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  • ACL Reconstruction

    ACL Reconstruction

    Definition:
    ACL reconstruction, sometimes known as anterior cruciate ligament repair, is surgery to reconstruct a torn ligament in the knee joint.

    The anterior cruciate ligament (ACL) is a tough cord of fibrous connective tissue that passes diagonally through the knee joint, connecting the femur (thigh bone) to the tibia (shin bone). Another ligament, the posterior cruciate ligament, passes through the joint in the opposite direction. Together they form an ‘X’ inside the joint. The purpose of the ACL, which is strong but not very flexible, is to keep the joint stable by limiting the rotation and forward movement of the tibia underneath the femur.

    If the ACL is torn it must be surgically reconstructed to restore stability to the joint. The ligament cannot be stitched successfully as the tissue will not knit back together, so tissue from another tendon is used to replace the damaged ACL. This can be taken from your own leg or from a donor. Surgeons have varying views on the best tissue to use, as each has advantages and disadvantages, but it is generally felt that using a tendon from the patella, the kneecap, has the best outcome. Your surgeon will discuss this with you and ask questions about your lifestyle and type of work, as this information will help in making the decision.

    Without surgery, ongoing and secondary problems with the knee are likely. If the joint remains unstable certain activities will be prohibited, such as sports. An unstable knee might prevent normal work being carried out, and continuing pain is possible. Uneven wear and tear on the joint increases the chances of developing arthritis.

    The purpose of reconstructive surgery is to restore both the stability of the knee and the proper function of the ACL.

    Considerations prior to surgery:
    Deciding whether or not to have ACL reconstruction depends on various factors:
    • The extent of the injury.
    • Whether other tissues are also damaged and need repair.
    • Your activity level: If your work and leisure activities involve a lot of twisting and turning, or heavy manual work, all of which strain the knee, surgery might be recommended.
    • Age: Early surgery on young people runs the risk of damaging the growth plates, which might lead to bone growth problems. Growth plates are areas of cartilage that turn into bone with age. Your surgeon can choose to either modify the surgical procedure, or delay surgery until the bone is more mature.
    Prognosis:
    ACL reconstruction is usually very successful, with up to 95% of patients recovering full stability and range of motion of the knee.

    Having some physiotherapy prior to surgery so that the knee is not stiff and swollen tends to produce a better surgical outcome.

    Procedure:
    Surgery is normally performed using a procedure known as knee arthroscopy. This can usually be done on an outpatient basis.

    You are given anesthesia so that you will be asleep during the surgery. The new ligament, the tissue graft, is prepared and kept ready. A very small camera is inserted into your knee joint through a small incision. This camera is connected to a monitor so the surgeon can clearly view the entire joint and its surrounding tissues. Some more small incisions are made around the knee to enable other instruments to be used.

    The torn ligament is then removed. At the point of original attachment of the ACL, narrow tunnels are drilled into the femur and the tibia. The new ligament is then pulled through the tunnels and attached to the bones with special screws. As healing progresses the tunnels fill with new bone, securely anchoring the ligament in place.

    When you wake up you may find that your knee is in a brace to keep it temporarily immobile.

    Rehabilitation:
    Careful and thorough rehabilitation is crucial to the success of the surgery. You will be placed in the care of a physiotherapist who will monitor your progress and supervise exercises, but it is extremely important that you follow the regime exactly. Doing too much or too little will jeopardize your chances of a full recovery. You must expect to spend many months healing, rebuilding strength and regaining use of the joint.

    Physiotherapy begins almost immediately after surgery, with you being encouraged to walk with the aid of crutches, to begin lifting your leg unaided, and to practice tightening the quadriceps muscles, which run from the hip to the knee. Your knee will be iced regularly to reduce swelling. You will then follow a graduated program of exercises designed to restore muscle activity and strength, which will protect the knee, and to regain range of motion in the joint.

    A return to sports can be considered when:
    • There is no longer any pain or swelling
    • Full range of motion has been regained
    • Muscle strength has been restored
    Exercises:
    These will help your recovery, but only do them with the permission of your physiotherapist.
    Ankle press:
    Point and then flex the toes 25-50 times. Repeat several times a day.
    Ankle circles:
    Rotate the feet at the ankle, forming circles with the toes. Do 10 circles in one direction, then 10 circles in the opposite direction. Repeat several times a day.
    Knee flex:
    Lying on your back with your legs stretched out and together, slide the heel of the injured leg along the bed towards your buttock. Stop when you feel a gentle stretch. Hold for 10 seconds then slowly return the leg to straight. Repeat 5-10 times for 1 set. Build up to 3 sets.
    Quad set:
    Lying on your back with legs stretched out and together, press the back of the knee down onto the bed. Hold for 5-10 seconds then relax. Repeat 5-10 times for 1 set. Build up to 3 sets, depending on the level of comfort.
    Leg raise:
    Lying on your back and keeping the injured leg straight, raise it about 6 inches off the bed. Hold 5-10 seconds then slowly lower. Repeat 5-10 times, working up to 20 times for 1 set. Build up to 3 sets.

    Braces and crutches:
    You are likely to wear a brace for up to four weeks, although this will be removed when you are exercising. You may wear a passive motion device at night, which holds the knee and very slowly moves it through its full range of motion. This decreases the chance of your knee stiffening up overnight. You will also probably use crutches to begin with, to avoid putting too much weight on the knee.

    Which brace you might wear will depend on your surgeon’s preference. Some recommend an adjustable rehabilitation brace, which can be locked to prevent any movement of the knee at all, or adjusted to allow a certain range of movement. Later, if returning to sports, a functional brace might be worn. These are not absolutely necessary, but athletes may feel more comfortable having a bit of extra support.
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  • ACL Sprain

    ACL Sprain


    An ACL sprain is a stretching or tearing injury to the anterior cruciate ligament in the knee joint.

    Three bones make up the knee joint: the femur (thigh bone), the tibia (shin bone), and the patella, which is the kneecap. These bones are kept in position by ligaments, strong cords of fibrous connective tissue that attach bone to bone. Two of the four main ligaments are the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL), which together form an ‘X’ shape inside the knee joint. The ACL is attached to the bottom of the femur at the back of the knee. It then passes through the joint diagonally and is attached to the top of the tibia at the front of the knee. Its purpose is to keep the joint stable by limiting the rotation and forward movement of the tibia underneath the femur. It is consequently very strong but not very flexible.

    ACL sprains are graded according to the severity of the injury. A Grade I sprain causes pain, but there are only microscopic tears to the ligament and the joint remains stable. A Grade II injury means that the ligament has been partially torn, or stretched to the point of looseness in the joint. Grade III sprains are more severe; the ligament has been completely torn and the knee joint is unstable.

    Causes:
    These injuries usually happen during sports. Only 20 per cent of such injuries are as a result of direct impact with another person or object; most happen without outside involvement. Examples of situations that might cause an ACL sprain are:
    • Sudden pivoting, or change of direction.
    • Sudden transference of body weight from one leg to another, as in landing from a jump.
    • A sudden stop can force the bones of the knee out of alignment.
    • Hyperextension of the knee (straightening of the leg beyond the normal range of motion).
    Symptoms:
    Along with the pain associated with an ACL sprain, there is often a loud ‘pop’ heard at the moment of injury. Depending on the severity of the sprain, there may be rapid and extensive swelling around the knee, caused by the rupture of a blood vessel that passes through the joint. There might be bruising with the swelling.

    One of the strongest indicators of an ACL sprain is the sensation that the knee might ‘give out’ at any time. An old, unrepaired sprain might cause the sufferer to feel that the knee might give way during strenuous activity, particularly during twisting movements.

    Diagnosis:
    It is recommended that you seek medical assistance quickly, before any swelling makes diagnosis more difficult.

    Your doctor will take a medical history from you and ask questions relating to:
    • The movement that caused the injury
    • Any popping sound heard at the time
    • The rapidity of the onset of swelling
    • The severity of the pain
    • Any feeling of instability in the knee joint
    A Lachman test might be performed to assess the amount of movement in the joint and the rigidity of the ligament. This test involves gentle pulling on the shin while the thigh is kept stable.

    An x-ray might be needed to view the structure of the knee joint, and occasionally an MRI scan, which shows the soft tissues as well as bones, might be ordered.

    Treatment:
    The appropriate treatment for an ACL sprain depends on the severity of the injury. For milder sprains, rest and rehabilitation will be sufficient, but Grade III sprains will require surgery. Unfortunately, anterior cruciate ligaments cannot be sewn together so, if surgery is necessary, a ligament or tendon from another part of the leg will be removed and then attached to the femur and tibia to support the knee joint.

    Self-help options if your injury is mild:
    • Limit your activity while the injury is in its acute phase.
    • Apply ice, crushed in a bag and covered with a towel, to the knee several times a day for 15 minutes at a time.
    • Wrap the knee with a compression bandage or wear a brace to help stabilize the joint.
    • Use crutches to avoid placing weight on the injured knee.
    • Elevate the knee above the level of the heart, when possible.
    • Take over the counter pain medication such as acetaminophen (Tylenol) or anti-inflammatories such as ibuprofen (Advil), naproxen (Aleve) or aspirin.
    Your doctor or physiotherapist will develop an exercise routine to rehabilitate the knee when sufficient healing has taken place. These will help to reduce any stiffness, increase range of motion of the knee joint and build strength in the leg muscles. Strong leg muscles, particularly the quadriceps, which run from the hip to the knee, are important for knee joint stability.

    Rehabilitation exercises:
    Be guided by your physiotherapist before beginning any exercise regime and gradually build up the number of repetitions. Do not continue if any exercises cause pain in the knee joint. Always remember to warm up properly before starting. A heat pad on the knee for 15 minutes before exercise will help reduce stiffness.
    Quads:
    Sitting down with legs stretched out, contract the thigh muscles (quads). Hold the stretch for 10 seconds. Release. Repeat 10 times for 1 set. Do 3 sets.
    Prone hamstring curls:
    Lying on the stomach, gently bend the injured knee so that the foot moves towards the buttocks. Hold for 5-10 seconds then slowly lower. Repeat 10 times for 1 set. Do 3 sets.
    Knee bend:
    Standing in front of a chair, with the feet shoulder width apart, slowly bend the knees until your buttocks reach halfway to the chair. If you feel any pain before you reach that point, stop there. Slowly straighten the legs to a standing position. Repeat 10 times for 1 set. Do 3 sets.
    Hip flexion:
    Lying down on the back with the injured leg extended and the other bent at the knee, lift the straight leg until the heel is about 5 inches off the ground. Hold 5-10 seconds then lower. Repeat 10 times for 1 set. Switch legs and repeat. Do 3 sets.
    Hip extension:
    Lying on the stomach with legs straight, tighten the quads and lift 1 leg as high as you can. Hold 5-10 seconds then slowly lower. Repeat 10 times for 1 set. Do 3 sets for each leg.

    What to look for in a brace for an ACL sprain:
    The purpose of wearing a knee brace is to protect the knee joint if you slip or fall, to allow the knee to rest while healing is taking place, and to keep the knee extended to avoid stretching the ligament further.

    Your doctor will probably suggest a particular brace for you. In order to gain the maximum benefit, get the brace properly fitted and ensure that it feels comfortably supportive and secure.

    Prevention:
    ACL sprains are caused by accident so they are difficult to prevent, but taking care to always warm up and stretch properly before exercise may help to avoid injury. Athletes are particularly vulnerable to ACL sprains, so if your sport requires equipment, make sure it fits properly.
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  • Baker's Cyst

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    Baker's Cyst

    Definition:
    A Baker’s cyst is an accumulation of synovial fluid behind the knee. It is also known as a popliteal cyst because it appears in the popliteal area at the back of the knee. It is a fairly common, benign condition; it is not a tumor and will not spread into other areas of the body.

    Synovial fluid is a slippery substance that lubricates and nourishes the articulating surfaces of the knee joint. It moves between pockets in the joint known as bursae, and is normally contained within the tough tissues of the joint capsule. If the joint becomes inflamed, one response of the body is to produce more synovial fluid. Occasionally, body weight compressing the fluid within the joint forces some of it to burst through the joint capsule where it collects in a bursa in the popliteal area behind the knee.

    Causes:
    Overproduction of synovial fluid, caused by inflammation of the knee joint, causes a Baker’s cyst. The reasons that such inflammation might occur are:
    • A tear in the meniscal cartilage (a pad of cartilage between the articulating bones), or another ligament in the knee
    • Osteoarthritis: this is the most common form of arthritis to cause a cyst
    • Rheumatoid arthritis
    • Juvenile arthritis
    • Some other injury causing swelling in the knee joint
    Symptoms:
    Often there are no symptoms at all. If symptoms exist they may include:
    • A soft swelling behind the knee, which might or might not be tender to the touch
    • The back of the knee may feel tight
    • The swelling can feel like a balloon filled with water
    • Any pain may be worse when the knee is fully stretched or bent, or when the leg is active
    • Symptoms can be constant or intermittent
    • Rarely, the cyst may rupture. In this instance there might be pain and rapid swelling with bruising at the back of the knee and calf. There may also be a feeling that water is running down the calf.
    If the symptoms of pain with rapid swelling and bruising occur, seek medical assistance immediately as such symptoms are very similar to those caused by a blood clot, which can be a very serious condition.

    Diagnosis:
    Your doctor will ask detailed questions relating to the onset and severity of the symptoms; whether any pain or stiffness is constant or comes and goes; whether your knee locks or feels unstable, and what, if anything, makes the symptoms better or worse.

    You will also have a careful physical examination to view any mass, if present. You may be asked to perform certain exercises to assess range of motion of the knee. The doctor will look for possible signs of a tear to the meniscal cartilage. Transillumination, or the passing of light through the cyst, will reveal if the cyst is fluid-filled or solid.

    Imaging tests such as x-ray, ultrasound or MRI (magnetic resonance imaging) might be used to look for any damage to the bones or surrounding tissues. Sometimes your doctor might use contrast dye injected into the joint, a test known as an arthrogram, to help with a diagnosis.

    Treatment:
    Often, the best course of treatment is observation as a Baker’s cyst can go away by itself.

    If pain is being experienced, the treatment usually consists of resolving the problem that is causing the cyst. The cyst itself is often not removed as it can return later and surgery might cause damage to nearby blood vessels or nerves.

    Self-help options:
    • Rest the knee by avoiding activities or movement that make the symptoms worse
    • Wear a knee sleeve or brace
    • Apply ice, crushed and wrapped in a towel, to the knee to reduce swelling
    • Elevate the knee above the level of the heart, when possible, to reduce swelling
    • Take over the counter medications such as acetaminophen (Tylenol), ibuprofen (Advil), naproxen (Aleve) or aspirin to relieve pain and reduce inflammation
    Needle aspiration of the cyst is a procedure often used to treat a Baker’s cyst. The needle is inserted into the cyst and the fluid drained off. This is very successful at relieving symptoms, but does not guarantee that the cyst will not reform. Your doctor might inject the area with a corticosteroid at the same time, to reduce inflammation.

