Orthopedics in Montana | Knee pain
Knee pain? You’re not alone.
If you have knee pain, rest assured you are far from alone. Each year 6 million Americans head to the doctor for knee pain issues. This translates into 2.5 percent of the U.S. population sitting in doctors’ offices for relief of knee pain. Even more people try to self-diagnose and treat themselves with pain pills, anti-inflammatories and home remedies.
A U.S. study found that 18% of men aged 60 years and older reported knee pain, and that percent goes up as we age. Women experience knee pain even more than men.
But it’s important to remember that pain symptoms are typically a warning mechanism to our brains that something is wrong that needs to be addressed. Simply masking pain symptoms with drugs, or even just anti-inflammatories, can have long term impact on internal organs and one’s lifespan. Masking symptoms can also encourage the person to further overuse and injure their knee joint.
Consequently, it’s important to address knee pain symptoms early on to determine if there are non-surgical or surgical treatment options that can relieve pain symptoms without drugs or pills.
Step #1 is understanding the complex knee joint and how it works so you can better relate to treatment options that may be recommended by a knee specialist.
The knee is a complex mechanism which absorbs shock as we jump, and is extremely flexible, permitting a change in direction while running at high speeds. The knee joint is composed of ligaments, which provide support, and muscles for strength.
The healthy young knee joint is a lubricated mechanism, which functions reliably unless twisted, bruised or broken. For example, of all the areas treated by orthopedic surgeons, the knee is the most commonly injured joint, representing 26 percent of orthopedic visits, followed by the spine (17 percent) and hip (15 percent).
Some cases of knee pain are caused by trauma, such as a fall or a car crash. According to the American Academy of Orthopedic Surgeons (AAOS), over a lifetime, each American will suffer two fractures. Many of which will occur at the knee.
However, trauma or fracture represents a small percentage of knee problems. The majority result from repetitive wear and tear. In these cases, the cartilage or joint surfaces are slowly damaged over time. One type of chronic injury is arthritis, which might be thought of as a “rusting” of the knee joint. It causes pain and robs the knee of flexibility. Indeed, half of all knee pain may be tied in some way to arthritis.
Cartilage is a natural lubricant tissue that helps your joints move smoothly. When cartilage begins to break down with age or injury, you experience bone-on-bone friction which causes symptoms like inflammation, knee pain, stiffness or inability to move the joint without extreme pain.
Many of the causes of osteoarthritis are out of a person’s control, e.g. heredity or accidental injury. But you can make lifestyle changes to reduce your risk of arthritis, ligament strain and a painful knee.
What causes knee pain?
Any mechanical device can and will fail if placed under excessive strain. That could be a fall down stairs or banging the knee into a dashboard during a car accident. But again, accidents and falls represent a relatively small percent of knee pain cases.
The vast majority of knee pain issues develop over a period of years. In these cases, the knee becomes like a creaky or unstable hinge that doesn’t get better, either because components in the knee are weak or unstable, or the lubrication in the joint and bone surface have been eroded over time.
That’s the bad news. The good news is that of all knees that hobble into doctors’ offices every year, only 20 percent will need surgery. Of those that don’t need surgery, many can get better with time and new non-surgical treatment options.
In some cases anti-inflammatories and specialized exercises increase range of motion, flexibility, strength, and resistance to future knee strain are usually prescribed. Sometimes knee braces are also used.
How a person causes their own knee pain
In 2020 Americans breeched a new undesirable record. The U.S. Government’s Centers for Disease Control (CDC) estimates that 42% of Americans are now classified as “obese” according to weight tables. This is a dramatic increase from 20 years ago in year 2000 when only 30% of Americans were “obese.”
A man 5’9” weighing more than 200 pounds is technically “obese” compared to normal weight of up to 168. (You can measure your own weight at: https://www.calculator.net/overweight-calculator.htm ) Sadly, the American culture has become more sedentary than other cultures and more prone to eat high carb foods with larger portions. Fact: there are more obese adults living in America today – 78 million – than in any other country in the world.
At the same time we are getting heavier, more of us could be classified as the “weekend warrior”. These are the middle-aged woman or man who works a desk job during the week, and then on Saturday morning jumps into a full-blown weekend of physical activity. Not surprisingly, by Sunday evening, these warriors are often trying to mask the damage done to their knees with pills and ice packs.
