Knee Injuries

[vindiesel]

KNEE INJURIES - a patient's guide
Dr Chris Milne

Overview

The knee is the most commonly injured joint in the body

It is a modified hinge joint and relies upon strong ligaments and muscles for its stability

Most injuries to the knee involve either the patellofemoral joint, a ligament strain or cartilage (meniscus) tear

Most knee injuries can be improved significantly by modified activity, and specific muscle rehabilitation exercises

If a clear structural problem exists (e.g. unstable meniscal tear) then surgery is necessary

How do knee injuries occur?

The most important clue to making the correct diagnosis in knee injuries is the mechanism of injury. That is in which direction the joint was forced when it became injured.

Common mechanisms of injury and the structures involved include:

Fall with impact on the front of the kneecap (patella). This injures the contact area behind the kneecap, called the patellofemoral joint.

Being tackled from the side, with the force causing opening up of the inner side of the knee, this strains the medial collateral ligament.

A twisting injury. This often injures the cartilage (meniscus) and a cartilage tear may result in knee locking.

A pivoting injury where the foot is planted. This injures the anterior cruciate ligament.

Symptoms you should take note of:

Pain

The location of pain can indicate which structure is injured. For example pain in the front of the knee is often associated with patellofemerol joint injury. Pain on the inner side of the knee may be associated with a medial ligament strain.

Locking

Locking is the inability to fully extend the knee. It may be caused by a torn cartilage (meniscus) with a fragment trapped in the knee, or a torn anterior cruciate ligament.

Instability

This is a feeling that the knee is about to give way. It is usually associated with anterior cruciate ligament rupture, but there may be other causes.

Swelling

The onset of swelling in relation to a knee injury is crucial. Swelling which develops in the first hour or two after the injury is due to blood accumulating within the joint. This happens with a torn anterior cruciate ligament, a fracture within the joint, or a dislocated patella. Swelling which is not evident until the next day is associated with accumulation of joint fluid such as occurs with a cartilage tear.

Making a specific diagnosis:

Your doctor will ask you about how your knee injury occurred, and the particular symptoms mentioned above. Following this, an examination is undertaken.

Initial observation will reveal whether or not there is excess fluid on the joint, and if any scars (from previous injury or surgery) are present. Touching gently around the joint (palpitation) can help determine the site of maximum tenderness. Joint line tenderness is associated with a cartilage tear.

Testing the range of knee motion is then undertaken. Normal knee motion is from 0 to 140 degrees.

Finally, specific stresses through the knee can help assess any associated ligament tears. If there is increased excursion (laxity) on testing a particular ligament, then the ligament has either been significantly stretched or completely ruptured.

Once the above tests have been performed, the doctor should be able to make a working diagnosis - that is give a label to the problem that can be used to plan treatment.

What about x-rays and scans?

X-rays are helpful in certain situations:

If a fracture is suspected, based on findings from the history and physical examination.

In all cases of haemarthrosis (blood within the knee joint) because there may have been a dislocated patella. If this is suspected, skyline views looking down through the knee joint are worthwhile.

If an orthopaedic surgeon is to be consulted, x-rays are useful to check for associated boney problems.

In cases of persistent pain, as bone tumours can occasionally present as pain after injury.

More specialised scans e.g. MRI scans are generally ordered by specialists e.g. orthopaedic surgeons or sports physicians.

What about rehabilitation?

All knee injuries can benefit from a planned programme of exercises. Initially, the aim is to reduce knee swelling and protect injured ligaments.

Ice, compression and elevation are important in the first 48 hours after a knee injury.

Anti-inflammatory tablets may be prescribed for a few days, particularly if joint swelling is present.

If there are signs of a complete rupture of the medial ligament, a limited range of motion brace is helpful.

Once the first few days have passed, there is an emphasis on gradually restoring the full range of motion of the knee. Careful attention to maintaining function of the quadriceps muscles (at the front of the thigh) and the hamstring muscles (at the back of the thigh) is important.

Over the next couple of weeks, the aim is to have these muscles working in concert. Even though a ligament may be strained, good muscles can help in maintaining knee stability as the ligament heals. Swimming is useful at this stage.

Once the full range of knee motion has been restored, it is important to build power and endurance. Functional exercises (e.g. stair climbing) are generally of more use than expensive machines in achieving this.

