inflammatory drugs (NSAIDs). Occasional steroid injections or hyaluronic acid injections can be given into the knee. Surgical options can include arthroscopic procedures to wash out the knee or debride the roughened areas about the tibia and femur of the knee. Arthroscopic debridement of the cartilage surfaces during arthroscopy does not guarantee long term pain relief. There are many surgical procedures to replace small areas of localized arthritis including transplanting cartilage tissue to this area. Ongoing arthritic problems in the knee lead to increasing pain, eventually possibly requiring a total knee arthroplasty.

A. You need to have surgery when the pain gets so bad that medicine can’t control it, if you have difficulty sleeping or cannot walk a few blocks. Surgery attempts to improve the quality of your life by decreasing pain and increasing motion.

A. Arthritis can come from trauma, but generally arthritis increases with age. There is a 50% hereditary component with arthritis. Arthritis is treated first conservatively with weight reduction, activity restriction, NSAIDs (nonsteroidal anti-inflammatory drugs) like Motrin, Aleve, Celebrex. Tylenol can help relieve the pain as well. Stretching and exercise is important to keep the joint loose. Physical therapy is used to work on strengthening the muscles around the knee, to limit stresses on the arthritic portions. Once conservative measures fail to provide pain relief surgical options can be discussed.

Arthroscopic debridement of torn meniscus or loose cartilage can provide pain relief for some patients but will not treat the arthritis pain.

Debridement is a measure to help delay more invasive surgery.

Microfracture is a procedure in which small holes are drilled into the areas where cartilage is damaged. These small holes provide blood and nutrients which can produce fibrocartilage, a material similar but less durable than normal hyaline cartilage.

Mosaicplasty/OATS are procedures in which pieces of cartilage from low stress locations of your knee are surgically removed and implanted in the areas of arthritis. The donor areas are harvested by using special drills which core out the healthy cartilage and bone. These bone plugs are then implanted into the region with arthritis.

Allograft transplantation is similar to mosaicplasty/OATS but uses cadaver tissue / bone plugs. The areas of arthritis in your knee are sized, and a matching area of the allograft (cadaver) cartilage and bone are harvested. The allograft tissue is then precisely fit into the area of your arthritis as a plug.

Autologous Chondrocyte Implantation (ACI) is a 2 stage procedure in which a cartilage biopsy is taken from your knee during an initial arthroscopy and then is sent to a lab to be grown. The cartilage cells are grown in a medium and are later injected back into your area of arthritis. The cartilage cells are covered with a graft which protects the cartilage cells while they attach to the bone.

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KNEE BURSITIS


A. Bursitis is an inflammation of the bursal tissue about the knee. There are several different bursas about the knee that can become inflamed from either trauma or repetitive activities.

A. Generally these can heal on their own. Initial icing followed by heat can help. Anti-inflammatory drugs can help decrease the pain. Steroid injections can be given to help decrease the inflammation.

A. A non-operative exercise program and NSAIDs generally take away the pain. Occasionally, surgery is necessary to excise a bursa. This can be open or arthroscopic.


MEDIAL AND LATERAL COLLATERAL LIGAMENT TEARS (MCL & LCL)


A. Generally, the ligaments on the sides of the knee are called collateral ligaments (medial – inside of knee, lateral – outside of knee) and can be injured with twisting, stopping, and turning activities. Traumatic injuries cause them to stretch or tear and not function correctly.

A. Symptoms include instability and “giving away.” Occasionally, you can feel the tibia slipping underneath the femur.

A. The inside medial collateral ligament (MCL) can heal on its own and rarely requires surgery. Injury to the outside lateral collateral ligament (LCL) is different altogether. This usually requires surgery, but is a rare injury.

A. Recovery is generally excellent for the medial collateral ligament. The medial collateral ligament rarely requires surgery. However, recovery from the lateral collateral ligament requires surgery and does not guarantee a return to high-level sports. This is a very serious type of injury, often associated with other ligament injuries in the knee.

A. Ligament injuries are termed sprains or strains, and are graded according to the severity of the ligament injury.

  • Grade 1: stretching of the ligament, little or no torn fibers, no laxity, no surgery needed.
  • Grade 2: partial tear, mild laxity, most commonly treated w/ bracing
  • Grade 3: complete tear, gross laxity, may require surgical repair or reconstruction

Physical exam and MRI studies are used to determine grade of sprain.


POSTERIOR CRUCIATE LIGAMENT (PCL)


A. The posterior cruciate ligament is less commonly injured than the anterior cruciate ligament (perhaps a ratio of 1 to 20). Posterior cruciate ligament injuries generally do not require surgery unless there is a great instability of the knee. Many athletes can function at a very high level without a posterior cruciate ligament. Often times in a car accident, when the knee cap (patella) is driven into the dashboard, a posterior cruciate ligament injury can occur. A fall onto the knee (or a direct below to the knee with a tackle in football) can cause this injury.

A. Feelings of instability with certain motions about the knee can occur with a damaged PCL. Occasionally, with a long standing injury, the knee cap can be painful.

A. The PCL tear does not heal on its own. It generally does not require surgery.

A. Treatment always begins with a conservative non-operative plan. Strengthening of the quadriceps and hamstring muscles in physical therapy is always advised. Bracing can also help with a posterior cruciate ligament injury.

A. Failure of a nonoperative treatment with persistence of ongoing pain and or knee instability would require a reconstruction of a posterior cruciate ligament.

A. Surgery for the PCL involves either an autograft or an allograft reconstruction of the ligament. Either a bone-tendon-bone, hamstring autograft, an achilles tendon or bone-tendon-bone allograft is used to reconstruct the posterior cruciate ligament.

A. Recovery is similar to the ACL. Immediate motion is attempted with strengthening of the quadriceps and hamstring in the first week. Crutches are used the first week. Quadriceps strengthening is strongly emphasized. Return to sports can be from anywhere from 6-9 months depending on the progress, the type of sports, and other possible damaged structures.


MISCELLANEOUS


A. Clicking/popping sounds are quite common occurrence in the knee. Painless sounds from the knee are a normal finding. If pain is associated with the click or pop, injury may have occurred. A loud popping sound, with immediate pain can occur w/ ACL tears. Cartilage lesions can also cause painful popping or clicking.


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