    If the cyst is large enough to restrict normal movement, and is causing pain, surgery may be performed to repair or remove any torn cartilage in the knee joint. The cyst itself might be removed if other treatment has failed to resolve the problem.

    Physiotherapy can include icing the knee, placing a wrap around the joint and using crutches to minimize weight being put on the leg. You might be instructed in how to perform certain exercises to increase the range of motion of the knee.

    Exercises:
    Be guided by your doctor or physiotherapist as to how much and what exercise you should do.
    Back of knee stretch:
    Standing up, place the ball of one foot on a step in front of you. Keeping the knees and back straight, lean forward as though to touch your toes. Hold the stretch for 20 seconds then stand up again. Switch legs and repeat the exercise.
    Straight leg raise:
    Attach light ankle weights to your ankles, not heavier than 1 pound. Sit on a chair with one leg straight out in front of you and resting on the seat of another chair. Keep the leg straight as you lift it up a few inches off the chair. Hold for 10 seconds then return the foot to the chair. Rest for 10 seconds and repeat. Do this for up to 3 minutes. Switch legs and repeat the exercise.

    Knee wrap or brace:
    Wearing a brace or wrap on the knee will provide support and restrict movement of the joint to aid healing, especially if surgery has been performed. The brace or wrap should feel comfortably tight when on the knee, but not so tight as to cause any tingling sensation, or swelling or numbness of the leg below the knee.

    Prevention:
    • If you are prone to developing these cysts, take care not to overdo exercises that stretch the hamstrings, which are the muscles in the back of the thigh.
    • Maintain a healthy weight: being overweight places stress on the knee joint, which can lead to arthritis, one of the causes of Baker’s cysts.
  • Compare and Contrast ACL Knee Brace

    Compare and Contrast ACL Knee Brace

    The anterior cruciate ligament (ACL) is one of the two main stabilizing ligaments in the knee joint. Damage to the ACL reduces stability of the joint, which increases the risk of further damage to the knee, in particular the cartilage. Wearing an ACL brace while the ligament heals after an injury, or following surgery to repair or reconstruct the ACL, can be an important part of recovery and rehabilitation.


    Shop for ACL Knee Braces

    Braces are available offering various levels of support ranging from basic to top-of-the-line, custom made braces.


    Basic:

    These provide a low level of support at a reasonable price and are suitable for mild sprains, bruises, or strains. They come in the form of a knee sleeve, usually made from a stretchy material such as neoprene, elastic, or Drytex that helps to keep the knee muscles warm and flexible. They are simple to put on and wear, and provide gentle compression around the knee, increasing joint stability. They can be worn for everyday activities and for low impact sports and are a good choice for people returning to sports post injury.


    Some conditions that might benefit from a basic ACL knee brace are light arthritis, minor pain, mild swelling, minor meniscus tears, and knee bursitis. They are designed for temporary use after minor injuries or strains, or for longer term use with mild to moderate knee conditions that need ongoing support.


    Light:

    The next level of brace is designed for mild to moderate ACL injuries and instability. They provide light support and a degree of protection. An example is the Donjoy Drytex Hinged brace. The compression provided by the material around the knee promotes blood flow, and straps attached with Velcro above and below the joint hold the brace in position. Hinges stabilize the joint, keeping the femur and tibia in their correct positions relative to each other. This particular model has a patellar cut out to help the kneecap track properly.


    A light knee brace is suitable if your knee is stable after reconstruction.


    Medium:

    These are similar to light braces, combining the compression features of a sleeve with hinges and straps that keep the knee joint in correct alignment, but providing a slightly higher level of support. They are suitable for mild to moderate sprains to mild tears of the ACL, and following ACL reconstruction. The DonJoy Playmaker is an example. Wearing this level of brace keeps your knee stable and protected when making front-to-back, side-to-side, and pivoting movements, allowing you to play non-contact sports and engage in moderate activity.


    Advanced:

    Advanced knee braces are for complete ACL tears or instability.


    They are low profile, aluminum, rigid braces that provide 4-point leverage, locking the knee into a stable position. This is achieved through the positioning of four straps that evenly distribute load on the knee. One example of a hinged, advanced brace is the DonJoy Legend. It provides excellent support, stability, and protection for the ACL and wearers can play contact sports or take part in highly athletic activities with confidence.


    Professional:

    These provide the highest level of stability and safety for the ACL and are designed for severe, complete tears. The 4-point leverage of the advanced braces is combined with a reinforced frame and some models feature special hinges. DonJoy Armor eXtreme is an example, and is a popular choice for athletes participating in high-impact, high-intensity or contact sports.


    Custom:

    These are, as the name suggests, custom made. They need to be fitted by a qualified professional, who customizes the brace to provide maximum support where it is most needed. This reduces the time that the knee is in an ‘at risk’ position. They are lightweight and extremely strong, preventing moderate or severe knee conditions from becoming worse. They are also suitable for post ACL reconstruction, or for safely participating in high impact sports and water sports.


  • Difference Between ACL, MCL, LCL

    Difference Between an ACL, MCL, and LCL Tear

    Three bones form the knee joint: the femur (thigh bone), the tibia (shin bone), and the patella, which is the kneecap. Ligaments, which are strong cords of fibrous connective tissue, connect the bones and hold them in position as the knee bends and straightens.


    ACL, MCL, LCL, and PCL All Present

    One of the four main ligaments of the knee is the anterior cruciate ligament (ACL). Together with the posterior cruciate ligament (PCL), it forms an 'X' shape inside the knee joint. The ACL runs from the bottom of the femur at the back of the knee, diagonally through the joint and attaches to the top of the tibia at the front of the knee. It provides stability to the joint by limiting the rotation and forward movement of the tibia underneath the femur. It is very strong but not very flexible. The ligament fibers can be torn by a sudden change of direction, a sudden transference of weight from one leg to the other, as when landing from a jump, a sudden stop, or by straightening the leg beyond the knee's normal range of motion. An injury of this kind is called an ACL tear.

    Another of the four main knee ligaments is the medial collateral ligament (MCL). This runs from the bottom of the femur, down the inside of the knee and over the joint to the top of the tibia. Like the ACL, it limits mobility of the knee joint and prevents it opening up too far when pressure is applied to the outside of the knee. Partial or complete tearing of the MCL ligament fibers is known as an MCL sprain. Although it can be injured in isolation, often the ACL is damaged at the same time. The most common cause of an MCL sprain is traumatic force applied to the outer side of the knee, and is an injury often sustained during the playing of contact sports.

    A third main knee ligament is the lateral collateral ligament (LCL). This is a strong narrow rope of ligamentous fibers that connects the femur and the tibia along the outside of the knee joint. It holds the outer surfaces of the joint closely together and limits the sideways movement of the knee. Damage to the ligament fibers of the LCL is known as an LCL tear. Of the four main stabilizing knee ligaments, the LCL is the least likely to be injured. However, an injury to the LCL commonly results in damage to other knee ligaments as well.

    An LCL sprain is normally caused by strong, direct force applied to the inside of the knee that forces the joint outwards, beyond its normal range of motion. Less commonly, a sudden, twisting motion can also tear the ligament. Athletes playing football, soccer or engaging in wrestling are more susceptible to LCL injuries.
  • Growth plate injuries

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    Growth Plate Injuries to the Knee

    Definition:
    A growth plate injury is a fracture of the physis, an area of supple, delicate tissue found near each end of the long bones in a growing child. Fractures may be confined to the physis itself, or they may involve the metaphysis (bone shaft), the epiphysis (head of the bone), or both.

    The growth plates determine the eventual length and shape of each long bone. During periods of growth, and particularly during an adolescent growth spurt, they are particularly vulnerable to damage as they are weaker than the surrounding ligaments and connective tissues. They are in fact the weakest part of the skeleton. Over time the cells in the physis harden, and by the time the child has stopped growing, the physis has been entirely replaced by solid bone.

    Injuries to the growth plate are therefore unique to children and young people who have yet to finish growing. Boys are twice as likely as girls to suffer a growth plate fracture, primarily because girls mature physically at a younger age, but also because boys tend to be more physically adventurous. Children between the ages of 10 and 16 are most at risk.

    Causes:
    About 30% of growth plate fractures happen as a result of direct trauma to the physis while playing competitive sports such as football, basketball or gymnastics. A further 20% of injuries are sustained during recreational activities. Overuse can also cause damage to the physeal tissues.

    Less common, but not unknown, causes are:
    • Abuse: A growth plate fracture is the second most common injury found in physically abused children.
    • Steroids or other medications
    • Bone infections
    • Radiation treatment
    • Neurological disorders
    • Genetics
    Symptoms:
    Because children heal so quickly, symptoms can be ignored. This is dangerous as lack of proper treatment can result in permanent damage to the growth plate, which may mean stunted or crooked limb growth.

    A child or adolescent should never work through any joint pain. If your child complains of any of the following symptoms, arrange to see your doctor as soon as possible.
    • Localized joint pain, particularly after a trauma
    • Swelling
    • Tenderness and warmth over the physis
    • Inability to bear weight on the leg
    • Knee may appear crooked in comparison with the unaffected leg
    Diagnosis:
    Your doctor will ask about the circumstances of the injury, and then perform a physical examination. The affected knee will be compared with the other knee. X-rays will be taken, usually of both legs: on an x-ray, a growth plate only shows up as a gap between the shaft and head of a bone. Taking an x-ray of each knee allows the doctor to compare the two. The results of x-rays can often be negative, in that the ends of the bone are not separated, but a diagnosis of an undisplaced growth plate fracture may still be made, based on tenderness of the physis.

    Imaging tests such as CT, MRI and ultrasound clearly show the soft tissues and are often used as an aid in evaluating the type and extent of the injury.

    The Salter-Harris classification system describes five types of growth plate fracture. There is now also the Peterson classification, which adds a sixth type.

    Type I: The fracture extends from the bone shaft into the growth plate, separating the head of the bone from the shaft.
    Type II: This common type of fracture involves part of the growth plate and the metaphysis, but not the epiphysis.
    Type III: This uncommon fracture passes through part of the growth plate and breaks off a portion of the epiphysis.
    Type IV: The fracture extends through the shaft, growth plate and end of the bone.
    Type V: These rare fractures result from the end of the bone being crushed, thus compressing the growth plate.
    Type VI: This type describes an injury in which a portion of the shaft, growth plate and end of bone is completely missing as a result of a wound.

    Treatment:
    If a growth plate fracture is sustained and treatment is delayed, permanent damage to the bone may result. Early diagnosis, treatment and careful follow up monitoring are extremely important in order to achieve the best outcome.

    Treatment depends on the age of the child and the type of fracture. The knee is a particularly complex joint with many blood vessels and nerves that may be involved in a growth plate fracture. Damage to such structures can impair further bone growth. Younger children who still have more growing to do are at increased risk of stunted bone growth than older children whose physes are nearly closed. An orthopedic surgeon will often advise delaying surgery to repair a growth plate fracture until the child is older.

    Type I, II, and V fractures are often treated by manipulating the bones to realign them, and immobilizing the leg in a cast or splint during healing. Sometimes the bones need to be surgically fixed with screws or pins to keep them in correct alignment while the fracture heals. Types III, IV and VI nearly always require surgery and immobilization in a cast for a few weeks or even a few months, depending on the type of injury.

    Physiotherapy to strengthen the muscles surrounding the knee, to improve and maintain the function of the joint, is required once the cast has been removed.

    Follow up treatment consists of x-rays every 3-6 months, for at least a year and sometimes until the bones have completely matured.

    Occasionally bones respond to a fracture by growing excessively, leading to uneven leg length. These cases can be surgically treated to achieve similarity. A bone can also respond to a fracture by forming a bony bridge across the injured area that restricts normal bone growth or causes the lengthening bone to curve. This bridge can be surgically removed and replaced with another material such as fat or cartilage to prevent it reforming.

    Prognosis:
    Due to the complexity of the joint, a growth plate injury to the knee carries the greatest potential for stunted or deformed bone growth. The long-term outcome depends on the severity of the original fracture, with Types IV, V and VI injuries being the most serious. Most cases, about 85%, have an excellent prognosis and resolve successfully with no lasting damage.
  • Knee Arthroscopy

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    Knee Arthroscopy

    Definition:
    Knee arthroscopy is a surgical procedure to allow evaluation and repair of the various structures and areas of the knee joint.

    The knee is a complex, hinged joint, made up from three bones, the femur (thighbone), tibia (shinbone), and the patella (kneecap). Strong ligaments attach the bones to each other, keeping the joint in correct alignment, and tendons run from muscles to bones. Surrounding the joint is a fibrous articular capsule with an inner membrane called the synovium. This membrane secretes a lubricating and nourishing fluid that flows around the joint. Within the joint, the articulating ends of the femur and tibia are covered with smooth cartilage that allows the bones to slide over each other without friction. Also within the joint, between the bones and attached to the synovium, are crescent-shaped pads of meniscal cartilage that act as shock absorbers for the knee.

    Injuries that have resulted in an unstable knee joint, or chronic conditions causing ongoing pain, are reasons to consider knee arthroscopy. The procedure might be suitable for:
    • Repairing or removing a torn meniscus
    • Reconstructing a torn anterior cruciate ligament or, rarely, a torn posterior cruciate ligament
    • Clipping broken or torn articular cartilage
    • Removing pieces of floating bone or cartilage
    • Removing damaged or swollen synovial tissue
    • Realigning a dislocated patella
    • Removing a Baker’s cyst
    • Repairing some fractures
    • Smoothing rough bone surfaces
    Before surgery:
    Knee arthroscopy can repair or relieve many, but not all, conditions, so careful consultation with an orthopedic surgeon is essential. Some knee problems caused by arthritis may not be successfully resolved by arthroscopy and pain might continue. Your health care providers will make as accurate a diagnosis as possible, based on your medical history, a physical examination, and imaging tests such as x-ray, MRI and CT scans. Occasionally the diagnosis might be uncertain, and your surgeon will only be able to fully assess the situation while performing the knee arthroscropy. In this case you would be advised beforehand of the probable course of treatment.

    You will be given detailed instructions on which, if any, medications you are allowed to take and which you should stop taking before the procedure. Medications that prevent blood clotting have to be discontinued for a brief period before surgery. For the same reason, alcohol intake should be stopped two or three days prior to the arthroscopy. Smoking delays healing of bone and tissue, so if you smoke it would be wise to attempt to stop. You may be asked to fast for 6-12 hours before surgery, depending on the anesthetic that will be administered.

    Procedure:
    Knee arthroscopy is normally performed on an outpatient basis, meaning that you will not stay overnight in the hospital.

