KNEE

• Anterior knee pain

  

  Introduction

  Anterior knee pain is classified based on etiologic factors . The term “chondromalacia” should be replaced with a specific diagnosis based on this classification.

  Tendon ruptures

  Quadriceps tendon ruptures occur most often in patients over 40 years old. Patellar tendon ruptures occur in younger patients (<40 years). A palpable defect and the inability to extend the knee are diagnostic. Primary repairs indicated.

• Iliotibial band friction syndrome

  

  Can occur in runners and cyclists and is a result of abrasion between the iliotibial band and the lateral femoral condyle. Localized tenderness, worse with the knee flexed 30 degrees, is common. Rehabilitation is usually successful.

• Semimembranosus tendinitis

  

  Most common in male athletes in their early thirties, this condition can be diagnosed with MRI often responds to stretching and strengthening. A steroid injection may be added if no improvement is seen.

• Patellofemoral arthritis

  Injury and malalignment can contribute to patellar DJD. Lateral release may be beneficial early only if there is objective evidence of patellar tilting; however, other procedures may be required for advanced patellar arthritis. Options include anterior (Maquet) or anteromedial (Fulkerson) transfer of the tibial tubercle or patellectomy for severe cases. Patellofemoral arthroplasty has been introduced as another treatment option but remains controversial.

  

• Prepatellar bursitis (housemaid's knee)

  

  The most common form of bursitis of the knee and associated with a history of prolonged kneeling. Supportive treatment (knee pads, occasional steroid injections) and (rarely) bursal excision are recommended. Aspiration is advocated in wrestlers because of the kneeling on the flexed knee required for this sport.

• Pes anserinus bursitis

  

  This is characterized by localized pain, tenderness, and swelling over the proximal anteromedial tibia at the insertion site of the sartorius, gracilis, and semitendinosus (approximately 6 cm inferior to the joint line). It is treated conservatively with oral anti-inflammatory medication, localized injections, and activity modification.

• Patellar tendinitis (jumper's knee)

  

  Is most common in athletes who participate in sports such as basketball and volleyball and is associated with pain and tenderness near the inferior border of the patella (worse in extension than flexion). Treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy (strengthening and ultrasound). Surgery involving excision of necrotic tendon fibers is rarely indicated.

• Anterior fat pad syndrome (Hoffa's disease)

  

  Trauma to the anterior fat pad can lead to fibrous changes and pinching of the fat pad, especially in patients with genu recurvatum. Activity modification, ice, knee padding, and injection can be helpful. Arthroscopic excision is occasionally beneficial.

• Lateral patellar facet compression syndrome

  

  This problem is associated with a tight lateral retinaculum and excessive lateral tilt without excessive patellar mobility. Treatment includes activity modification, NSAIDs, and VMO strengthening. Arthroscopy and lateral release are occasionally required but indicated only in the setting of objective evidence of lateral tilt that has not responded to extensive nonoperative management.

• Patellar instability

  

  Recurrent subluxation/dislocation of the patella can be characterized by lateral displacement of the patella, a shallow intercondylar sulcus, or patellar incongruence. When it is associated with femoral anteversion and genu valgum, the symptoms can be exacerbated, especially in adolescents (“miserable malalignment syndrome”). Extensive rehabilitation is often curative. Females with previous instability are at increased risk. Several radiographic findings are somewhat helpful in diagnosing patellar malalignment. Surgical procedures include proximal and/or distal realignment. Acute, first-time patella dislocations may be best treated with arthroscopic evaluation/débridement and acute repair of the medial patellofemoral ligament (usually at the medial epicondyle). This is still somewhat controversial. These patients should be evaluated with radiographs for fractures and loose bodies. If a loose body is suspected, an MRI can help make the diagnosis. The articular cartilage of the medial patellar facet is the most common donor site.

  

  Abnormalities of patellar height Patella alta (high-riding patella) and patella baja (low-riding patella) are determined based on various measurements made on lateral radiographs of the knee (Patella alta can be associated with patellar instability because the patella may not articulate with the sulcus, which normally constrains the patella. Patella baja is often the result of fat pad and tendon fibrosis and may require proximal transfer of the tubercle in refractory cases.

• Knee Osteoarthritis

  While age is a major risk factor for osteoarthritis of the knee, young people can get it too. For some individuals, it may be hereditary. For others, osteoarthritis of the knee can result from injury or infection or even from being overweight.

  

  What Is Osteoarthritis?

  Osteoarthritis, commonly known as wear and tear arthritis, is a condition in which the natural cushioning between joints -- cartilage -- wears away. When this happens, the bones of the joints rub more closely against one another with less of the shock-absorbing benefits of cartilage. The rubbing results in pain, swelling, stiffness, decreased ability to move.

  What Causes Knee Osteoarthritis?

  ΗThe most common cause of osteoarthritis of the knee is age. Almost everyone will eventually develop some degree of osteoarthritis. However, several factors increase the risk of developing significant arthritis at an earlier age.