Accordingly, orthopedic surgeons are discovering new ways — NON-surgical as well as surgical — to repair or replace the worn out knee.
Your current choices will affect your retirement
When you are 80 years old, will you be frail and brittle and wheelchair-bound? A lot depends on the choices you make from age 30 onward. The more you lose control of your weight and place more and more strain on your knees, the more likely you will damage your knee joint.
This in turn limits your ability to be active and to keep weight off. This is the beginning of the vicious disability cycle: The less active you are, the more weight you gain, which makes movement even more uncomfortable.
When golfing, riding in a cart is certainly easier than walking and carrying clubs on your back or pushing a cart. But those are the choices that can dictate your level of activity years later in retirement.
While there are certainly exceptions, and skinny people can certainly have arthritic knees, the reality is that most knee replacements are done not on skinny people, but those who are obese, or worse, morbidly obese.
The knee joint is simply not designed to carry that much weight and it’s just a matter of time before the joint is destroyed. While orthopedic surgeons will recommend a knee replacement patient to lose weight before surgery, most don’t, and they then wear out the artificial knee prematurely which in turn requires more complex revision surgery for a second artificial knee joint surgery.
Risk of knee problems
Aging baby boomers might also be of higher than normal risk, where poor conditioning matched with overuse, joint strain, and joint degeneration can combine with the natural onset of arthritis.
Women may not play much football, but they have plenty of knee problems. The American Journal of Sports Medicine reports that women injure their anterior cruciate ligament (ACL) four to eight times more often than men. Why? It’s thought that the menstrual cycle and estrogen levels may increase risk of knee injury. Other theories relate to high heel shoes and tripping.
Differences in pelvic structure between men and women may also be an issue. A woman’s pelvis, which is wider, creates a sharper angle between the calf and thigh, increasing pressure on the knee. In addition, a woman’s kneecap rides in a shallower groove, making the mechanism less stable. Another factor discovered by researchers at the University of Michigan is that women don’t use their quadriceps and hamstring muscles in the same way as men. Men are equally reliant on the quadriceps and hamstrings, whereas women tend to rely more on their quadriceps during sports activities.
While overweight women are most often the ones to need a knee replacement for worn-out knees in their sixties, simple knee injuries occur more frequently in men. In fact, knee pain is one of the top ten reasons men see a doctor. Overall, knee pain occurs more in men because they participate more in sports, and they find knee pain stops them in their tracks.
The Most Common Knee Problems
Knee pain can start with issues from overuse or strain. Most knee problems come from the following areas:
- Pain from the kneecap. Those with kneecap pain typically notice an increase in pain when going up or down stairs, when running downhill, or even while sitting.
- Torn meniscus. The bottom of the femur (thigh bone) and the top of the tibia (shin bone) that come together in the knee joint, are covered by cartilage which enables the bones to glide against each other with a minimal amount of friction. But if the knee is twisted, or banged, the cartilage can become damaged or loosened out of its normal position. A common symptom of this type of injury is that the knee may “catch” or grind at a certain point as it moves through its normal range of motion.
- Ligament problems. If you think of the knee as a hinge between the upper leg and lower leg, it is the awesome work of the supporting muscles, ligaments, and tendons to make sure that it is supported and working properly—often while the leg is twisting, turning and absorbing shock from jumping. There are four key ligaments that can be injured in the knee:
- Anterior cruciate ligament (ACL) is often the victim of non-contact injury, where the knee is twisted while the foot is planted. You may feel a pop, and the whole knee may give way.
- Posterior cruciate ligament (PCL) injuries can be caused by a blow to the knee, or when the knee is forced backward.
- Medial collateral ligament (MCL) can be injured from a blow to the outside area of the knee.
- Lateral collateral ligament (LCL) injury can be caused by a blow to the inside area of the knee.
- Tendon problems. Sometimes the tendons that attach the kneecap (patella) to the shinbone (tibia) can become inflamed.
- Arthritis. Aside from pain from ligament and tendon problems, osteoarthritis accounts for a large percent of knee pain symptoms and is the most difficult to treat. The incidence of an arthritic joint goes up with age.