    You will meet with an anesthetist who will inform you about the particular form of anesthetic you will receive. Sometimes a local anesthetic is administered, where only the knee is numbed. In other situations a spinal epidural anesthetic is more appropriate, in which case you will be numb below the waist. Occasionally a general anesthetic is used to send you completely to sleep. With a local or regional (spinal) anesthetic it is sometimes possible to look at a screen and watch the surgery as it takes place.

    After proper anesthesia, a small incision is made into the knee joint to allow for the insertion of the arthroscope. The arthroscope is a very narrow, soft, tube with a fiber-optic light, a magnifying lens, a fluid-exchange system, and a tiny camera. It is attached to a cable leading to a large video monitor, enabling the surgeon to easily view the knee during evaluation and surgical treatment.

    The knee joint is filled with a sterile saline fluid. This serves three purposes: it replaces the fluid in the knee with a clear liquid, giving the surgeon a better view of the structures, the pressure of the fluid helps to control bleeding, and the joint space is expanded, giving the surgeon more room in which to operate.

    When the surgeon has properly evaluated the joint and decided on the course of treatment, between 2 and 4 further incisions are made around the knee. These are again small, less than half an inch in length. Various instruments can be inserted through these incisions and used by the surgeon to repair or remove damaged tissue.

    A knee arthroscopy usually takes under 2 hours to complete. When the surgeon has finished, the incisions are closed with sutures and a compression bandage put on the knee. Normally you will be allowed home after an hour or two. You will not be able to drive, so you will need to have arranged transport.

    Rehabilitation:
    Recovery times depend upon your original state of health, the particular injury or condition that has necessitated surgery, the level of activity you wish to return to, and how willing you are to spend the necessary time recovering. Simpler conditions such as a torn meniscus, or the removal of a Baker’s cyst, usually heal quickly and a return to normal activity is possible within 6-8 weeks. Ligament reconstruction, on the other hand, can take up to a year to fully heal.

    Using a crutch temporarily will prevent weight being put on the recovering knee and, depending on the surgery you have undergone, you may also wear a knee brace for a time. Your surgeon will advise you on this matter.

    Ice packs placed on the knee will help to relieve swelling, as will elevating the knee above the level of the heart, whenever possible. Pain medications can be taken, according to instruction.

    Physiotherapy after knee arthroscopy is sometimes needed, in which case you will be taught certain exercises to restore strength and range of motion in the joint. To begin with, any exercises will be to stretch the muscles, and should only be performed if no pain is felt and you have your doctor’s approval.

    Exercises:
    Quadriceps contraction:
    Lie on your back on the floor with a rolled up towel under the ankle of the affected leg. Gently press the ankle down onto the towel and straighten your knee as much as you can. Hold for 5 seconds then relax. Repeat 10 times.
    Hamstring contraction:
    Lie on your back on the floor with your knees slightly bent. Without moving the leg, pull the heel down into the floor. You should feel the stretch in the back of the thigh. Hold for 5 seconds then relax. Repeat 10 times.
    Gluteus contraction:
    Lie on your back on the floor with your knees slightly bent. Squeeze the buttock muscles and hold the squeeze for 5 seconds. Relax then repeat 10 times.
    Straight leg raise:
    Lie on your back on the floor. Bend the unaffected leg to a 90-degree angle, keeping the foot flat on the floor. Keep the affected leg straight and, using the thigh muscles, slowly lift the leg 6 inches off the floor. Hold for 5 seconds then slowly lower to the floor. Repeat 10 times.

  • Knee Hyperextension

    Knee Hyperextension

    Definition:
    Hyperextension of the knee is a condition where the back of the knee joint opens too widely, allowing the tibia (shinbone) to slip backwards, beyond its normal limit.

    The knee is a complex, hinged joint. It is formed where the femur (thighbone), the tibia and the patella (kneecap) meet. These bones articulate with each other to allow the leg to bend and, to a limited degree, twist. The parts of the bones that come into contact with each other are covered with a smooth cartilage that prevents friction as the bones move over each other. Also within the joint are cushions of cartilage that act as shock absorbers to protect the bones. Several ligaments connect the bones, keeping them in alignment and limiting the extent of movement. Surrounding the joint is a capsule lined with synovium, a membrane that secretes a nourishing and lubricating fluid that flows throughout the joint.

    If for any reason the ligaments are too loose, or are damaged, they cannot maintain the position of the bones and therefore the stability of the knee, which can then no longer support the weight of the body.

    Causes:
    Knee hyperextension is thought to cause as much as a fivefold increase in the risk of injuring the ACL.

    A common cause is a straight leg receiving a severe blow that forces the knee backwards, for example during a car crash. This usually results in injury to several knee ligaments and possibly dislocation of the knee.

    Hyperextension can also happen as a result of a fall, or while playing a sport that puts great stress on the knee. Examples of such sports are volleyball, football, basketball or gymnastics. This happens less frequently and usually only the anterior cruciate ligament (ACL) within the knee is damaged.

    If the quadriceps muscles at the front of the thigh are weak, the hamstring muscles at the back of the thigh will compensate, leading to an imbalance between the two and an increased likelihood of the joint being pulled out of position backwards - hyperextension.

    Symptoms:
    Depending on the severity of the injury, your symptoms may include:
    • Pain felt at the back and sides of the knee
    • Possible ‘pop’ sound or feeling at the moment of injury
    • Swelling that begins within three hours of injury
    • Instability of the knee and a feeling that it might give way
    • Decreased range of motion of the knee
    Diagnosis:
    Because the knee is an intricate joint and can be damaged easily, it is important to seek professional help if your knee has been injured. Correct treatment is necessary to achieve a full recovery.

    Your doctor will ask you questions relating to the injury, such as how and when it happened, the position that your leg was in at the time, and the onset and duration of symptoms. He or she will also need to know about any previous knee injuries. A complete medical history will include questions about your general health, lifestyle, activities, and sports participation.

    During the physical examination the doctor will carefully evaluate your knee, and compare it with your unaffected leg. Swelling, discoloration, and any obvious deformity will be noted. The range of motion will be tested and, if pain and swelling allow, the doctor will bend your knee and gently push and pull on the shin to assess the strength of the ligaments.

    Depending on the suspected damage, you may need to have some diagnostic tests. These will probably include x-rays to view the bones, and CT or MRI scans, which clearly show the soft tissues. Arthroscopy (camera-guided knee surgery) is sometimes used for diagnostic purposes.

    Treatment:
    Treatment for knee hyperextension depends on which ligaments or other knee structures are damaged and, if so, the severity of the damage.

    For mild cases, time and conservative treatment will usually be sufficient, with recovery taking only a few weeks. For more severe injuries surgery may be necessary, in which case your orthopedic surgeon will discuss all the available options with you. Recovery and rehabilitation of the knee would take several months.

    Self-help:
    • Rest: Avoid putting weight on the knee or bending it. Use crutches when walking. Your doctor may recommend a temporary knee brace.
    • Ice: Apply ice, crushed in a bag and covered with a towel, to the sides and back of the knee for as long as is comfortable, several times a day.
    • Compression: Wrap the knee in an ace bandage for support.
    • Elevation: Raise the knee above the level of your heart, whenever possible.
    • NSAIDs: Over the counter pain and anti-inflammatory medicine will relieve some of your symptoms.
    Your doctor or physiotherapist will develop an exercise program to restore mobility to your knee and strengthen the quadriceps muscles. It is important that you follow professional advice in order to achieve full recovery and prevent further injury.

    Exercises:
    Make sure that you exercise both legs equally to avoid creating imbalance.

    Quad tightening:
    Sitting on the floor with your injured leg straight out in front of you and the unaffected leg bent with the foot on the floor, contract the quadriceps of the injured leg by pressing the knee towards the floor. Hold the position for 5-10 seconds then relax. Repeat 10 times.
    Quad extensions:
    Place a rolled towel under the injured knee. Lie on your back with your unaffected leg bent, the foot flat on the floor. Slowly straighten the injured leg by engaging the quadriceps. Hold the position for 5-10 seconds then lower. Repeat 10 times.
    Heel slide:
    Lying on your back, bend the injured knee and keep the foot on the floor. Slide the heel towards the buttocks as far as you can without pain. Repeat 10-20 times.
    Straight leg raise:
    Lying on your back on the floor, bend your unaffected knee and rest the foot on the floor. Keeping the knee of the injured leg straight, contract the thigh muscles and lift the leg up until the heel is about 6 inches off the ground. Hold for 5-10 seconds then relax. Repeat 10 times.

    What to look for in a brace:
    Your doctor will probably recommend a particular brace for you. There are many brands available, but you may want to consider a hinged knee brace that can be locked to prevent any hyperextension. The brace should be properly fitted so that it provides comfortable support without being constricting.

  • Lateral Collateral Ligament (LCL) Tear or Sprain

    Lateral Collateral Ligament (LCL) Tear or Sprain


    Definition:

    A lateral collateral ligament (LCL) sprain is an injury to the ligament on the outer surface of the knee joint.

    The LCL connects the femur (thighbone) and the tibia, the outer bone of the two shinbones. It is a strong narrow rope of fibers that supports the outside of the knee, limiting sideways movement and keeping the outer surfaces of the joint in close proximity to each other. Of the four main ligaments that stabilize the knee, the LCL is the least likely to be injured but when it is, other ligaments are often damaged at the same time.

    As with the other ligaments of the knee, sprains are graded according to the severity of the injury.
    Grade I:
    The ligament has been stretched, causing microscopic tears in the fibers, but the joint is still stable.
    Grade II:
    There is a partial tear in the ligament and mild to moderate instability in the joint.
    Grade III:
    The ligament has been completely torn, either in the middle of the ligament, or at the point of attachment to one of the bones and the joint is unstable.

    Causes:
    An LCL sprain is usually caused by a direct blow to the inside of the knee that forces the joint outwards beyond its normal range of motion. It is a common injury amongst athletes, particularly those participating in football, soccer or wrestling. A sudden twisting motion can also induce a sprain.

    Symptoms:
    Grade I sprain:
    • Mild tenderness on the outside of the knee over the LCL position
    • Very mild or no swelling
    • Some pain upon stressing of the joint
    • No looseness of the joint
    Grade II sprain:
    • The area over the LCL is moderately tender
    • Some swelling
    • Pain upon stressing of the joint
    • Some looseness in the joint, but it cannot be completely bent sideways
    Grade III sprain:
    • Variable pain which sometimes is less than with a grade II sprain, but can be very severe
    • Significant looseness in the joint
    • Knee feels extremely unstable and as though it will ‘give out’
    Diagnosis:
    A thorough physical examination of the knee will be performed. The knees will be compared with each other and note taken of any differences in size and appearance. Observation and palpation (touch) of the knee will provide information on the extent of swelling, tenderness, bruising and any physical deformity.

    You will be asked questions relating to the moment of injury; what type of movement or collision caused it; how rapidly any swelling appeared; if there was any popping sound heard at the time of injury; whether the knee feels unstable and if any weight can be placed upon it, and the severity of any pain being experienced.

    If possible, your doctor will gently put stress on the ligament to evaluate the stability of the joint and to determine what movement or position causes pain. Swelling and pain may restrict the range of motion possible, but you might be asked to perform some motions to assist in the evaluation.

    An x-ray might be taken to rule out a bone fracture, and an MRI taken to better view the soft tissues of the knee.

    Treatment:
    For grade I and grade II LCL sprains, conservative treatment is the preferred option. The goal is to reduce pain and inflammation and then to restore full stability and mobility of the knee joint.

    Refraining from any activities that cause pain will rest the ligament and allow it to begin healing. For grade II injuries, using crutches for a time will prevent weight being placed on the joint, and wearing a hinged knee brace will provide support and stability. Ice, crushed in a bag and wrapped in a towel, can be applied to the knee to help reduce inflammation and swelling. NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen, naproxen or aspirin, will also help reduce swelling and pain.

    Following the acute phase of the injury, exercises to increase flexibility can begin. Other therapeutic measures might include ultrasound and massage. A gradual progression to strengthening exercises will be initiated and a return to full activity should be accomplished within 8 weeks.

    Grade III sprains are often repaired by surgery. The torn ligament can either be stitched together or reconstructed using part of a tendon. Rehabilitation includes using a crutch and wearing a hinged knee brace, and a careful and graduated program of exercises. A return to full activity might take months to accomplish, but the prognosis is excellent as surgical repair of the LCL is highly successful.

    Exercises:
    Do not undertake any exercise program after an LCL sprain without the permission of your doctor or physiotherapist.

    Flex and extend:
    Sit on the edge of a table or stand and simply bend and straighten the knee as much as is possible without pain. Do not try to completely straighten the knee as this might stress the joint. Repeat 10-20 times for 1 set. Do 3 sets, 3 times a day.
    Heel slide:
    Lie on your back on the floor with your legs straight out in front on you and together. Slide the heel towards the buttocks as far as possible. Hold for 5 seconds then straighten.
    Knee flex:
    Standing, put the foot of the injured leg on a chair and slowly bend the knee forward as far as it will go. Hold for 10 seconds. Repeat 10 times.
    Hamstring flex:
    Sit on the floor with your legs straight out in front of you. Lean forward from the hips until a stretch is felt under the thighs. Hold 30 seconds. Repeat 2-3 times, 3 times a day.
    Quad stretch:
    Standing or lying down, hold the foot of the injured leg and draw it backwards towards the buttocks as far as possible until a stretch is felt in the front of the thigh. Hold 30 seconds. Repeat 2-3 times, 3 times a day.

    Strength exercises:
    Quad contraction:
    Tighten the quadriceps muscles at the front of the thigh. Hold for 10 seconds then relax for 3 seconds. Do this 10-20 times.
    Straight leg raise:
    Sit on the floor with your legs straight out in front of you. Lift the injured leg up off the floor, keeping the knee straight. Hold for 10 seconds then relax for 3 seconds. Repeat 10-20 times.
    Calf raise:
    Stand with your feet shoulder width apart. Lift your heels off the floor as high as possible then slowly lower to the ground. Repeat 15-20 times for 1 set. Build up to 2-3 sets.

    Prevention:
    • Warm up properly before exercise
    • Strengthen the leg muscles, particularly the quadriceps
    • Gradually increase the intensity of training
    • Wear correct footwear, including orthotics if necessary
    • Make sure any sporting equipment is properly fitted
    Bracing:
    Wearing a knee brace may not be necessary for a mild sprain, but for more severe injuries it can provide support as the ligament heals and some protection from sideways force when you return to normal activities. Your doctor will advise you on the most appropriate brace, but you should make sure that it is properly fitted. It should not be uncomfortably tight, but your knee joint should feel secure and reinforced.
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  • Low Impact Exercises

    Low Impact Exercises to Stay in Shape During Recovery

    Compare and Contrast ACL Knee Braces


    The anterior cruciate ligament (ACL) is one of the two main stabilizing ligaments in the knee joint. Damage to the ACL reduces stability of the joint, which increases the risk of further damage to the knee, in particular the cartilage. Wearing an ACL brace while the ligament heals after an injury, or following surgery to repair or reconstruct the ACL, can be an important part of recovery and rehabilitation.


