Knee
There are numerous ligament injuries and joint conditions of the knee. Please select a condition below to learn more. If you do not see a specific condition listed, please feel free to discuss your concerns during your visit with Dr. Dedhia.
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Overview
Athletes who participate in high demand sports like soccer, football, and basketball are more likely to injure their anterior cruciate ligaments.
If you have injured your anterior cruciate ligament, you may require surgery to regain full function of your knee. This will depend on several factors, such as the severity of your injury and your activity level.
Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella). Your kneecap sits in front of the joint to provide some protection.
Bones are connected to other bones by ligaments. There are four primary ligaments in your knee. They act like strong ropes to hold the bones together and keep your knee stable.
Collateral Ligaments
These are found on the sides of your knee. The medial collateral ligament is on the inside and the lateral collateral ligament is on the outside. They control the sideways motion of your knee and brace it against unusual movement.
Cruciate Ligaments
These are found inside your knee joint. They cross each other to form an “X” with the anterior cruciate ligament in front and the posterior cruciate ligament in back. The cruciate ligaments control the back and forth motion of your knee.
The anterior cruciate ligament runs diagonally in the middle of the knee. It prevents the tibia from sliding out in front of the femur, as well as provides rotational stability to the knee.
Description
About half of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments.
njured ligaments are considered “sprains” and are graded on a severity scale.
Grade 1 Sprains. The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly stretched, but is still able to help keep the knee joint stable.
Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose. This is often referred to as a partial tear of the ligament.
Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable
Causes
The anterior cruciate ligament can be injured in several ways:
- Changing direction rapidly
- Stopping suddenly
- Slowing down while running
- Landing from a jump incorrectly
- Direct contact or collision, such as a football tackle
Symptoms
When you injure your anterior cruciate ligament, you might hear a “popping” noise and you may feel your knee give out from under you. Other typical symptoms include:
- Pain with swelling. Within 24 hours, your knee will swell. If ignored, the swelling and pain may resolve on its own. However, if you attempt to return to sports, your knee will probably be unstable and you risk causing further damage to the cushioning cartilage (meniscus) of your knee.
- Loss of full range of motion
- Tenderness along the joint line
- Discomfort while walking
Treatment
Treatment for an ACL tear will vary depending upon the patient’s individual needs. For example, the young athlete involved in agility sports will most likely require surgery to safely return to sports. The less active, usually older, individual may be able to return to a quieter lifestyle without surgery.
Nonsurgical Treatment
A torn ACL will not heal without surgery. But nonsurgical treatment may be effective for patients who are elderly or have a very low activity level. If the overall stability of the knee is intact, your doctor may recommend simple, nonsurgical options.
Bracing. Your doctor may recommend a brace to protect your knee from instability. To further protect your knee, you may be given crutches to keep you from putting weight on your leg.
Physical therapy. As the swelling goes down, a careful rehabilitation program is started. Specific exercises will restore function to your knee and strengthen the leg muscles that support it.
Surgical Treatment
To surgically repair the ACL and restore knee stability, the ligament must be reconstructed. The torn ACL will need to be replaced with a tissue graft. This graft acts as a scaffolding for a new ligament to grow on.
Grafts can be obtained from several sources. The graft can either come from one’s own body (autograft) or from a donor (allograft). Whether to use an autograft vs. allograft is based on several factors including age, activity level, and patient preference. If using one’s own tissue, Dr. dedhia typically uses the hamstring tendons at the back of the thigh.
Procedure: Surgery to rebuild an anterior cruciate ligament is done with an arthroscope using small incisions. Through one incision, an arthroscope (a small camera about the size of a pencil) is inserted into the knee joint. The arthroscope transmits the image to a video monitor where Dr. Dedhia can see the structures of the knee in great detail. The other incision is utilized for pencil-sized instruments necessary to complete the surgical procedure.
If the graft needs harvesting, the start of the procedure begins by making a 3cm incision just below the knee joint where the hamstrings attach on the tibia. Two hamstring tendons are extracted. They are then prepared for later implantation into the knee.