  • Age. The ability of cartilage to heal decreases as a person gets older.
  • Weight. Weight increases pressure on all the joints, especially the knees. Every pound of weight you gain adds 3 to 4 pounds of extra weight on your knees.
  • Heredity.
  • Gender. Women who are 55 and older are more likely than men to develop osteoarthritis of the knee.
  • Repetitive stress injuries. These are usually a result of the type of job a person has. People with certain occupations that include a lot of activity that can stress the joint, such as kneeling, squatting, or lifting heavy weights (55 pounds or more), are more likely to develop osteoarthritis of the knee because of the constant pressure on the joint.
  • Athletics. Athletes involved in soccer, tennis, or long-distance running may be at higher risk for developing osteoarthritis of the knee. That means athletes should take precautions to avoid injury. However, it's important to note that regular moderate exercise strengthens joints and can decrease the risk of osteoarthritis. In fact, weak muscles around the knee can lead to osteoarthritis.
  • Other illnesses. People with rheumatoid arthritis, the second most common type of arthritis, are also more likely to develop osteoarthritis. People with certain metabolic disorders, such as iron overload or excess growth hormone, also run a higher risk of osteoarthritis.

  
  

  
  

  What Are the Symptoms of Knee Osteoarthritis?

  Symptoms of osteoarthritis of the knee may include:

  • pain that increases when you are active, but gets a little better with rest
  • swelling
  • feeling of warmth in the joint
  • stiffness in the knee, especially in the morning or when you have been sitting for a while
  • decrease in mobility of the knee, making it difficult to get in and out of chairs or cars, use the stairs, or walk
  • creaking, crackly sound that is heard when the knee moves

  
  

  How Is Osteoarthritis of the Knee Diagnosed?

  The diagnosis of knee osteoarthritis will begin with a physical exam by your doctor. Your doctor will also take your medical history and note any symptoms. Make sure to note what makes the pain worse or better to help your doctor determine if osteoarthritis, or something else, maybe causing your pain. Also find out if anyone else in your family has arthritis. Your doctor may order additional testing including: X-rays, which can show bone and cartilage damage as well as the presence of bone spurs, and magnetic resonance imaging (MRI) scans (MRI scans may be ordered when X-rays do not give a clear reason for joint pain or when the X-rays suggest that other types of joint tissue could be damaged). Doctors may use blood tests to rule out other conditions that could be causing the pain, such as rheumatoid arthritis, a different type of arthritis caused by a disorder in the immune system.

  
  

  How Is Osteoarthritis of the Knee Treated?

  The primary goals of treating osteoarthritis of the knee are to relieve the pain and return mobility. The treatment plan will typically include a combination of the following:

  

  Weight loss. Losing even a small amount of weight, if needed, can significantly decrease knee pain from osteoarthritis.

  Exercise. Strengthening the muscles around the knee makes the joint more stable and decreases pain. Stretching exercises help keep the knee joint mobile and flexible.

  Pain relievers and anti-inflammatory drugs. This includes over-the-counter choices such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen sodium (Aleve). Don't take over-the-counter medications for more than 10 days without checking with your doctor. Taking them for longer increases the chance of side effects. If over-the-counter medications don't provide relief your doctor may give you a prescription of an anti-inflammatory drug or other medication to help ease the pain.

  Injections of corticosteroids or hyaluronic acid into the knee Steroids are powerful anti-inflammatory drugs. Hyaluronic acid is normally present in joints as a type of lubricating fluid.

  Physical and occupational therapy If you are having trouble with daily activities, physical or occupational therapy can help. Physical therapists teach you ways to strengthen muscles and increase flexibility in your joint. Occupational therapists teach you ways to perform regular daily activities such as housework with less pain.

  

  

  Surgery. When other treatments don't work surgery is a good option.

  If your doctor wants to treat the osteoarthritis of the knee with surgery the options are arthroscopy, osteotomy and arthroplasty.

  Arthroscopy uses a small telescope (arthroscope) and other small instruments. The surgery is performed through small incisions. The surgeon uses the arthroscope to see into the joint space. Once there, the surgeon can remove damaged cartilage or loose particles, clean the bone surface, and repair other types of tissue if those damages are discovered. The procedure is often used on younger patients (55 years old and younger) in order to delay more serious surgery.

  An osteotomy is a procedure that aims to make the knee alignment better by changing the shape of the bones. This type of surgery may be recommended if you have damage primarily in one area of the knee. It also might be recommended if you have broken your knee and it has not healed well. An osteotomy is not permanent and further surgery may be necessary later on.

  

  Joint replacement surgery or arthroplasty, is a surgical procedure in which joints are replaced with artificial parts made from metal or plastic. The replacement could involve one side of the knee or the entire knee. Joint replacement surgery is usually reserved for people over age 50 with severe osteoarthritis. The surgery may need to be repeated later if the joint wears out again after several years but with today's modern advancements most new joints will last over 20 years. The surgery has risks, but the results are generally very good.