    Braces are available offering various levels of support ranging from basic to top-of-the-line, custom made braces.


    Basic:

    These provide a low level of support at a reasonable price and are suitable for mild sprains, bruises, or strains. They come in the form of a knee sleeve, usually made from a stretchy material such as neoprene, elastic, or Drytex that helps to keep the knee muscles warm and flexible. They are simple to put on and wear, and provide gentle compression around the knee, increasing joint stability. They can be worn for everyday activities and for low impact sports and are a good choice for people returning to sports post injury.


    Some conditions that might benefit from a basic ACL knee brace are light arthritis, minor pain, mild swelling, minor meniscus tears, and knee bursitis. They are designed for temporary use after minor injuries or strains, or for longer term use with mild to moderate knee conditions that need ongoing support.


    Light:

    The next level of brace is designed for mild to moderate ACL injuries and instability. They provide light support and a degree of protection. An example is the Donjoy Drytex Hinged brace. The compression provided by the material around the knee promotes blood flow, and straps attached with Velcro above and below the joint hold the brace in position. Hinges stabilize the joint, keeping the femur and tibia in their correct positions relative to each other. This particular model has a patellar cut out to help the kneecap track properly.


    A light knee brace is suitable if your knee is stable after reconstruction.


    Medium:

    These are similar to light braces, combining the compression features of a sleeve with hinges and straps that keep the knee joint in correct alignment, but providing a slightly higher level of support. They are suitable for mild to moderate sprains to mild tears of the ACL, and following ACL reconstruction. The DonJoy Playmaker is an example. Wearing this level of brace keeps your knee stable and protected when making front-to-back, side-to-side, and pivoting movements, allowing you to play non-contact sports and engage in moderate activity.


    Advanced:

    Advanced knee braces are for complete ACL tears or instability.


    They are low profile, aluminum, rigid braces that provide 4-point leverage, locking the knee into a stable position. This is achieved through the positioning of four straps that evenly distribute load on the knee. One example of a hinged, advanced brace is the DonJoy Legend. It provides excellent support, stability, and protection for the ACL and wearers can play contact sports or take part in highly athletic activities with confidence.


    Professional:

    These provide the highest level of stability and safety for the ACL and are designed for severe, complete tears. The 4-point leverage of the advanced braces is combined with a reinforced frame and some models feature special hinges. DonJoy Armor eXtreme is an example, and is a popular choice for athletes participating in high-impact, high-intensity or contact sports.


    Custom:

    These are, as the name suggests, custom made. They need to be fitted by a qualified professional, who customizes the brace to provide maximum support where it is most needed. This reduces the time that the knee is in an ‘at risk’ position. They are lightweight and extremely strong, preventing moderate or severe knee conditions from becoming worse. They are also suitable for post ACL reconstruction, or for safely participating in high impact sports and water sports.


  • MCL Sprain

    MCL Sprain

    MCL or Medial Collateral Ligament Sprain Definition:
    An MCL sprain is an injury sustained by the medial collateral ligament (MCL). This ligament is one of the four main ligaments that stabilize the knee joint. It is attached to the bottom of the femur (thighbone), runs down the inside of the knee, over the joint, and attaches at its other end to the top of the tibia (shinbone). Its role is to limit mobility of the knee joint and prevent it from opening up too far when subjected to pressure at the outside of the knee. The MCL is made of tough fibrous connective tissue that, when injured, can be torn, either partially or completely. This is known as an MCL sprain. Although it can be injured in isolation, often the meniscus and ACL are damaged at the same time.


    Such sprains are graded according to the severity of the injury:
    Grade I: The ligament has microscopic tears, but the joint is still stable.
    Grade II: The ligament has been partially torn and there is a certain amount of instability in the joint.
    Grade III: The ligament has been completely ruptured, either in the middle of the ligament, or torn away from one of the attachments to bone and the knee joint is completely unstable.

    MCL Sprain Causes:
    The most usual cause of a sprained MCL is force applied to the outside of the knee, which pushes the knee inwards and beyond its normal range of motion. This is an injury often sustained during contact sports.

    Sprained MCL Symptoms:
    The severity of any symptoms will increase with the extent of the injury. Grade I sprains will produce milder symptoms than a Grade III sprain.
    • Pain at the inside of the knee
    • Swelling
    • Instability of the knee joint
    • Perhaps a popping sound heard at the moment of injury
    MCL Sprain Diagnosis:
    Your doctor will ask you questions relating to the circumstances of the injury, the symptoms you are experiencing and your medical history. You will also have a physical examination during which your doctor will carefully examine the structures of your injured knee, and then compare it with the unaffected joint. If pain and swelling allow, your doctor might gently manipulate the knee joint to assess its stability and flexibility. You may also be asked to perform some movements yourself.

    The medical history and physical examination are usually enough to diagnose an MCL sprain, but an x-ray image might be taken to rule out a bone fracture. Sometimes an MRI (magnetic resonance imaging) scan might be needed to better view the soft tissues of the ligaments.

    MCL Sprain Treatment:
    Injuries to the MCL usually respond to conservative treatment, and surgery is rarely required.

    During the acute phase of the injury it is important to reduce any swelling and alleviate pain. This is achieved by:
    • Applying crushed ice, in a bag and covered with a towel, to the affected area. The ice pack should be kept in place for 15 minutes at a time, several times a day.
    • Resting the knee joint. Refrain from any activity that places stress on the joint, and perhaps use crutches to avoid placing weight on the leg.
    • Bracing. A knee brace may be recommended to prevent any further sideways motion of the joint in order to allow healing to begin.
    • Elevating the knee above the level of the heart, whenever possible.
    • Taking pain medication such as acetaminophen (Tylenol) or NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Advil), naproxen (Aleve) or aspirin.
    After the initial acute phase, and provided that no new pain or swelling is experienced as a result, you may be allowed to begin some gentle stretching exercises to restore mobility to the knee. Further exercises will be gradually introduced to strengthen the leg muscles that support the knee joint, thereby helping to prevent further injury. Stationary bicycle riding may also be helpful in rehabilitation.

    Ultrasound may be used on the knee by a physiotherapist: It is thought that this technique assists with the formation of healing scar tissue.

    MCL Sprain Rehab: Exercises:
    Any exercise should only be undertaken with the permission of your health care practitioner. Stop exercising if you experience any pain.
    Flex and extend:
    Sitting, standing or lying on your stomach, gently bend and straighten the knee as far as you can without pain. One set is 10-20 repetitions; build up to 3 sets, 3 times a day.
    Heel slide:
    Lying on your back, bend the injured knee and keep the foot on the floor. Slide the heel towards the buttocks as far as you can without pain. Repeat 10-20 times.
    Quad stretch:
    Hold the right foot with your right hand and gently pull the foot up and behind you towards the buttocks, stopping when you feel a stretch. Keep your knees together. Hold the stretch for 10 seconds then relax. Switch legs and repeat exercise.
    Hamstring stretch:
    Standing, place one leg slightly in front of the other. Bend the back knee and keep the front knee straight. Keeping your weight on the bent knee, lean forwards until you feel a stretch in the back of the thigh. Hold the stretch 5-10 seconds then relax. Switch legs and repeat exercise.

    Bracing:
    Your doctor will recommend the most appropriate knee brace for you to wear during recovery and rehabilitation. Often this is a lightweight hinged knee brace that can be set to allow for a gradual increase in range of motion as the MCL heals.

    A different brace may be recommended as you return to full activity, particularly sports, in order to provide support and protection for the knee. When in the brace the knee can flex and extend, but not move sideways. It should be properly fitted so that it feels comfortable yet firmly supportive. It should not cause any swelling below the knee, or any feeling of constriction.

    Prognosis and recovery time:
    The outlook for an MCL sprain is usually very good. A mild sprain may take anything from a few days to two weeks to repair, a grade II sprain can take up to four weeks, and a severe sprain anywhere from four to eight weeks, but full recovery with minimal long-term effects is highly likely.


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  • Meniscectomy

    Untitled

    Meniscectomy

    Definition:
    A meniscectomy is a surgical procedure to remove all or part of a damaged meniscal cartilage.

    The knee is a complex, hinged joint, formed by the articulation of three bones, the femur (thighbone), tibia (shinbone), and the patella (kneecap). At the inner and outer edges of the knee joint, between the femur and tibia and attached to the synovium (a membrane within the fibrous joint capsule), are two crescent-shaped pads of tough cartilage, the menisci. These serve as shock absorbers for the knee, cushioning the articulating ends of the bones, and providing stability for the knee by balancing body weight across the joint. Because they are, effectively, spacers between the femur and tibia, they also allow the nourishing and lubricating synovial fluid in the joint to diffuse into the articular cartilage at the ends of the bones, thereby helping to prevent arthritis.

    Causes:
    Injuries to the meniscus are common. As we age, cartilage begins to deteriorate and becomes increasingly vulnerable to injury. A relatively minor twisting of the knee might cause a meniscal tear. Another common cause are sporting injuries that can happen when an athlete squats then twists the knee.

    Factors in deciding on surgery:
    • The outer third of a meniscus has a rich supply of blood, which means that tears in this area usually heal well. If surgery is necessary for a meniscal tear in the ‘red zone’, a successful outcome is likely.
    • The inner two-thirds of a meniscus, the ‘white zone’, has no blood supply and therefore tears may not heal. Surgery may be necessary to remove a fragment of meniscal cartilage if it has been torn away and become wedged in the small space between the femur and tibia, as it will cause painful swelling and loss of mobility in the knee if untreated.
    • Surgery may be required to smooth rough areas of cartilage.
    • Sometimes a tear will travel through the red zone into the white zone, in which case the decision whether or not to have surgery is more difficult.
    • The shape of a tear: Some tears, such as a flap or a horizontal tear, need to be surgically trimmed.
    • Your age, general health and activity level
    • The condition of the entire knee
    Treatment:
    After proper diagnosis of the injury, including medical history, physical examination, x-rays and possibly an MRI scan, a decision will be made, in consultation with you, as to whether surgery is indicated and whether you require a partial or complete meniscectomy. It is considered preferable to try to retain as much of the meniscus as possible, in order to best protect the joint from degeneration, which is likely to lead to arthritis.

    A meniscectomy is usually performed using arthroscopy, and is done on an outpatient basis, which means that you will not have to spend the night in hospital, although you will need to have arranged transport to take you home after the procedure. Very occasionally open knee surgery is necessary, in which case your hospital stay will be longer.

    You will meet with an anesthetist who will explain the type of anesthetic that you will receive. It might be local, in which case just your knee will be numbed, regional, meaning that you will be completely numb below the waist, or general, in which case you will be asleep throughout.

    After appropriate anesthesia, surgery will begin. Arthroscopy involves making three or four very small incisions around the knee, through which various instruments are passed into the joint in order to make the necessary surgical repairs. The arthroscope is a flexible, narrow tube with a light and a tiny camera. The camera is connected by cable to a video monitor screen in the theatre, enabling the orthopedic surgeon to clearly view the knee joint. To prepare the knee for surgery, a saline solution is flushed through the joint to both clear out any cloudy fluid and to enlarge the space, thereby giving the surgeon the clearest possible view and room in which to work.

    Depending on your particular needs, the surgeon will remove some, or all, of the damaged meniscus. Every attempt will be made to preserve as much cartilage as possible. Loose or detached fragments are removed, and any rough areas smoothed.

    Recovery:
    The length of time it takes to recover after an arthroscopic meniscectomy depends on several factors. Your age, general health and activity levels will all influence the length of time it takes to get back to your pre-injury state.

    Immediately after the surgery you will be required to wear a knee brace for about 6 weeks, to keep the knee straight. You will also need crutches when walking. Pain medication will be provided, as you will experience some discomfort from the surgery. Ice packs applied to the knee will help reduce swelling. These should be used for 15-20 minutes at a time, several times a day. You should also keep the knee elevated above heart level whenever possible.

    Physical therapy usually begins soon after surgery and will include exercises that focus on restoring range of motion, followed by weight-bearing and strengthening exercises, as your knee heals. Follow instructions as to when and how much you are allowed to exercise, and seek permission from your doctor before returning to full sporting activities.

    Exercises:
    Quad sets:
    Sitting or lying down, press the knee down against the table or floor. Hold the position for 5-10 seconds then relax. Repeat 10-15 times for 1 set. Do 3 sets.
    Straight leg raise:
    Lie on your back on the floor. Bend the unaffected leg to a 90-degree angle, keeping the foot flat on the floor. Keep the affected leg straight and, using the thigh muscles, slowly lift the leg about 1 foot off the floor. Hold for 5 seconds then slowly lower to the floor. Repeat 10 times for 1 set. Do 3 sets. Low weights may be added gradually, starting with a 2 lb weight.
    Knee bend and flex:
    Sit on a table with the knee at the edge, letting the lower leg hang down. Simply straighten and bend the knee as far as it will comfortably go. Repeat 10-15 times.
    Quad extensions:
    Lying on your back with your unaffected leg bent and the foot flat on the floor, and with a rolled towel under the injured knee, gradually straighten the injured knee as far as you can. Hold the position for 5-10 seconds then slowly lower. Repeat 10 times for 1 set. Build up to 3 sets.
    Knee flexion:
    Lying face down with a rolled towel under the ankle of the injured leg (to prevent the toes hitting the floor), slowly raise and lower the foot by bending the knee. Repeat 10-15 times for 1 set. Weights may be added as strength is gained.

  • Meniscus Tear

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    Meniscus Tear

    Definition:
    A tear in the meniscus refers to an injury sustained by a meniscal cartilage in the knee joint.

    The knee is a hinged joint formed by the femur (thighbone), tibia (shinbone) and patella (kneecap). At the inner and outer edges of the knee, between the femur and tibia, are two crescent-shaped pads of tough cartilage that serve as shock absorbers, cushioning the ends of the bones and providing stability by balancing body weight across the joint.

    A meniscus tear is a common injury. The cartilage can tear in many different ways, and treatment depends on the type of tear that has been sustained. Parrot-beak, bucket handle, longitudinal and flap are just some of the terms used to describe various meniscal tears.

    Causes:
    Normal wear and tear and the aging process causes cartilage to weaken and thin, which leaves it vulnerable to injury. A relatively minor twisting motion might be enough to tear a meniscus.

    Another common cause is a sporting injury when an athlete has squatted down and twisted the knee awkwardly.