Once the graft has been harvested, Dr. Dedhia re-enters the knee joint with the scope. The anatomical footprints of the ACL are cleaned. A tunnel is then drilled into the femur (thigh bone). A second tunnel is then drilled into the tibia (shin bone). Using a tagging stitch, the new ACL graft gets shuttled through the tibial tunnel and femoral tunnel. The graft is secured in the tunnel with a button fixation on the femur. A screw is placed in the tibial tunnel to secure the graft on the other end. Once the graft has been securely fixated, the scope is removed and the incisions are closed.
Overview
Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative,”wear-and-tear” type of arthritis that occurs most often in people 50 years of age and older.
In osteoarthritis, the cartilage, which is the protective coating on the ends of the bones, gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the space between the bones decreases. This can result in bone rubbing on bone, and produce painful bone spurs.
The knee is the largest and strongest joint in your body. It is made up of the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap). The ends of the three bones where they touch are covered with articular cartilage, a smooth, slippery substance that protects and cushions the bones as you bend and straighten your knee.
Two wedge-shaped pieces of cartilage called meniscus act as “shock absorbers” between your thighbone and shinbone. They are tough and rubbery to help cushion the joint and keep it stable.
The knee joint is surrounded by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage and reduces friction.
Symptoms
A knee joint affected by arthritis may be painful and inflamed. Generally, the pain develops gradually over time, although sudden onset is also possible. There are other symptoms, as well:
- The joint may become stiff and swollen, making it difficult to bend and straighten the knee.
- Pain and swelling may be worse in the morning, or after sitting or resting.
- Vigorous activity may cause pain to flare up.
- Loose fragments of cartilage and other tissue can interfere with the smooth motion of joints. The knee may “lock” or “stick” during movement. It may creak, click, snap or make a grinding noise (crepitus).
- Pain may cause a feeling of weakness or buckling in the knee.
- Many people with arthritis note increased joint pain with rainy weather.
Imaging studies
- X-rays.These imaging tests create detailed pictures of dense structures, like bone. They can help distinguish among various forms of arthritis. X-rays of an arthritic knee may show a narrowing of the joint space, changes in the bone and the formation of bone spurs (osteophytes).
- Other tests.Occasionally, a magnetic resonance imaging (MRI) scan, a computed tomography (CT) scan, or a bone scan may be needed to determine the condition of the bone and soft tissues of your knee.
Treatment
There is no cure for arthritis but there are a number of treatments that may help relieve the pain and disability it can cause.
Nonsurgical Treatment
As with other arthritic conditions, initial treatment of arthritis of the knee is nonsurgical.
Activity Modification:Minimize activities that aggravate the condition, such as climbing stairs. Switching from high impact activities (like jogging or tennis) to lower impact activities (like swimming or cycling) will put less stress on your knee. Losing weight can reduce stress on the knee joint, resulting in less pain and increased function.
Physical therapy: Specific exercises can help increase range of motion and flexibility, as well as help strengthen the muscles in your leg.
Assistive devices: Using devices such as a cane, wearing shock-absorbing shoes or inserts, or wearing a brace or knee sleeve can be helpful. A brace assists with stability and function, and may be especially helpful if the arthritis is centered on one side of the knee. There are two types of braces that are often used for knee arthritis: An “unloader” brace shifts weight away from the affected portion of the knee, while a “support” brace helps support the entire knee load.
Other remedies: Applying heat or ice, using pain-relieving ointments or creams, or wearing elastic bandages to provide support to the knee may provide some relief from pain.
Medications: Several types of drugs are useful in treating arthritis of the knee including Tylenol, anti-inflammatories, and steroids.
Joint Injections: Joint injections can also be helpful in relieving pain associate with osteoarthritis. Corticosteroid injections help reduce inflammation within the joint that should then relieve pain. Viscosupplementation injections involve injecting hyaluronic acid into the joint to increase joint fluidity and less pain.
Supplements: Glucosamine and chondroitin sulfate, substances found naturally in joint cartilage, can be taken as dietary supplements. Although patient reports indicate that these supplements may relieve pain, there is no evidence to support the use of glucosamine and chondroitin sulfate to decrease or reverse the progression of arthritis.