- Osgood-Schlatter disorder. This is an overuse problem where the quadriceps tendon causes inflammation in the knee. This disorder is more common in children and teens.
Diagnosing the Cause of Knee Pain
Diagnosing knee problems can be tricky, partly because of the subjective nature of pain. Orthopedic surgeons during a physician exam will look for outward signs of injury to the knee, such as sudden swelling and deformity.
They will also interview the patient to determine if the pain symptoms came on suddenly (e.g. traumatic injury or fall) or if the symptoms worsened gradually over time. Other tests involve manipulating the knee joint to determine if there is too much play in the joint, or if specific movements worsen pain symptoms.
X-rays are typically taken of the knee from several angles, which can reveal a fracture and signs of arthritis. But because X-rays show only bone, and not soft tissue, an MRI may be needed to reveal ligament problems, meniscus tears and other soft tissue issues.
In many cases, the orthopedic surgeon is playing detective to determine what is causing your knee pain. The goal of a visit to the knee doctor is to determine if the knee pain is caused by ligament strain or joint problems like bone-on-bone abrasion from a cartilage tear.
The orthopedic specialist exam typically involves the following steps:
- The medical history: The medical history may include your family as well as your personal story. The reason a doctor asks questions about your siblings or parents is to determine whether inherited conditions, such as arthritis, exist within the family. If so, you may be prone to the same problem. You will be asked questions about how and when you first noticed pain in your knee. This part of the exam may seem tedious, but your answers are crucial. For example, if you reveal that your knee pain occurred precisely when you came down from a rebound and you heard a loud pop . . . the doctor will have a high degree of confidence that you probably tore your anterior cruciate ligament.
- The hands-on knee exam: Each maneuver that the knee specialist performs reveals something only to the doctor who has done thousands of such exams. Some of these knee joint movements may be painful. Some movements of the joint can imply a meniscus tear while other movements can confirm a ligament tear.
- X-rays and/or MRI diagnostic tests: Unlike X-rays that only show bones clearly, magnetic resonance imaging (MRI) scans reveal the soft tissues, such as the meniscus and tendons. They go beyond the X-ray in what they demonstrate but, because of cost, are used sparingly.
Unlike X-rays, MRI uses the power of magnetic fields to draw images of the internal structures of the body. MRI is a relatively safe test, and in fact, safer than most tests which use radiation. However, a person undergoing an MRI must remain very still for some time while the computer is creating the image.
- Diagnostic treatments: In a sense, “diagnostic treatments” may sound like contradictory terms. But there are certain “treatments” that a doctor may try. If they succeed, they may confirm a doctor’s suspicions about the cause of your pain. This can include use of oral medications to reduce inflammation, draining fluid, or injections into the knee joint.
- Arthroscopic examination: One tool, both diagnostic and surgical, which has dramatically improved knee care is the arthroscope. Years ago, if a surgeon needed to inspect the knee he or she would have to make a long incision to enter and visually explore the site. Unfortunately, this incision damaged soft tissues and slowed rehabilitation. The arthroscope changed that. Instead of a three-inch incision, knee surgery is now done through small puncture incisions about one to two mm in length.
What things could cause knee pain?
Picture a tall radio tower, that has four main cables that anchor it to the ground. You knee is similar. It has four main “ligaments” that hold it in place: ACL, PCL, MCL, and LCL. Unless you are a football player who is tackled roughly around the knees, which can tear any of these four, 90% of the time the ACL — anterior cruciate ligament — is the single ligament that most often tears. It’s the one that weaves from the front of the shin, through the kneecap, and attaches to the thighbone.
If you are playing tennis, for example, and you stretch to reach a ball, and hear a pop, chances are you tore your ACL. The sensation is then followed by a feeling of instability, wobbliness and pain, and sometimes nausea. You typically have no doubt that something terrible has gone wrong and you stop playing. You officially have had a bad day.
If the ACL is partially torn, non-surgical treatment, customized therapy and rest can in some cases heal the tear.