    Symptoms:
    • A feeling of a ‘pop’ in the knee at the moment of injury
    • Pain felt at the center or side of the knee. The pain might be sharp when twisting or squatting.
    • Swelling, increasing over two to three days
    • Stiffness, increasing over two to three days
    • 'Locking’ of the knee
    • A feeling of instability in the knee, although it may still be possible to walk
    • Loss of full range of motion in the knee
    • In severe cases, the knee might ‘give out’ without warning
    Diagnosis:
    Your doctor will carefully review with you the circumstances of the injury and the symptoms you are experiencing. Your knee joint will be assessed during a physical examination, which will include observation, palpation (touch) and probably some gentle manipulation to evaluate the stability of the joint, the range of motion of the knee and what movements might cause discomfort.

    X-rays will probably be taken and, in some cases, an MRI (magnetic resonance imaging) scan might be needed in order to better view the soft tissues of the knee.

    Treatment:
    The particular treatment needed will depend on the location, size and type of meniscal tear that you have sustained as well as your general health, level of activity and age.

    The outside of each meniscus is richly supplied with blood, so many tears in that area can either heal on their own or be repaired surgically. The inner two-thirds, however, has no blood supply, so tears have to be cut away. Sometimes a piece of meniscus can be completely torn off and float freely in the knee joint, causing ongoing painful symptoms that would need surgery to relieve.

    Initial treatment after diagnosis would include:
    • Resting the joint
    • Applying ice, crushed in a bag and wrapped in a towel, to the knee for 15 minutes at a time, several times a day
    • Wearing a compression bandage on the knee
    • Elevating the knee above heart level, whenever possible
    • Wearing a knee brace and possibly using crutches for a time
    • Taking NSAIDs (non-steroidal anti-inflammatory drugs) to reduce pain and swelling
    Physiotherapy to restore full range of motion to the joint will be an important part of the recovery process. You will be taught certain exercises to perform, at first under supervision and then at home.

    If surgery is deemed to be the best option for you, based on factors such as the location and extent of the injury, and your age and activity levels, one of three options will be chosen.
    • Repair: The pieces of torn cartilage are sewn back together.
    • Partial meniscectomy: This procedure surgically removes part of the torn cartilage, trimming it back to a smooth shape.
    • Total meniscectomy: This entails the surgical removal of the entire meniscus. This option is the least desirable due to the risk of developing arthritis in the knee.
    Arthroscopy is the preferred surgical technique. Very small incisions are made around the knee, through which instruments, including the arthroscope (a soft, flexible tube with a camera on the end) can be passed in order to perform the surgery.

    There is an experimental treatment, meniscal transplant, that some people may be able to have, depending on factors such as age, weight, the failure of previous treatment, and whether the knee has correct alignment.

    Rehabilitation after surgery will include many of the same features as for a less severe injury, but the time it takes for complete recovery will necessarily be longer and will also depend on your age and general level of fitness.

    Exercises:
    Quad tightening:
    Sitting on the floor with your injured leg straight out in front of you and the unaffected leg bent with the foot on the floor, contract the thigh muscles of the injured leg (the quadriceps) by pressing the knee towards the floor. Hold the position for 5-10 seconds then relax. Repeat 10 times, 3 times a day.
    Straight leg raise:
    Lying on your back on the floor, bend your unaffected knee and rest the foot on the floor. Keeping the knee of the injured leg straight, contract the thigh muscles and lift the leg up until the heel is about 6 inches off the ground. Hold for 5-10 seconds then relax. Repeat 10 times, 3 times a day.
    Hamstring curls:
    Lying on your stomach on the floor, and with your legs straight out behind you, bend the injured knee and move your foot towards the buttocks as far as it will go without producing any pain. Repeat 10 times, 3 times a day.
    Heel raise:
    Standing with your feet shoulder width apart, and holding on to the back of a chair for support, slowly lift your heels off the ground as far as you can. Hold the position for 5-10 seconds then slowly lower your heels back to the ground.

    Bracing:
    The best brace for you will depend on the cause of your meniscal tear. Any brace will provide support and a degree of pain relief, but there are braces available that offer different levels of reinforcement. A hinged knee brace might be appropriate if you need significant support after a severe tear, or surgery to repair the injury. A degenerative meniscal tear might be better served by a brace that gently compresses the joint. Your health care provider can help you make the right choice.

  • Osgood Schlatters Disease

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    Osgood-Schlatter Disease

    Definition:
    Osgood-Schlatter disease is a condition sometimes found in growing adolescents as a result of inflammation of the patellar tendon in the knee. It most commonly affects children going through a growth spurt, with onset usually between the ages of 11 and 12 in girls, and 13-14 in boys.

    The patella (kneecap) is attached to the tibia (shinbone) by the patellar tendon, a sheath of fibrous connective tissue. The tendon provides a measure of stability to the joint by preventing it widening too far when the knee is bent. The point of attachment to the tibia is known as the tibial tubercle. The tendon is also attached to the strong muscles of the thigh, the quadriceps. If the patellar tendon becomes inflamed as a result of overuse, it can cause tenderness or pain at the tibial tubercle.

    At the end of each long bone in the arms and legs of a growing child are areas of cartilage that will eventually become bone. These areas are called epiphyseal plates, or growth plates and, as they are made of cartilage, they are softer than bone.

    Causes:
    When the quadriceps muscles contract, they pull on the patellar tendon at its point of attachment to the tibia, which, in a child, is a growth plate.

    Many sports and activities that young people participate in, such as soccer, basketball, ballet, football, volleyball, skating and gymnastics, require repeated contraction of the quadriceps in order to jump, run and quickly change direction. Such contractions can result in inflammation of the patellar tendon as it is repeatedly strained at its point of attachment to the tibia. The tendon can become slightly detached from the tibia, resulting in the symptoms of Osgood-Schlatter disease.

    Symptoms:
    • Pain that is worse with activity and better with rest
    • Pain, swelling and tenderness at the tibial tubercle, just below the patella
    • Symptoms in one knee only, although occasionally both knees may be affected
    • A painful bony lump just below the kneecap: The body sometimes responds to inflammation of the patellar tendon by growing a bone spur on the point of tendon attachment to the tibia
    Diagnosis:
    The doctor will perform a physical examination of the knee that will include observation and palpation (touch). Any pain, swelling or tenderness will be noted, and questions asked about the frequency and severity of the symptoms, and what movements make the symptoms better or worse.

    X-rays might be required to evaluate the condition of the bones in the leg and knee and to rule out any other possible conditions that might be causing the symptoms.

    Treatment:
    Osgood-Schlatter disease is only found in children whose long bones are still growing, so in most cases time and rest will result in a cure. Until bone growth has stopped and the patellar tendon has become stronger, time spent playing sports may have to be curtailed. As the severity of the symptoms varies from person to person, your doctor will advise on the recommended level and type of activity for your child. It is important that your child does not ignore symptoms as carrying on with normal activities while suffering from this condition will make it worse and make treatment more difficult.

    In order to relieve pain and reduce swelling, the following treatments can be carried out at home:
    • Apply ice, crushed in a bag and covered with a towel, to the painful area for 15 minutes at a time, several times a day
    • Rest the knee from any activity, such as deep knee bends, that makes the pain worse
    • Wear a compression bandage over the knee
    • Elevate the knee above heart level, whenever possible
    • Use NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Advil and others), and pain relievers such as acetaminophen (Tylenol) as necessary and according to instructions
    If these treatments fail to alleviate the symptoms, a knee brace or strap can be worn and, if your doctor recommends it, use crutches when walking.

    A physiotherapist may teach certain exercises targeted to stretch the quadriceps and hamstrings, and also exercises to strengthen the quadriceps, thereby increasing the stability of the knee joint.

    Surgery is rarely needed to treat this disease.

    Prognosis:
    As this condition usually disappears with time, the outlook for a full recovery and return to normal activities is excellent. It may, however, take weeks or months for the symptoms to completely disappear and in some cases a non-painful lump may continue to be present.

    Knee support:
    The best support for a child with Osgood-Schlatter disease is a knee sleeve with a strap. The strap is placed between the patella and tibial tubercle where it provides pressure on the tendon, thereby decreasing its pull on the tibia. The compression provided will also help to reduce inflammation and pain.

    When playing sports, a knee sleeve with a contoured pad over the patella can provide some protection for the affected area.

    There are many knee supports available; if wearing one is recommended, your doctor or physiotherapist will suggest one, based on your child’s needs.

  • Osteoarthritis

    Osteoarthritis of the Knee


    Definition:

    Arthritis is the medical term for inflammation of a joint. There are different types of arthritis that can develop in the knee.

    Osteoarthritis: This is the most common form. It is a progressive condition also known as degenerative joint disease. The knee joint is formed where the femur (thighbone), the tibia (shinbone) and the patella (kneecap) meet. The bone surfaces that come into contact with each other are covered with a protective smooth cartilage that cushions the bones and enables them to slide across each other without friction. With age and use this articular cartilage deteriorates, leaving bone surfaces exposed and the joint space narrowed. Bones often respond by growing more bone, further decreasing the distance between them. Eventually movement of the knee joint causes the bones to rub directly against each other, triggering inflammation, pain and deformity.


    Juvenile rheumatoid arthritis (JRA)
    : This is an autoimmune disease that commonly affects the knees, destroying articular cartilage. The term autoimmune means that for unknown reasons the body attacks its own healthy tissues.

    Gouty arthritis

    Pseudogout arthritis

    Lupus arthritis: This is a symptom of Systemic Lupus Erythematosus, another autoimmune disease.

    Causes:
    A number of factors can contribute to the development of arthritis and it is often difficult to isolate one main cause, but some risk factors are:
    • Age: Cartilage degenerates over time and with use, becoming thinner and more brittle, and therefore more vulnerable.
    • Weight: As the knees bear most body weight, they are more susceptible to damage if a person is overweight.
    • Heredity: A family history of arthritis increases the risk of developing the disease.
    • Injury: A previous injury to the knee can lead to arthritis later in life.
    • Infection or illness: Inflammation caused by an infection can result in arthritis.
    • Occupation: Some occupations that involve repetitive movements of the knee, or extended periods of time squatting, are more likely to cause injuries that may lead to arthritis.
    • Gender: Women over the age of 50 are more likely than men to develop osteoarthritis.
    • Gouty arthritis is caused by the accumulation of urate crystals in the joint.
    • Pseudogout arthritis is similar to gouty arthritis, but is caused by the accumulation of calcium deposits.
    Symptoms:
    Arthritis is a progressive disease, and symptoms usually appear gradually. The most common symptoms are:
    • Pain
    • Stiffness that often lasts for longer than an hour
    • Swelling of the knee, which may be red and tender
    Symptoms tend to be worse in the morning, or after sitting still for a length of time. Any activity that involves bending the knee is likely to increase the pain, and there may be a feeling of weakness in the knee. The weather can also affect the level of pain for some people, with cold and damp weather making it worse.

    Other symptoms might include:
    • Obvious deformity of the knee
    • Loss of range of motion
    • Fatigue or a vague sense of feeling unwell
    • Crepitus, or a grinding sensation on bending the knee
    Diagnosis:
    Your doctor will ask about your medical history, including any previous knee injuries. You will be asked to describe your symptoms and what makes them better or worse. You will have a physical examination that will include testing for range of motion of the knee joint. You will probably be asked to stand and walk so that the doctor can evaluate your posture and how you distribute weight on the knees. Any swelling, tenderness, or deformity of the joint will be noted.

    You may have some blood or synovial fluid taken for testing, and it is likely that you will have x-rays, which can clearly show structural changes in the joint.

    Treatment:
    Treatment for arthritis of the knee is primarily aimed at relieving symptoms and increasing function. The precise plan of treatment will depend on the cause of your disease and its stage of advancement.

    The two most effective treatments for osteoarthritis are weight loss and low impact, aerobic exercise. The use of Tylenol (acetaminophen) and NSAIDs can also be helpful, as can cortisone injections, although the cumulative side-effects of these mean that only a few injections may be given each year. Using a knee brace may alleviate symptoms. Some research has shown that using custom orthotics for shoes, taking supplements such as glucosamine and chondroitin, and receiving saline injections into the knee are not effective treatments. That being said, if these measures provide relief and if your doctor agrees, you should use them.

    Treatment for juvenile rheumatoid arthritis includes medications such as anti-inflammatory drugs, disease modifying anti-rheumatic drugs and corticosteroids, as well as biologic agents. When taking medication for JRA you will need to be very carefully monitored by your doctor.

    Gouty arthritis is treated with diet modification and medication such as colchicine.

    Treatment of infectious arthritis will depend on the cause, but will almost certainly require surgery to clear the joint.

    If conservative treatment for arthritis fails, surgery might be indicated. Surgery can be used to repair torn cartilage, graft new cartilage onto the bones, replace severely damaged cartilage with other materials such as metal and plastic, or trim part of the bones to improve joint alignment. Arthroscopy (camera-guided knee surgery) is the preferred technique as it minimizes trauma to the knee, but open knee surgery is sometimes required.

    Your doctor or physiotherapist will develop an exercise program specifically for you, tailored to increase flexibility and mobility of the knees, and strength of the leg muscles. Swimming and cycling are excellent ways to exercise aerobically without putting weight on the knees. Tai chi, yoga and Pilates are safe ways to develop flexibility and core body strength.

    What to look for in a brace for arthritis of the knee:
    Research on the benefits of wearing a knee brace for arthritis is mixed but your doctor may feel that it would be beneficial for you. There are two types commonly used: an ‘unloader’ brace, which diverts weight away from the damaged part of the knee, and a ‘support’ brace which spreads the load across the whole knee. Which type would be best for you will depend on your particular situation. Take professional advice and ensure that it is properly fitted.

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  • Osteochondritis Dissecans of the Knee

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    Osteochondritis Dissecans

    Definition:
    Osteochondritis dissecans (OCD) is a relatively uncommon condition in which a part of articular cartilage, together with a layer of bone, becomes damaged and eventually detached from the end of a bone. Although OCD can occur in other joints of the body, this condition mostly affects the knee.

    The knee is a hinged joint formed from three bones, the femur (thighbone), the tibia (shinbone) and the patella (kneecap). Where the bones meet they are covered with articular cartilage, a smooth connective tissue that allows them to slide over each other without friction. The bottom end of the femur is rounded, with the area of bone to the outside of the knee known as the lateral femoral condyle, and the area to the inside of the knee, the medial femoral condyle. Over eighty percent of cases of OCD are found on the medial femoral condyle, probably because this part of the knee bears more body weight.

    Depending on the age at which this condition manifests, it is termed juvenile osteochondritis dissecans (JOCD) or OCD. The average age when symptoms first appear is between ten and twenty years old, although it can appear at any age.

    Causes:
    Osteochondritis dissecans is caused by a reduction in the blood supply to the end of the bone, leading to the collapse of an area of bone. The cartilage overlying the area then becomes damaged and can eventually detach, along with a layer of bone to which it is attached. This is known as an osteochondritis lesion.

    Although it not certain what conditions might lead to such a reduction in the blood supply, one theory is that repeated small and unnoticed injuries cause accumulated damage and when such damage is extensive enough, symptoms become apparent. Another possibility is that there is a genetic component and certain individuals are therefore susceptible to developing OCD. Currently males are two to three times more likely than females to develop OCD.