As knee function improves, cycling then light jogging can commence. Once the person can jog painfree, then they can start speeding up and slowing down. If this causes no problem, they can try running around cones in a figure 8 pattern. The next step is to try cutting and turning movements. If these cause no problem, it is safe to return to team training.

Once skills have been re-established, the player can return to competition. It may be advisable to play half a game initially, and be prepared to come off the field if the knee gives any problem.

The role of surgery:

Surgery has a significant place in the management of more severe knee injuries. If there is a torn cartilage with locking of the knee, or a torn anterior cruciate ligament causing recurrent instability, then surgery is very useful.

There are only rare instances where surgery is necessary in the first few days after a knee injury. Generally these involve fractures, or complete dislocations of the knee, which are uncommon. For injuries such as a torn anterior cruciate ligament, it is best to settle the acute swelling and restore muscle function before embarking on ligament reconstruction. The pre-surgical rehabilitation is called pre-habilitation and enables better results to be achieved from surgery.

Following surgery, post-operative rehabilitation is necessary to restore optimal knee function. All this takes time, approximately five months for a torn anterior cruciate ligament. There's no point in rushing things, you want this knee to work well for the rest of your life!

[TheChosen1]

Locking

Locking is the inability to fully extend the knee. It may be caused by a torn cartilage (meniscus) with a fragment trapped in the knee, or a torn anterior cruciate ligament.
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Speaking from experience, this is NO pleasure cruise. My left knee was constantly locking up on me from the time I was 22 until I had a 2nd operation on it when I was 32. I had an operation on my left knee when I was 26 but apparently, the surgeon didn't finish the job. It always locked on me when I would do something simple like tie my shoes or standing from a seated position and it would lock in a slightly bent position. The doctor placed my leg in a stiff brace that reached from my upper thigh to the ankle and I had to wear it for a week.

Although I've not had my knee lock on me since 1994, it still have limited bending ability. Since my first operation in 1988, I've already had a 3rd operation on it in 2004 and a first on my right knee in 2003 (which never locked).

[vindiesel]

I have had quite a few surgeries on my right knee and sometimes, when I walk on a slippery road, my knee kinda give way and swells like a balloon. Same when I do squats. THat's one of the reasons why I avoided squats like the plague until a cute cuban guy with great legs persuaded me to start squatting I never do full squats though.

[TheChosen1]

Originally Posted by missdiesel

I have had quite a few surgeries on my right knee and sometimes, when I walk on a slippery road, my knee kinda give way and swells like a balloon. Same when I do squats. THat's one of the reasons why I avoided squats like the plague until a cute cuban guy with great legs persuaded me to start squatting I never do full squats though.

I'm right there with you, MissDiesel. Prior to my 1994 knee operation, my doctor told me to quit powerlifting and return to bodybuilding training. Sadly, I did this after my operation for maybe a couple of weeks before getting bored with it. I slowly returned to powerlifting and continued doing squats as well. Well ironically in 2003, I had broken my squatting record the night before having major pains and problems with my knees at work.

Once again after surgery, I was told to quit powerlifting. About a month ago, I once again broke my squatting record and felt that I could still go further. So far, no problems. I've since returned to bodybuilding training and hadn't done any leg training in about 2 months because I have a difficult time bending my legs on the extension machine.

And btw, don't worry about the cute Cuban guy at your gym. I won't tell Mr. Diesel about him.ct*)

[vindiesel]

Originally Posted by TheChosen1

Once again after surgery, I was told to quit powerlifting. About a month ago, I once again broke my squatting record and felt that I could still go further. So far, no problems. I've since returned to bodybuilding training and hadn't done any leg training in about 2 months because I have a difficult time bending my legs on the extension machine.

And btw, don't worry about the cute Cuban guy at your gym. I won't tell Mr. Diesel about him.ct*)

I kinda needed that guy to push me around and tell me that I would have great legs and butt by doing squats

I didn't know that you were a powerlifter. What was your training routine like?

I have started using the oblique press as part of my routine but I don't push an impressive amount of weight I must say (half the weight I push at the horizontal leg press).

[Teamorbit]

Yeah the knees are sensitive. I arivate mine once in a while when I do inclines. I am up to 130s now but I have a thing where I have to pick them up from the ground but when they slam on my kne/leg sometimes it can bother my knee where it gets sore.

[ruffneck]

Knee injuries suck especially if it is an injury that is not constant. One that has almost gone away by the time you get to see an ortho doc but comes back the next time you twist it the wrong way. THe doc thinks you just making a mountian out of a mole hill.