A complete tear however needs surgery to repair it. During surgery, the knee surgeon harvests a tendon from either your hamstring or your patellar tendon, and weaves a new ACL into place and anchors it on the femur and tibia. The good news is that ACL surgery is somewhat common and done in day surgery. With some rehab, and some customized exercises, you’ll be back in action within a couple months.
Pain from Meniscus Tears
To keep the top of the shin (tibia) from rubbing on the bottom of the thighbone (femur), Mother Nature provided us meniscus tissue that acts as a shock absorber pad and lubricant between the bones. But abuse and excessive wear and tear can tear this protective tissue. That again can require a minimally invasive surgery to correct.
Meniscal tears can occur at any age. In the younger age group, they are usually sports-related and result from violent trauma. Contact sports like football account for a large number of tears. The type of movement that most often causes meniscal injury is one in which the foot is firmly planted on the ground while the knee is twisted. Shoes with cleats often contribute to this type of injury by anchoring the lower leg into the ground and preventing it from moving with the knee.
Along with other sports, which call for cutting, pivoting, or decelerating, basketball and tennis can also lead to meniscal tears. Traumatic meniscal injuries may also be accompanied by the tearing of a ligament, such as the anterior cruciate ligament.
For those forty and older, meniscal tears are less likely to be due to sports injury. With age the meniscus weakens and becomes more fragile. Individuals in this age group can tear a meniscus by performing simple activities, such as squatting.
Meniscal tears come in a variety of sizes and shapes. Often torn fragments lodge between the tibia and femur causing mechanical obstruction and pain. When this happens, the knee is said to “lock up” which means that the patient is unable to extend the knee fully outward. Fluid accumulates as the result of an inflammatory process, and walking becomes difficult.
Menisci lack blood supply except at their outer rim. Once torn, they heal poorly, if at all, and function is lost. Symptoms often vary in intensity depending upon the level of one’s activity.
Arthritis and a degenerative joint surface:
Just like the chrome on a trailer hitch can get pitted with age, so can the joint surfaces become pitted and damaged in the knee joint. When this happens, the friction can be excruciatingly painful. Typically, when this becomes severe, joint replacement is the last option. But this is a major surgery, and because of the lifespan of an artificial joint is only about 15 to 20 years, this option is held out for those who can’t respond to other treatment options.
Arthritis literally means “fire in the joints.” People who suffer from the disease can attest to the accuracy of this description. Statistics from the Arthritis Foundation estimate that one in seven Americans is affected. Many are elderly, but arthritis is not a disease which discriminates according to age. It affects every strata of the population, young and old, women more so than men.
Osteoarthritis is the most common form of arthritis and makes a particularly strong showing in the middle aged. The term osteoarthritis is synonymous with “wear and tear” arthritis, or degenerative joint disease. The terms refers to the actual wear and erosion of the articular cartilage, which continues until finally no cartilage remains and bone rubs against bone.
Symptoms include pain, stiffness, and swelling. At first they may be intermittent, but as deterioration progresses, they occur with greater regularity and intensity. When the entire thickness of the articular cartilage has worn away and bone rubs harshly against bone, pain increases dramatically and may be incapacitating.
The tendency to develop osteoarthritis is often inherited. Other factors include injury or repetitive stress from excessive use. Those who are bowlegged or have knock-knees are at increased risk. The last, but perhaps the most common factor is excess body weight.
Pre-patellar bursitis involves the bursae sacs on the front of the kneecap. Bursae are fluid-filled sacs that are found throughout the body in areas where the skin must glide over bones. They help to minimize friction. One of the jobs of bursae in the knee is to enable the kneecap to move about freely underneath the skin. When pressure is placed on the knee from either a direct blow or from kneeling repetitively, problems can arise.
For example, this problem in the past was also called “housemaid’s knees,” because often those women who scrubbed floors on hands and knees suffered from this knee problem. Similarly, brick masons, carpet layers, and electricians are also afflicted. At times the condition occurs when the bursal sac becomes infected, often for reasons which are not readily apparent. Regardless of the cause of inflammation, pain and swelling can be present in front of the kneecap.
A rubbery, bulging mass in front of the kneecap that may feel sore and tender, can develop. Except in the case of infection, treatment consists of relieving pressure. Kneeling is avoided or only performed with knee pads. The good news is that only in persistent cases is surgery necessary.