    Symptoms:
    If a detached fragment stays in place, there may be no or few symptoms. If, however, it moves within the knee joint, symptoms may include:
    • Aching pain, mild at the beginning, but worse with time and worse with movement
    • A snapping sensation, caused by bone moving across a notched area of cartilage
    • Knee locking or popping, which can be caused by a fragment getting stuck between the bones of the joint
    • Weakness in the knee joint, possibly leading to an inability to bear weight
    • Decreased range of motion
    • Swelling and tenderness around the area
    Diagnosis:
    Your doctor will ask questions relating to your previous medical history, particularly any prior knee injuries. He or she will also ask about the symptoms being experienced, their onset, duration and severity. Your knee will be examined, during which time it will be moved and felt. You may be asked to perform certain movements in order to evaluate what causes pain.

    You will probably have an x-ray taken, and possibly also CT or MRI scans. A combination of images will provide your doctor with a good view of the bones and soft tissues of your knee. If the OCD is in its early stages, a bone scan may be taken. This involves injecting a special dye into the blood, which attaches to rapidly changing bone, such as a fracture healing. The image taken after injection of the dye will provide information to assist the doctor with the diagnosis.

    Osteochondritis dissecans can be graded, depending on the progression of the lesion:
    • Grade I: Positive diagnosis, but the articular cartilage is still whole
    • Grade II: Some damage to the articular cartilage is visible
    • Grade III: There is a loose fragment, but it is still within the depressed area of bone
    • Grade IV: The loose fragment has become dislodged and is elsewhere within the joint
    Treatment:
    Younger patients whose skeletons are still immature have the best outcome with non-operative treatment, although the decision will depend on the stability or looseness of the lesions (fragments). If the lesion is unstable, surgery might be necessary.

    Older patients will almost certainly have to undergo surgery, as the OCD will not heal completely on its own.

    Non-surgical treatment:
    • Rest: activity must be restricted and movement of the knee limited. This can be achieved with the use of a knee immobilizing brace, or a hinged and adjustable brace that can be set for a limited range of motion, and the use of crutches when walking.
    • An ice pack on the knee, kept in position for fifteen minutes at a time, to reduce inflammation.
    • Elevate the knee above heart level, whenever possible.
    • The use of over the counter pain medication such as acetaminophen (Tylenol) and NSAIDs (Advil, Motrin, Aleve).
    • Physiotherapy to gradually stretch and strengthen the knee and its supporting muscles, and increase the range of motion of the joint
    Non-surgical treatment is usually tried for at least three to six months before surgery is considered.

    Surgical treatment:
    When surgery is necessary, arthroscopy is preferred to open knee surgery as trauma to the knee is less and recovery times are quicker. Depending on the size and location of the fragment, the surgeon might:
    • Drill small holes at the site of the damage, in an attempt to stimulate a new supply of blood to the area
    • Secure the fragment back in position using pins or screws, which may need subsequent removal.
    • Remove the fragment from the joint
    • Graft another piece of bone and cartilage onto the damaged area of bone. This might be tissue from your own body (usually taken from a non-weight-bearing area of the joint) or from a donor.
    There is currently an experimental technique being developed where articular cartilage is grown from cartilage cells (chondrocytes) and then implanted.

    Following surgery, a continuous passive motion machine may be used to help prevent stiffness. You will have to avoid putting weight on the leg for up to six weeks, and up to four months if you have had a tissue transplant. Using a walker or crutches will help you get around. A physiotherapist will work with you, initially to relieve pain and reduce swelling, and then to introduce a program of exercises designed to restore range of motion, flexibility and strength to the knee joint.

    Prognosis:
    The younger the patient, and the smaller and more stable the lesion, the better the outcome will be. It is possible, and more likely in older patients, that a diagnosis of osteochondritis dissecans will result in eventual degenerative or osteoarthritis of the knee.

  • Patellar Subluxation

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    Patellar Subluxation

    Definition:
    Patellar subluxation occurs when the kneecap (the patella) is partially and temporarily dislocated from its normal alignment within the knee joint. Patellar tracking disorder is similar, in that the kneecap is not kept within its normal position, but it occurs on a regular basis as the knee bends and straightens.

    The knee is a complex, hinged joint formed by the articulation of three bones, the femur (thighbone), the tibia (shinbone) and patella. Strong ligaments attach the bones to each other, keeping the joint in correct alignment, and tendons run from muscles to bones. Surrounding the joint is a fibrous articular capsule. Within the joint, where the bones come into contact, they are covered with smooth cartilage, enabling them to slide over each other without friction. The patella itself is held within a tendon sheath and ligaments on either side keep it within a groove in the bottom of the femur, called the trochlea. As the knee bends and straightens, the patella slides up and down within the trochlea. If the patella is subjected to an unusual sideways force, it can become subluxated. Patellar tracking disorder occurs when the patella regularly does not move correctly within the trochlea. Both of these conditions result in pain and inflammation.

    Causes:
    • An abnormality in the structure of the knee, for example the patella or the femur
    • Underdevelopment of the inner thigh muscles
    • Overdevelopment of the outer thigh muscles
    • Overly tight or too loose ligaments and tendons
    • Damaged cartilage
    • Severe blow to the side of the knee
    Symptoms:
    If patellar subluxation has occurred due to a traumatic sideways force to the knee:
    • Severe pain
    • The kneecap will be obviously out of position, unless it has repositioned itself
    • Rapid swelling
    • Inability to put weight on the leg
    • Pain on attempting to bend or straighten the knee
    If symptoms are being caused by patellar tracking disorder, they may include:
    • Pain or discomfort, made worse by bending and straightening, or sitting still for a long time
    • A feeling of the kneecap slipping or catching
    • A grinding or popping sensation
    • A feeling that the knee may suddenly give way
    Diagnosis:
    Your doctor will ask about your medical history, particularly with regard to any previous knee problems. You will probably be asked about the circumstances of any injury, the onset of your symptoms, their duration and severity and what seems to make them better or worse. The physical examination of your knee will involve the doctor feeling and moving the joint to judge the alignment, stability and tracking of the patella.

    X-ray, CT (computerized tomography) and MRI (magnetic resonance imaging) tests might be taken to rule out other possible causes of your symptoms.

    Treatment:
    Unless surgery is indicated, treatment usually includes the following methods. It is extremely important to take the necessary time to heal properly in order to avoid permanently damaging your knee. Do not rush, and follow professional advice in order to achieve the best outcome.

    Rest the knee to allow the ligaments to heal. A knee brace is worn to limit movement and keep the kneecap in its correct position. Crutches may have to be used temporarily to avoid placing too much weight on the leg.

    Apply ice packs to the affected knee for twenty minutes at a time, several times a day for the first few days to reduce swelling and relieve pain. Icing the knee after doing rehabilitation exercises is also recommended.

    Elevate the knee so that it is above the level of your heart in order to help reduce swelling.

    Take over the counter medications (NSAIDs such as ibuprofen, naproxen or aspirin or acetaminophens such as Tylenol) will help with pain and inflammation. Do not give aspirin to anyone under the age of twenty.

    Undertake an exercise program, initially under the supervision of a professional, to strengthen the leg muscles, particularly the quadriceps.

    Surgery:
    If your patellar subluxation or patellar tracking disorder is severe and chronic, surgery may be indicated. Usually damage to the knee can be repaired and the kneecap repositioned to stay in alignment. This is normally a successful procedure in that it makes the knee stable, but it may increase the risk of osteoarthritis in later years.

    Your surgeon will discuss with you all the options, risks and likely outcomes of the various surgical procedures available.

    Rehabilitation after surgery will include the above treatments, but it will necessarily take longer to return to full mobility.

    Exercises:
    With prior approval from your doctor or physiotherapist, you can start doing these exercises to increase range of motion in the knee and strength of the supporting muscles.
    Quad sets:
    Tighten the quadriceps muscles at the front of the thigh. Hold for 10 seconds then relax for 3 seconds. Repeat 10 times for 1 set. Do 3 sets.
    Hamstring stretch:
    Standing, place the heel of the affected leg on the seat of a chair. Keep your knee and back straight and bend forwards at the hips until you feel a stretch in the back of the thigh. Hold for 15-30 seconds. Repeat 3 times.
    Quad stretch:
    Standing or lying down, hold the foot of the injured leg and draw it backwards towards the buttocks as far as possible until a stretch is felt in the front of the thigh. Keep the knees together. Hold 30 seconds. Repeat 2-3 times, 3 times a day.
    Side leg lift:
    Lying on your side with the affected leg uppermost and straight, tighten the quadriceps muscles and slowly lift the leg about 10 inches up. Lower slowly. Repeat 10 times for 1 set. Do 3 sets.
    Straight leg raise:
    Sit on the floor with your legs straight out in front of you. Lift the injured leg up off the floor, keeping the knee straight. Hold for 10 seconds then slowly lower. Repeat 10 times for 1 set. Do 3 sets.

    Prevention:
    • Modify your activities or sports participation to avoid those that worsen your condition.
    • Maintain a healthy weight: Being overweight places extra stress on the joints, in particular the knees and ankles as these bear most of the body's weight.
    • Warm up and stretch carefully before activity.
    • Exercise to strengthen the leg muscles that keep your knee in proper alignment, particularly the quadriceps.

    More Info ›

  • Patellar Tendonitis | Jumpers Knee

    Patellar Tendinitis

    Patellar tendinitis is the inflammation, damage or rupture of the patellar tendon. The patellar tendon is a very strong sheath of connective tissue that connects the kneecap (patella) to the shinbone (tibia). Although called a tendon, anatomically it is actually a ligament, as ligaments attach bone to bone while tendons attach muscle to bone.

    Extending, or straightening, the lower leg is made possible by a combination of muscles and tendons, the ‘extensor mechanism’. The quadriceps muscles, the quadriceps tendon and the patellar tendon form part of this mechanism.

    Causes:
    Overuse of the tendon is the main cause of patellar tendinitis. As it is used every time a person straightens their leg, the tendon is at risk of injury through excessive repetition of particular movements, such as jumping. Basketball and volleyball players, as well as runners and soccer players, are particularly at risk of developing what is often called ‘jumper’s knee’.

    Sometimes the condition may be triggered by a trauma to the front of the knee, but this is less common than injury due to overuse.

    Repeated stress on the tendon can cause microscopic tears in the fibers. These heal with time but, if activity is continued without allowing adequate healing time, the inflammation will persist and worsen.

    Certain factors increase the risk of developing the condition. Some of these are:
    • Sudden increase in intensity or frequency of physical activity
    • Being overweight, which increases stress on the tendon
    • Overly tight quadriceps or hamstrings
    • A kneecap naturally positioned slightly higher than usual, which places the tendon under increased stress
    Symptoms:
    • Pain which begins as a twinge but becomes more severe with time and activity
    • Pain felt over the patellar tendon, between the kneecap and shinbone
    • Pain, often sharp, worse with jumping or kneeling
    • Aching pain, persisting after activity
    • Occasionally there is swelling of the area around the tendon
    Diagnosis:
    Your doctor will make a diagnosis based primarily on your reported symptoms and the results of a physical examination of the knee.

    You may have an x-ray to rule out possible bone fractures or a bone spur. Ultrasound can reveal tiny tears in the tendon, and an MRI (magnetic resonance imaging) clearly shows all the soft tissues and any damage sustained by them.

    Many other conditions produce similar symptoms to patellar tendinitis, so your doctor may use a combination of procedures to arrive at a positive diagnosis.

    Treatment:
    Conservative, or non-surgical, treatment usually resolves the problem. However, if symptoms persist for over a year, surgery may be necessary to repair tears in the tendon or remove damaged parts.

    Initially, any activity that makes the condition worse must be avoided. Refrain from doing anything that causes pain in the tendon. Recovery from patellar tendinitis is a slow process, ranging from a few weeks to several months, depending on the severity of the injury. It is very important to allow adequate time for healing. ‘Pushing through’ the pain will only cause more damage and delay healing.

    Use ice packs on the front of the knee to reduce swelling of the tendon. Crush ice in a bag then cover the bag with a towel and place on the painful area for as long as possible without excessive discomfort, several times a day. This is especially effective during the first few days.

    Do not use any kind of heat on the area for the first three days as this will increase swelling and pain.

    You may find that an infrapatellar (or Chopat) strap helps to relieve pain. This is a strap that is worn around the leg, just under the kneecap. It applies pressure on the tendon, which directs force away from it and through the strap instead. Your doctor may recommend a particular knee brace for you.

    Amongst other techniques such as massage and ultrasound, a physiotherapist may use an anti-inflammatory and pain-relieving technique called iontophoresis. A corticosteroid ointment is applied to the skin over the painful area then a gentle electric charge delivers the medication deep into the tissues of the tendon. Sometimes your doctor may inject the patellar tendon sheath with a corticosteroid, usually combined with an anesthetic.

    Your physiotherapist will also develop an exercise program aimed at stretching and strengthening the leg muscles, particularly the quadriceps. A relatively new system known as eccentric exercise is proving to be highly beneficial, but a professional must teach you how to perform these exercises properly.

    Exercise:
    The following exercises should not be done without prior approval from your doctor or physiotherapist. Try to do them twice each day.
    Hamstring stretch:
    Keeping the knee straight, place the heel of your foot on the seat of a chair. Lean forward from the hips, making sure you do not bend at the waist. When you feel a gentle stretch in the back of the thigh, hold the position for 15-30 seconds. Repeat 3 times. Switch legs and repeat exercise.
    Quad stretch:
    Place the left hand on a wall for support. Hold the right foot with your right hand and gently pull the foot up and behind you towards the buttocks, stopping when you feel a stretch. Keep the knees together. Hold the stretch for 15-30 seconds. Repeat 3 times then switch legs and repeat exercise.
    Leg extension:
    Lie down on the floor with your legs straight out in front of you. Raise one leg (keeping it straight) about 6 inches off the ground. You can use a rolled towel under one thigh for support. Hold the position for 5-10 seconds then slowly bend your knee to lower the foot to the floor. Repeat 10 times. Switch legs and repeat exercise.
    Straight leg raise:
    Lying on your back on the floor, bend your unaffected knee and rest the foot on the floor. Keeping the knee of the injured leg straight, contract the thigh muscles and lift the leg up until the heel is about 6 inches off the ground. Hold for 5-10 seconds then slowly lower. Repeat 10 times. Switch legs and repeat exercise.
    Quad sets:
    Sit on the floor with your injured leg straight out in front of you and the unaffected leg bent with the foot on the floor. Contract the thigh muscles of the injured leg by pressing the knee towards the floor. Hold the position for 5-10 seconds then relax. Repeat 10 times. Switch legs and repeat exercise.