In addition, the U.S. Food and Drug Administration does not test dietary supplements before they are sold to consumers. These compounds may cause side effects, as well as negative interactions with other medications. Always consult your doctor before taking dietary supplements.
Alternative therapies:Acupuncture uses fine needles to stimulate specific body areas to relieve pain or temporarily numb an area. Although it is used in many parts of the world and evidence suggests that it can help ease the pain of arthritis, there are few scientific studies of its effectiveness. Be sure your acupuncturist is certified, and do not hesitate to ask about his or her sterilization practices.
Surgical Treatment
Dr. Dedhia may recommend surgery if your pain from arthritis causes disability and is not relieved with nonsurgical treatment. Depending on the severity of the osteoarthritis in your knee, there are a few different surgical approaches. The only definitive solution for arthritis is a knee replacement.
Arthroscopy: Arthroscopic surgery is not often used to treat arthritis of the knee. In cases where osteoarthritis is accompanied by a degenerative meniscal tear, arthroscopic surgery may be recommended to treat the torn meniscus.
Partial Knee Replacement: A partial, or unicompartmental, knee replacement is an option for patients with osteoarthritis of the knee that is confined to a single part (compartment) of your knee.
In a unicompartmental knee replacement, only the damaged compartment is replaced while the remaining healthy cartilage and bone in the rest of the joint is left alone. Advantages associated with this surgery versus a total knee replacement include less pain, faster recovery, and more natural range of motion.
Total Knee Replacement: A total knee replacement is an option for patients with osteoarthritis that has damaged more than one compartment of the knee. Those patients who also have arthritis along with ligamentous injuries, particularly an ACL tear, likely require a total knee replacement as well.
Anatomy
Meniscus tears are among the most common knee injuries. Athletes, particularly those who play contact sports, are at risk for meniscus tears. However, anyone at any age can tear a meniscus.
Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella).
Two wedge-shaped pieces of cartilage act as “shock absorbers” between your thighbone and shinbone. These are called meniscus. They are tough and rubbery to help cushion the joint and keep it stable.
Description
Menisci tear in different ways. Tears are noted by how they look, as well as where the tear occurs in the meniscus. Common tears include bucket handle, flap, and radial.
Sports-related meniscus tears often occur along with other knee injuries, such as anterior cruciate ligament tears.
Causes
Sudden meniscus tears often happen during sports. Players may squat and twist the knee, causing a tear. Direct contact, like a tackle, is sometimes involved.Older people are more likely to have degenerative meniscus tears. Cartilage weakens and wears thin over time. Aged, worn tissue is more prone to tears. Just an awkward twist when getting up from a chair may be enough to cause a tear, if the menisci have weakened with age.
Symptoms
You might feel a “pop” when you tear a meniscus. Most people can still walk on their injured knee. Many athletes keep playing with a tear. Over 2 to 3 days, your knee will gradually become more stiff and swollen.
The most common symptoms of meniscus tear are:
- Pain
- Stiffness and swelling
- Catching or locking of your knee
- The sensation of your knee “giving way”
- You are not able to move your knee through its full range of motion
Without treatment, a piece of meniscus may come loose and drift into the joint. This can cause your knee to slip, pop, or lock.
Imaging Tests
Because other knee problems cause similar symptoms, your doctor may order imaging tests to help confirm the diagnosis.
X-rays. Although x-rays do not show meniscus tears, they may show other causes of knee pain, such as osteoarthritis.
Magnetic resonance imaging (MRI). This study can create better images of the soft tissues of your knee joint, like a meniscus.
Treatment
Treatment will depend on the type of tear you have, its size, and location.
Nonsurgical Treatment
If your tear is small and on the outer edge of the meniscus, it may not require surgical repair. As long as your symptoms do not persist and your knee is stable, nonsurgical treatment may be all you need. This may be in form of medications, physical therapy, or injections.
Surgical Treatment
If your symptoms persist with nonsurgical treatment, Dr. Dedhia may suggest surgery. In order for meniscal repairs to be successful, the tear must be located near the blood supply. If the meniscus tear is not repairable then a meniscectomy is indicated. A meniscectomy is a procedure that involves using the arthroscope and various instruments to remove or trim partial tears of the meniscus in the knee. During a meniscectomy, the tear is identified and probed to determine the extent of injury. Dr. Dedhia will evaluate your imaging studies and determine if this is a viable option for you.