Rheumatoid arthritis is a second form of arthritis. Instead of a process of wear and tear, it begins with inflammation, which eventually leads to destruction of one or many joints. Its cause is unknown. It affects all age groups, but most often attacks women in middle age. It may attack a single joint, but more commonly simultaneously attacks many joints within the body.
The disease manifests itself in many ways. In some cases the symptoms involve one or two joints, are transient, and vanish without causing permanent damage. More commonly, many joints are affected, rapid deterioration occurs, and joints become grossly deformed. Both large and small joints may be damaged. The knee is often affected along with other large joints such as the hips.
“Chondro” indicates cartilage, while “malacia” means softening. Consequently, chondromalacia together means softening of the cartilage. But chondromalacia really refers specifically to softening of the under surface of the patella, or kneecap. It is a degenerative condition which occurs as the result of chronic wear of the kneecap against the femur. The articular cartilage gradually softens and then frays.
At other times, a traumatic blow around the knee is the cause of chondromalacia. Symptoms of chondromalacia include pain in front of the knee, especially when walking up and downhill, stiffness after prolonged sitting, and a grinding or clicking sensation as the knee is flexed and extended.
Symptoms typically vary according to the level of activity and may limit one’s participation in sports. As problems progress, patients may also lose speed and strength, and notice swelling. The condition is increasingly common in middle age. For reasons unknown, it occurs most in women, and may begin as early as the teenage years.
It has even been suggested that some people may be predisposed to chondromalacia. Women suffer most from this condition possibly due to muscle weakness in the extension mechanism and anatomical factors, which cause the kneecap to slip out of alignment. Symptoms may be especially severe with repetitive activities like running or aerobics, although cyclists are not immune to the problem.
Which knee pain symptoms are an emergency?
Does your knee crack and click as your leg goes through a range of movements? If so, you may be worried that it is broken. Sound alone is a bad indicator of trouble. Provided there is no accompanying swelling or pain, clicking sounds are typically harmless.
Pain can also be misleading. Sometimes a knee with a serious problem has little or no associated pain, while a relatively healthy knee may display troubling signals following something as routine as a change in weather.
Generally speaking, the intensity of pain and how rapidly it comes on, are good indicators of the severity of a knee problem, and the need to seek care. Extreme knee pain after falling down, or hearing a pop from your knee area, could mean a fracture or torn anterior cruciate ligament.
Fractures are the most typical injury to require a trip to the emergency room. Whether the result of sports or a vehicular accident, these typically require immediate care. A fracture may extend horizontally across the bone or spiral down its length. At times the bone breaks into many parts; these are labeled comminuted fractures.
Often the fracture fragments remain in normal alignment with each other. These are called non-displaced fractures, meaning that the bone is broken but remains in its proper position. On the other hand, there are displaced fractures in which the bony fragments have broken apart and fall out of alignment, often distorting the shape of the leg.
These fractures have to be “reduced” and often are immobilized with a cast. At times, because of the number of fracture fragments or tenuousness of the reduction, fractures require surgery. The orthopedic surgeon makes an incision, takes hold of the bony fragments and manipulates them back into position, typically securing them with a rod or plate and screws.
Finally there are “open” fractures. Not only is the bone fractured, but the overlying skin is cut. This opening in the skin lets in dirt and bacteria. Without prompt treatment, infection may occur.
The two most disastrous types of fractures are spiral fractures, where extreme rotational twisting has created a break line that goes up and around the bone like a spiral staircase, and comminuted fractures. Comminuted fractures are the worst possible kind of fracture. They often happen when the knee is slammed into a dashboard in a car accident, causing the bone to shatter into many pieces. In some cases, the leg might be saved in complex surgery where a metal rod called an intramedullary nail is used to reconstruct the leg and retain its same length.
For simple fractures, the doctor may perform “closed reduction,” in which the bone is manipulated back into proper placement without an incision through the skin, and then a cast or brace is used to immobilize the leg while it heals. For nondisplaced fractures, no reduction may be needed before the leg is immobilized.
Complex fractures may require “open reduction,” in which an orthopedic surgeon makes an incision in the leg, and during surgery manually repositions the bones into proper position so they can heal correctly.
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