    Prevention:
    • Stretch and strengthen your leg muscles.
    • Ensure that you use proper technique when exercising.

  • Patellofemoral Pain Syndrome / Runner's Knee

    Untitled

    Patellofemoral Pain Syndrome

    Definition:
    Patellofemoral pain syndrome, often known as Runner’s Knee, is the term used to describe pain under or around the patella (kneecap), caused by one of a number of conditions that lead to unusual stress on the knee joint.

    The knee is a complex, hinged joint, made up from three bones, the femur (thighbone), tibia (shinbone), and patella (kneecap). Strong ligaments attach the bones to each other, keeping the joint in correct alignment, and tendons run from muscle to bone. Within the joint, the ends of the femur and tibia are covered with smooth articular cartilage that allows them to slide over each other without friction.

    Causes:
    • Overuse: The term ‘runner’s knee’ indicates that overuse or excessive training might cause patellofemoral pain syndrome. Athletes participating in any sport that repeatedly puts heavy stress on the knee are vulnerable.
    • The kneecap may not track properly within the trochlea, the groove in the bottom of the femur, up and down which the patella slides as the knee bends and straightens.
    • The patella may have been dislocated, either partially or completely, thereby damaging the ligaments that hold the knee joint in correct alignment.
    • The quadriceps muscle in the front of the thigh might be too tight, pulling the patella out of position. Alternatively, it may be weak or imbalanced, allowing improper patellar tracking.
    • Damage to the patellar tendon that holds the kneecap in position.
    • Flat feet
    • Referred pain from an injury to the hips or the back.
    Symptoms:
    • Pain felt as a dull ache under or around the top part of the kneecap, where it comes into contact with the femur.
    • Pain worse when kneeling, walking up and down stairs, sitting for a long time or other situations when the knee is bent.
    • The knee may unexpectedly give way.
    • A grinding, catching or popping sensation when walking.
    Diagnosis:
    Your doctor will make a diagnosis based on your medical history and a thorough physical examination.

    Questions you may be asked will relate to the onset, duration, severity of your symptoms and what makes them better or worse; any previous injuries to the knee; your lifestyle and, if you are an athlete, any changes in your exercise program such as intensity of training or using a different type of surface.

    The physical examination will include manipulating and palpating (touching) all parts of the knee to evaluate joint alignment and determine the focus of the pain. The range of motion of your knees, hips, ankles, and feet will be assessed, as will the strength and flexibility of the thigh muscles.

    Imaging tests such as x-ray, CT and MRI scans may be required to view the bones and soft tissues. Blood tests might be ordered if an infection is suspected.

    Treatment:
    Treatment of patellofemoral pain is usually non-surgical. Surgery may occasionally be required to remove or repair a piece of damaged cartilage, or to realign the patella. Arthroscopy is the preferred technique as it minimizes trauma to the knee.

    Patellofemoral pain syndrome responds better to early treatment so, in order to gain relief from pain and to avoid doing further damage that may make treatment more difficult, follow the conservative treatments listed below, and arrrange to see your doctor.
    • Rest: Avoid any activity that aggravates the condition. Use crutches when walking to avoid putting weight on the knee. If you want to continue exercising, switch to an activity like swimming, which does not place weight on the knee.
    • Ice: Apply ice, crushed in a bag and wrapped in a towel, to the knee for as long as possible without causing great discomfort, several times a day. This will help to reduce swelling and inflammation.
    • Compression: Using a knee brace or taping the knee can relieve pain.
    • Elevation: Raise the knee above the level of your heart, as often as possible, to reduce swelling.
    • NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen, naproxen or aspirin, will help to relieve pain and reduce inflammation.
    When no more pain is present, you will probably need to rehabilitate the knee. Your doctor or physiotherapist will provide a program of exercises designed to gradually stretch and strengthen the leg muscles.

    Exercises:
    Try to do these exercises twice a day. Repeat exercises with both legs to avoid developing an imbalance.
    Quad stretch:
    Standing or lying down, hold the foot of the injured leg and draw it backwards towards the buttocks as far as possible until a stretch is felt in the front of the thigh. Hold 30 seconds. Repeat 5 times.
    Quad tightening:
    Sitting on the floor with your injured leg straight out in front of you and the unaffected leg bent with the foot on the floor, contract the thigh muscles of the injured leg by pressing the knee towards the floor. Hold the position for 5-10 seconds. Repeat 10 times.
    Straight leg raise:
    Lying on your back on the floor, bend your unaffected knee and rest the foot on the floor. Keeping the knee of the injured leg straight, contract the thigh muscles and lift the leg up about 6 inches off the ground. Hold for 5-10 seconds. Repeat 10 times.
    Iliotibial band stretch:
    Stand with your right leg crossed in front of the left, both feet flat on the floor with the right foot only slightly in front of the other. Bend forward from the hips and reach your hands toward the floor, stopping when you feel a stretch in the outer part of the left thigh. Hold for 10-20 seconds. Repeat 10 times.
    Hamstring stretch:
    Sit on the floor with your legs straight out in front of you. Lean forward from the hips until a stretch is felt under the thighs. Hold 30 seconds. Repeat 5 times.
    Calf stretch:
    Stand facing a wall and place hands on it for support. Lean forwards until stretch is felt in the calves. Hold for 30 seconds. Bend at knees and hold for a further 30 seconds. Repeat 5 times.

    Brace for patellofemoral pain syndrome:
    Ask your doctor’s advice as to whether a knee brace would be helpful for you. There are many types available, and it is important that, should you wear one, it be properly fitted. A patellar stabilizing brace holds the kneecap in its correct position within the trochlea and can be useful until the leg muscles are adequately strong.

    Prevention:
    • Maintain a healthy weight to avoid putting excessive strain on the knee
    • Always warm up and stretch properly before exercising
    • Exercise regularly to maintain flexibility and strength in the legs
    • Use properly fitted sporting equipment
    • Wear orthotics if necessary
    • Use good technique when participating in your particular sport

  • PCL Injuries

    PCL Injuries

    Definition:
    The posterior cruciate ligament (PCL) is one of the four main stabilizing ligaments in the knee. It attaches at its upper end to the bottom of the femur (thighbone), crosses diagonally through the joint, and attaches at its lower end to the top of the tibia (shinbone). Together with the anterior cruciate ligament (ACL), which lies in front of the PCL, it forms an ‘X’ shape within the joint, hence the name cruciate. Its purpose is to limit the backwards motion of the tibia, thereby keeping the knee joint stable. It is a strong ligament and is consequently injured less often than the ACL, although it is thought that many PCL injuries remain undiagnosed.

    Causes:
    An injury to the posterior cruciate ligament is usually the result of the tibia being subjected to a powerful force, which drives it up and behind the femur. Such injuries are often known as ‘dashboard’ injuries as they commonly occur in car collisions when the shin has struck the dashboard. An athlete can injure the PCL by falling onto the front of the knee when the knee is fully bent backwards and the foot is pointing down. Twisting or overextending the knee can also damage the PCL, although this is a less common cause of injury. PCL injuries often occur in conjunction with injuries to other structures of the knee.

    Symptoms:
    Sometimes an isolated PCL injury (one that does not involve other parts of the knee) may simply produce some swelling that goes down after a few days. Patients may therefore not visit their doctor. If untreated, however, a PCL injury can lead to problems such as abnormal movement of the joint and eventual degenerative arthritis.

    Some commonly experienced symptoms may include:
    • Knee pain
    • Swelling that begins within three hours of the injury
    • Decreased range of motion of the knee and difficulty walking
    • Instability of the joint
    • A feeling that the knee might give way
    Diagnosis:
    Injuries to the PCL can be quite difficult to diagnose. Your doctor will ask you questions about your medical history and any previous injuries to the knee. You will be asked about the circumstances of the injury, for example, how and when it happened and the position that your leg was in at the time.

    You will have a physical examination, during which your doctor will look at and feel the structures of the knee. A comparison will be made with the uninjured leg. A test called the posterior drawer test will probably be used to assess the viability of the PCL. Your injured knee will be bent, and then the doctor will gently push backwards on the tibia. If the tibia moves too far backwards, it is an indication that the PCL has been damaged.

    You may have an X-ray to determine if a piece of bone has torn away with the ligament. MRI (magnetic resonance imaging) scans provide clear pictures of soft tissues, so one may be used to help with a diagnosis and to detect any damage to other parts of the knee.

    PCL injuries are termed sprains, and are graded according to the severity of the damage.
    Grade I indicates that the ligament has been stretched and that there are microscopic tears, but the joint is still stable.
    Grade II is termed a partial tear. The ligament has been stretched to the point of looseness.
    Grade III means that the ligament has been completely torn into two pieces and the joint is unstable.

    Most PCL sprains are partial tears and can heal with conservative treatment and time. The prognosis for a return to full, pre-injury activities and sports is good.

    Treatment:
    Initial treatment of a partial tear to the posterior cruciate ligament includes:
    • Rest: You may find it helpful to avoid putting any weight on the knee by using crutches when walking.
    • Ice: Apply ice, crushed in a bag and covered with a towel, to the knee for as long as is comfortable, several times a day.
    • Compression: Wrapping the knee in an ace bandage to reduce pain.
    • Elevation: Raise the leg above the level of your heart, whenever possible, to reduce swelling.
    • Take NSAIDs (non-steroidal anti-inflammatory drugs) to relieve pain and reduce inflammation.
    Following the acute stage of the injury and when the swelling has gone down, you might be able to begin rehabilitation exercises. Follow the advice of your doctor or physiotherapist. Such exercises are designed to restore mobility to the knee and to strengthen the leg muscles that support the joint, particularly the quadriceps muscle of the thigh.

    Sewing a torn PCL back together is not successful, so surgery, if required, would be to reconstruct the ligament using a tissue graft taken either from another part of your body, or from a donor. Due to the position of the PCL in the knee, surgery can be difficult and over time grafts can stretch and lose function. Surgery therefore tends to be restricted to cases where there is significant damage to other major knee ligaments. Arthroscopy, using small incisions around the knee, is the preferred surgical technique as it minimizes trauma and enables swifter healing. You would have to use crutches for a time, and wear a knee brace to temporarily immobilize the knee.

    Exercises:
    Follow professional advice as to when to begin exercising. Do not rush: recovering from a PCL sprain will take time. Try to do these exercises twice a day.
    Quad contraction:
    Tighten the quadriceps muscles at the front of the thigh. Hold for 10 seconds. Repeat10 times.
    Straight leg raise:
    Lie on the floor with one leg bent and the other straight out in front of you. Lift the straight leg up about 5 inches off the floor, keeping the knee straight. Hold for 10 seconds. Repeat 10 times. Switch legs and repeat exercise.
    Quad stretch:
    Hold the right foot with your right hand and gently pull the foot up and behind you towards the buttocks, stopping when you feel a stretch. Keep your knees together. Hold the stretch for 10 seconds then relax. Switch legs and repeat exercise.
    Hamstring stretch:
    Sit on the floor with one leg bent and the other straight out in front of you. Keep your toes pointing to the ceiling and lean forward from the hips until a stretch is felt under the outstretched thigh. Hold 10 seconds. Repeat 10 times. Switch legs and repeat exercise.
    Half-knee bends:
    Stand with your feet about shoulder width apart. Slowly bend your knees as though you were about to sit on a chair. Stop halfway, or earlier if you feel any pain, and then stand up straight again. Repeat 10 times.

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  • Pes Anserine Bursitis

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    Pes Anserine Bursitis

    Definition:
    Pes anserine bursitis is the medical term for inflammation of the pes anserine bursa in the knee.

    Muscles are joined to bones by tendons. The tendons from three hamstring muscles in the thigh, the sartorius, gracilis and semitendinosus, conjoin to form the pes anserinus (Latin for ‘goosefoot’ due to the tendons webbed shape). The tendon has its insertion into the tibia (shinbone) about an inch or two below the knee joint, on the inner (medial) side of the knee. The medial collateral ligament (MCL) also has its tibial insertion at this point, and lies just deep to the pes anserinus. Between these structures and the tibia is a bursa, a potential space lined with a synovial membrane that secretes lubricating and nourishing synovial fluid. When constant friction irritates the bursa, the synovium produces more fluid, causing swelling and pain.

    Causes:
    Tight hamstring muscles are the predominant cause of pes anserine bursitis. Athletes, particularly runners, are prone to this condition although any sport that requires side-to-side movement, such as basketball, soccer and racket sports, can trigger bursitis as well.

    Older patients who already suffer from osteoarthritis are at increased risk. It is thought that up to 75% of people with degenerative knee joint disease have symptoms. People with flat feet, knock-knees or certain other anatomical conditions that might increase stress on the tendon at that point are also vulnerable. Pes anserine bursitis can also be found in conjunction with other knee conditions and injuries, such as a meniscal tear or Osgood-Schlatter disease.

    Women, especially if they are middle-aged and obese, can develop pes anserine bursitis. It is thought that the wider female pelvis, the angle of the legs at the knees, and extra body weight, all of which increase stress on the knee joint, might be responsible.

    Direct trauma to the inner knee can cause the synovial lining of the bursa to produce more fluid, leading to inflammation and pain.

    Symptoms:
    • Tenderness over a diffuse area of the inner knee
    • Mild to moderate pain
    • Local swelling
    • Discomfort increased when climbing stairs (occasionally when going down) and standing up from a seated position
    • Little or no pain when walking on a level surface
    Diagnosis:
    Your doctor will make a diagnosis based on your medical history, current symptoms and a physical examination of the knee. Palpation (touch) of the area will help to pinpoint the exact location of the pain. The tightness of your hamstrings will be assessed.

    An x-ray image will be taken to rule out a bone fracture, as the symptoms caused by a fracture can be very similar to those caused by pes anserine bursitis. MRI scans are used to look at the soft tissues of the knee.

    If infection is suspected, synovial fluid from the bursa may be removed for testing.