- Partial meniscectomy: In this procedure, the damaged meniscus tissue is trimmed away.
- Meniscus repair: Some meniscus tears can be repaired by suturing (stitching) the torn pieces together. Whether a tear can be successfully treated with repair depends upon the type of tear, as well as the overall condition of the injured meniscus. Because the meniscus must heal back together, recovery time for a repair is much longer than from a meniscectomy.
(Left): Close-up of partial meniscectomy.
(Right): A torn meniscus repaired with sutures.
Procedure: Knee arthroscopy is one of the most commonly performed surgical procedures. In it, a miniature camera is inserted through a small incision (portal). This provides a clear view of the inside of the knee. Dr. Dedhia inserts miniature surgical instruments through other portals to trim or repair the tear. This should alleviate the catching, pinching, and mechanical symptoms felt from a tear. Dr. Dedhia then re-inspects the whole joint to make sure there are no other abnormal findings before finishing the procedure.
Illustration and photo show a camera and instruments inserted through portals in a knee.
After a meniscectomy most patients can immediately put full weight on their knee and start bending as tolerated. Physical therapy may be indicated to progress motion and strengthening. Many patients can return to work quickly after this procedure depending on job demands.
Dr. Dedhia will give you specific details about your activity levels after your procedure.
Photos courtesy of AAOS.org
Anatomy
Tendons are strong cords of fibrous tissue that attach muscles to bones. The patellar tendon works with the muscles in the front of your thigh to straighten your leg.
Small tears of the tendon can make it difficult to walk and participate in other daily activities. A large tear of the patellar tendon is a disabling injury. It usually requires surgery and physical therapy to regain full knee function.
The tendons of the knee. Muscles are connected to bones by tendons.
The patellar tendon attaches the bottom of the kneecap (patella) to the top of the shinbone (tibia). It is actually a ligament that connects to two different bones, the patella and the tibia.
Description
Patellar tendon tears can be either partial or complete.
Partial tears. Many tears do not completely disrupt the soft tissue. This is similar to a rope stretched so far that some of the fibers are frayed, but the rope is still in one piece.
Complete tears. A complete tear will disrupt the soft tissue into two pieces.
When the patellar tendon is completely torn, the tendon is separated from the kneecap. Without this attachment, you cannot straighten your knee.
A complete tear of the patellar tendon.
Causes
Injury
Falls. Direct impact to the front of the knee from a fall or other blow is a common cause of tears. Cuts are often associated with this type of injury.
Jumping. The patellar tendon usually tears when the knee is bent and the foot planted, like when landing from a jump or jumping up.
Tendon Weakness
A weakened patellar tendon is more likely to tear. Several things can lead to tendon weakness.
- Patellar tendinitis.Inflammation of the patellar tendon, called patellar tendinitis, weakens the tendon. It may also cause small tears.
- Corticosteroid injections to treat patellar tendinitis have been linked to increased tendon weakness and increased likelihood of tendon rupture. These injections are typically avoided in or around the patellar tendon.
- Chronic disease.Weakened tendons can also be caused by diseases that disrupt blood supply.
Surgery
Previous surgery around the tendon, such as a total knee replacement or anterior cruciate ligament reconstruction, might put you at greater risk for a tear.
Symptoms
When a patellar tendon tears there is often a tearing or popping sensation. Pain and swelling typically follow, and you may not be able to straighten your knee. Additional symptoms include:
- An indentation at the bottom of your kneecap where the patellar tendon tore
- Bruising
- Tenderness
- Cramping
- Your kneecap may move up into the thigh because it is no longer anchored to your shinbone
- Difficulty walking due to the knee buckling or giving way
Treatment
There are several fators when planning your treatment, including:
- The type and size of your tear
- Your activity level
- Your age
Nonsurgical Treatment
Very small, partial tears respond well to nonsurgical treatment.