    Treatment:
    Surgery is rarely needed for this condition as most cases resolve with time and non-operative treatment. If surgery is necessary, it will be to remove the bursa and any bony spur present. Rehabilitation would include keeping the knee immobilized for 1-2 weeks post-surgery, followed by a gradual return to activity, and the treatments listed below.
    • Rest: Reduce activities that aggravate the condition. Such activities might include climbing stairs or playing sports.
    • Ice: Apply ice to the area, crushed and in a bag, covered with a towel, for 15 minutes at a time, several times a day.
    • Medication: Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil), naproxen (Aleve) or aspirin will reduce inflammation and relieve pain.
    • Corticosteroid injection: This may be used as part of the diagnostic testing: if an injection into the bursa improves symptoms, it is indicative of pes anserine bursitis. The injection, usually given in conjunction with an anesthetic, will relieve symptoms for several weeks and in some cases longer. Up to 3 injections may be given in any year.
    • Physiotherapy may make use of ultrasound to promote healing. Your physiotherapist will devise an individualized and progressive exercise program, which will focus on stretching the hamstring muscles and strengthening the quadriceps. This program will probably last for 6-8 weeks, although athletes would benefit from continuing with such exercises on a regular basis.
    • Athletes may wish to wear a protective pad over the knee when returning to sports.
    Exercise:
    Follow the advice of your physiotherapist or doctor.
    Hamstring stretch:
    Lie on your back on the floor, near a doorway, so that you are able to raise one leg and rest it on the wall next to the doorframe. Your other leg should remain straight out in front of you, extending through the doorway. Hold the stretch in the back of your thigh for 20-30 seconds. Repeat 3 times. Switch legs and repeat the exercise.
    Calf stretch:
    Put your hands against a wall for support. Place one lege behind you with the heel on the floor, and keep the other leg forward. Slowly lean into the wall until you feel a stretch in the back of your calf. Hold for 20- 30 seconds. Repeat 3 times. Switch legs and repeat the exercise. This can be done several times each day.
    Quad stretch:
    Place the left hand on a wall for support. Hold the right foot with your right hand and gently pull the foot up and behind you towards the buttocks, stopping when you feel a stretch. Keep your knees together. Hold the stretch for 10 seconds then relax. Switch legs and repeat exercise.
    Hip Adductor stretch:
    Lie on your back on the floor with bent knees and feet flat on the floor. Let your knees fall open as far as they will comfortably go. Hold the position for 20-30 seconds. Repeat 3 times.
    Quad sets:
    Sitting on a table or lying down, press the knee down against the table or floor by tightening the quadriceps muscles in the top of your thigh. Hold the position for 5-10 seconds then relax. Repeat 10 times for 1 set. Do 3 sets.
    Heel slide:
    Lie on your back on the floor with your legs straight out in front on you and together. Slide the heel towards the buttocks as far as possible. Hold for 5 seconds then straighten. Repeat 10 times for 1 set. Do 3 sets.

    Prevention:
    For older patients with pes anserine bursitis, exercise is important in order to avoid atrophy of the muscles. For younger patients, maintain flexibility and strength in the leg muscles.
  • Prepatellar Bursitis

    Prepatellar Bursitis

    Definition:
    Prepatellar bursitis is an inflammation of the prepatellar bursa. A bursa is a pouch containing lubricating and nourishing synovial fluid that is secreted by a thin membrane lining the sac. Bursae are found around joints, where their purpose is to facilitate the smooth movement of skin, muscles or tendons over bones. The prepatellar bursa lies under the skin on top of the kneecap, where it acts as a cushion between the two and prevents friction as the kneecap moves up and down when the knee bends or straightens. The bursa is normally thin and flattened, but when irritated or injured it can fill with fluid, blood or pus, causing painful swelling on top of the kneecap.

    Causes:
    Prepatellar bursitis is sometimes known as ‘housemaid’s knee’ as it occurs most frequently in people whose occupations require them to spend extended periods of time on their knees. Chronic irritation caused by repeated small injuries to the bursa can lead to this painful condition.

    Other possible causes include:
    • Trauma to the kneecap, such as a fall onto the knee, which can damage the tissues of the bursa and lead to it filling with blood. Even after the body has reabsorbed the blood, the bursa may remain thickened and swollen.
    • Infection, which may or may not have been caused by an injury to the skin over the patella. In this case the bursa will become filled with pus.
    • Gout
    Symptoms:
    • Pain around the kneecap, worse with movement of the knee and better with inactivity
    • Swelling on top of the kneecap
    • Tenderness on top and around the kneecap
    • Redness and warmth around the knee, particularly if the bursa is infected
    • Reduced range of motion of the knee joint due to swelling and pain
    • Inability to kneel on the affected knee
    • Sometimes small tender lumps can be felt under the skin over the knee. These are areas of thickened bursa.
    Diagnosis:
    Your doctor will ask you questions related to your symptoms, your lifestyle, occupation and activities, and any previous injuries to your knee. The physical examination will include a visual evaluation and palpation (touch) of the knee to assess the amount of fluid over the kneecap and areas of tenderness. Your knee will be flexed and extended to determine the amount of mobility there is in the joint.

    X-ray or other imaging techniques will probably only be necessary if a fracture is suspected, or initial treatment has failed to manage the problem.

    Treatment:
    Before your appointment with the doctor, the following measures can be taken to provide some relief from painful symptoms. Usually, prepatellar bursitis will respond to conservative treatment.

    Self-help options:
    • Rest the knee. Avoid kneeling or any activity that aggravates the condition.
    • Apply ice, crushed in a bag and covered with a towel, to the knee for as long as possible without causing excessive discomfort, several times a day.
    • Use NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Advil), naproxen (Aleve) or aspirin.
    • Elevate the knee above heart level whenever possible.
    • Perform exercises designed to increase range of motion of the knee and flexibility of the quadriceps and hamstring muscles of the thigh.
    • Use a kneepad if kneeling is unavoidable.
    • Wearing a knee brace, taping the kneecap or wearing orthotic inserts in the shoes may be helpful, depending on your particular circumstances.
    Your doctor may drain some or all of the liquid from the bursa, using a needle and syringe. This simple procedure, known as needle aspiration, can be performed in the doctor’s office. It will reduce the swelling and thereby relieve pain, and the fluid can be tested for possible infection. Sometimes your doctor may inject the bursa, at the same time, with cortisone medication to reduce the inflammation, if an infection has been ruled out. If an infection is present, you will be prescribed antibiotics.

    If the bursa continues to fill, and symptoms are persistent and painful, your doctor will discuss the possibility of surgery to remove the bursa entirely. After surgery, the body may grow a new bursa in response to the movement of the skin over the patella. This is often a normal bursa so new painful symptoms should not be experienced.

    Rehabilitation exercises:
    These exercises should be performed twice each day, if possible. They will help to stretch and strengthen your leg muscles. Always exercise both legs.
    Hamstring stretch:
    Lie on your back on the floor, near a doorway, so that you are able to raise one leg and rest it on the wall next to the doorframe. Your other leg should remain straight out in front of you, extending through the doorway. Hold the stretch in the back of your raised thigh for 30 seconds. Repeat 3 times.
    Calf stretch:
    Stand facing a wall and place hands on it for support. Lean forwards until a stretch is felt in the calves. Hold for 30 seconds. Bend at the knees and hold for a further 30 seconds. Repeat 5 times.
    Quad stretch:
    Standing or lying down, hold the foot of the injured leg and draw it backwards towards the buttocks as far as possible until a stretch is felt in the front of the thigh. Keep the knees together. Hold the stretch for 30 seconds. Repeat 3 times.
    Quad tightening:
    Sitting on the floor with your injured leg straight out in front of you and the unaffected leg bent with the foot on the floor, contract the thigh muscles (the quadriceps) of the injured leg by pressing the knee towards the floor. Hold the position for 5 seconds. Repeat 10 times.
    Heel slide:
    Lie on your back on the floor with your legs straight out in front of you and together. Slide the heel towards the buttocks as far as possible. Hold for 5 seconds then straighten. Repeat 10 times.

    Brace for prepatellar bursitis:
    A kneepad, or knee sleeve that incorporates a pad over the patella, may help to alleviate pain caused by bursitis, and protect the kneecap from further injury.

  • What is a Heel Float?

    What is a Heel Float?

    A heel float is a type of soft boot designed to protect the heel skin of patients who are either bedridden or able to walk around a little.


    Shop for Heel Floats

    The heel is the second most common anatomical location for skin damage due to pressure. Damage occurs in two ways: Friction injury is caused by the constant movement of the heel on another material such as a shoe, or bed linen, which can lead to blisters. Shear injuries, which are caused by gravity and friction, damage deeper fatty tissues and blood vessels, leading to pressure ulcers.

    Heel ulcers can take up to a year or longer to heal, depending on individual patient health, and in severe cases can lead to amputation, so it is obviously imperative to do as much as possible to prevent ulcers developing. It is recommended that heel floats should be used for any patient who is immobilized for longer than twelve hours. Studies have shown that patients who move around in bed or who are otherwise at high risk for ulcers benefit greatly from wearing a heel float boot.

    The heel float boot is designed to raise the heel and suspend it over an air cavity in order to protect fragile skin from developing ulcers or sores through pressure or friction. It does this by supporting the lower leg by way of a removable gel pad or integral foam under the calf or ankle. This holds the heel up over the cavity. The boot surrounds the lower leg, foot, and ankle.

    The intention is to avoid any pressure on the vulnerable areas of the foot and ankle. To this end, the boots may have cutouts, or open ‘window’ areas to allow air circulation for skin health and healing of any existing sores. These may be positioned to eliminate pressure on the anklebones. Straps will be positioned so they attach below any bunions. Some boots are adjustable to accommodate patients who may not be able to stretch their feet normally. Sometimes a firm insert is provided for extra support and to keep the foot at a 90-degree angle, thereby avoiding foot drop.

    The heel float boots are kept comfortably and securely in position with Velcro straps that do not touch the skin. Soft, cushioned fabric protects the skin and wicks away moisture.

    They are primarily designed for immobilized patients, but some styles have a detachable tread pad that makes them suitable for standing and walking in. These pads can be removed for cleaning and to keep bed linens clean. Another feature that may be offered is extended foot supports that help to keep bed linens away from the toes.

  • What is the Best Knee Brace for Arthritis?

    What is the Best Knee Brace for Arthritis?

    In common with other joints in the body, the knee is susceptible to developing arthritis. The three main types that afflict the knee are osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis, all of which generally develop gradually.

    Cartilage covers the ends of the bones that form the knee joint. It serves to cushion the bones, preventing them grinding against each other; it also helps to absorb the shock of impact.

    Osteoarthritis is a degenerative condition of the cartilage, caused by age and general wear and tear on the joint. Rheumatoid arthritis is not age-related. It is an inflammatory disease that can destroy cartilage, causing pain and swelling in the joint. Post-traumatic arthritis, which is similar to osteoarthritis, can develop years after an injury such as a fracture, meniscal tear, or damage to a ligament.

    Symptoms of knee arthritis are pain, swelling, stiffness, weakness, and sometimes a feeling that the knee may suddenly give way. To get the most effective treatment you should get a proper diagnosis from your medical practitioner, who may recommend that you wear a knee brace to enable you to walk longer distances.

    Braces for knee arthritis tend to be either support braces or unloader braces.

    A support brace or sleeve provides warm, comfortable compression and a certain amount of stability for the knee joint. These are good for mild arthritis that affects part of, or the entire, knee. The Neo G Closed Knee Support, a lightweight compression sleeve, has adjustable straps to accommodate differing amounts of swelling, and stays in position, unlike many other knee sleeves on the market.

    For mild to moderate arthritis, an advanced support brace helps to support the ligaments, reducing the weight that passes through the knee. These types of brace can offer a patellar cutout that stabilizes the kneecap (patella) without putting pressure on it; many are adjustable to allow for varying degrees of swelling. The Neo G Stabilized Open Support is one to consider, as is the McDavid Pro Stabilizer, which is a lightweight brace giving excellent support. The McDavid Pro is one of the most popular hinged knee braces available.

    An unloader brace, which are specifically designed for knee arthritis sufferers, changes the angle of the knee joint to shift weight from the affected side of the knee to the unaffected side, relieving symptoms. Unloaders are especially good if just one side of the knee is affected. DonJoy makes an excellent range of unloader braces. Some to consider are the DonJoy OA Lite, the OA Assist (commended by the Arthritis Foundation), and the OA Everyday (designed for moderate to severe cases). A Breg OA knee brace is also worth considering, particularly the Freestyle.

    Although a knee brace will not cure your arthritis, it can relieve symptoms, allow you to continue with your regular activities, and may even delay the need for surgery. Always take your doctor’s advice, and try several types of brace in order to find the best one for your particular condition.

  • What Knee Brace is Best for a Torn Meniscus?

    What Knee Brace is Best for a Torn Meniscus?

    The meniscus is a tough, rubbery, crescent-shaped piece of cartilage between the bones in the knee joint. There are two menisci in each knee, the medial and the lateral. They act as shock absorbers, cushioning the impact of the bones against each other, and stabilizing the joint. They also aid proper weight distribution through the joint. The meniscus can tear as the result of an injury, or be worn down through age and use. Usually it is the medial meniscus (on the inner side of the knee) that gets damaged, although both parts are vulnerable.

    A meniscus tear may or may not be initially painful. Sometimes part of the meniscus may become lodged in an area of the knee where it doesn’t belong, causing the knee to lock up. Any pain may be worse during twisting or squatting movements. Often, a symptom of the injury is a feeling that the knee might give way at any time. Whatever the pain level, it is an injury that requires rest, ice, and support, followed by exercises to strengthen the knee. Surgery is occasionally necessary to repair the tear.

    During healing or post-operatively, a knee brace can provide support and stability, although it will not treat the actual injury. If you have had surgery, or your tear was a severe one, a hinged knee brace will give you significant support and help to prevent rotational movements of the knee that would aggravate the injury. A brace that provides gentle compression to the joint would be a better choice for a degenerative meniscal tear.

    A knee sleeve is what to look for if your meniscus tear is relatively mild and you just want some compression and warmth around the knee to relieve your symptoms. Another benefit of wearing a sleeve is to remind the wearer that the knee is damaged, so to avoid making movements that might make the injury worse. These are usually made from neoprene, and are available with or without a patellar (kneecap) cutout. The DonJoy Comfort Knee Brace is an example of this type of sleeve.

    Unloader braces are designed to displace weight from the injured side of the knee to the uninjured side. These are suitable for more severe meniscal tears. DonJoy make several knee braces that help to prevent the side-to-side and twisting movements that will cause more pain. They also provide a greater feeling of stability. One brace that gives significant support is the DonJoy Drytex Hinged Air Knee Brace. This brace is particularly suitable for post-operative meniscectomies (removal of the meniscus).

    For a brace that is somewhere in the middle in terms of support, consider the DonJoy Tru-Pull Advanced Hinged Patellar Knee Brace.

    Bregg also has a good range of knee braces suitable for meniscus tears.

    Try on several braces to find the one that is best for you, and remember to follow medical advice in order to achieve optimal healing.

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Common Knee Injuries & Problems

Knee injuries can range from slight discomfort due to overextension to a more serious torn ACL, MCL or LCL. Whether it’s a sprained knee or just a bout of knee pain that requires a little TLC, MMAR Medical strives to offer you the most comprehensive library of knee injury resources on the web. Read our articles, written by medical professionals, to learn how to deal with an ACL, MCL or LCL injury for a speedy recovery.

We’ll teach you how to prevent an ACL, LCL or MCL sprain, how to recognize the symptoms of common knee problems and how to treat an ailing knee. We’ll also recommend proper knee bracing solutions for when you’re ready to start rehabilitating your injury. If you’ve already been diagnosed with a particular condition, find it in our articles above and learn how to deal with it in the quickest and most comfortable way possible.

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