- Your doctor may recommend you wear a knee immobilizer or brace. This will keep your knee straight to help it heal. You will most likely need crutches to help you avoid putting all of your weight on your leg. You can expect to be in a knee immobilizer or brace for 3 to 6 weeks.
- Physical therapy.Once the initial pain and swelling has settled down, physical therapy can begin. Specific exercises can restore strength and range of motion.
Surgical Treatment
Most people require surgery to regain knee function. It is important that surgery be done quickly after the injury to prevent the tendon from scarring and tightening into a shortened position.
Procedure: A central incision is made directly over the patellar tendon. To reattach the tendon, sutures are placed in the tendon and then threaded through drill holes in the kneecap. The sutures are tied at the top of the kneecap. Dr. Dedhia will carefully tie the sutures to get the correct tension in the tendon. This will also make sure the position of the kneecap closely matches that of your uninjured kneecap.
To reattach the tendon, small holes are drilled in the kneecap (left) and sutures are threaded through the holes to pull the tendon back to the bone (right).
If surgery is delayed and the tendon has shortened too much, additional tissue graft may need to be used to lengthen the tendon. This sometimes involves using donated tissue (allograft).
Once the tendon has been successfully attached, the incision is then closed and a cylindrical cast will be applied. This is a cast that spans from the upper thigh to the ankle and prevents the leg from bending while the tendon heals. Patients may put weight on the leg while in the cast.
Complications. The most common complications of patellar tendon repair include weakness and loss of motion. Re-tears sometimes occur, and the repaired tendon can detach from the kneecap. In addition, the position of your kneecap may be different after the procedure.
As with any surgery, the other possible complications include infection, wound breakdown, a blood clot, or anesthesia complications.
Rehabilitation. 2 weeks after surgery, the cylindrical cast will be removed and your skin sutures or staples will be removed. A new cylindrical cast will be applied and worn for another 4 weeks.
After 6 weeks, physical therapy will be initiated to begin progressive knee range of motion. Complete recovery takes about 6 months. Some patients may require 12 months before they reached all their goals.
Courtesy of AAOS.org
Anatomy
Tendons are strong cords of fibrous tissue that attach muscles to bones. The quadriceps tendon works with the muscles in the front of your thigh to straighten your leg. The quadriceps tendon attaches to the top of the kneecap.
Small tears of the tendon can make it difficult to walk and participate in other daily activities. A large tear of the quadriceps tendon is a disabling injury.
The four quadriceps muscles meet just above the kneecap (patella) to form the quadriceps tendon. The quadriceps tendon attaches the quadriceps muscles to the patella. The patella is attached to the shinbone (tibia) by the patellar tendon. Working together, the quadriceps muscles, quadriceps tendon and patellar tendon straighten the knee.
Partial tears. Many tears do not completely disrupt the tendon. The fibers are stretched but not completed detached. The tendon can still function to straighten the leg.
Complete tears. A complete tear will split the soft tissue into two pieces. When there is a complete tear, the tendon is no longer attached to the kneecap and therefore the knee cannot straighten.
Causes
- Injury: A quadriceps tear often occurs when there is a heavy load on the leg with the foot planted and the knee partially bent>
- Tendon Weakness: From chronic inflammation of the tendon or chronic illness
- Steroid use
- Prolonged immobilization that can weaken the tendon
Symptoms
- A tear or popping sound during injury
- Sagging kneecap
- Knee swelling
- Instability when trying to walk
Treatment
Treatment varies depending on the type of tear, your age, and activity level.
Nonsurgical treatment
- Immobilization: A knee immobilizer is recommended for 6 weeks to allow the tendon to heal to the patella without interruption. The leg must stay straight during this time so the tendon does not retract.
- Physical therapy: Once the initial pain and swelling has settled down, physical therapy can begin. Specific exercises can restore strength and range of motion.
Surgical treatment
Surgery involves repairing the quadriceps tendon back to the patella. To reattach the tendon, sutures are placed in the tendon and then threaded through drill holes in the kneecap. The sutures are tied at the bottom of the kneecap. A long leg cast is then placed to keep the leg straight and is usually required for 6 weeks after surgery.
Content courtesy of AAOS.org
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P: 219-924-3300
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