Category Archives: Knees

Runner’s Knee

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Chondromalacia, refers to a condition in which there is damage to the joint surface of the patella (kneecap).  It is common in runners, cyclists, catchers –any athlete that is constantly bending their knees.  At a large runner’s clinic several years ago, knee problems predominated, and the most common cause of the pain was patella disease.

Runners with chondromalacia complain of a deep ache under the patella.  It is present during running and is aggravated by jogging up and down hills.  Frequently, the runner will complain of a noisy knee—a crackling sound is heard and felt.  Running through this injury only produces more pain and swelling.

CAUSE

The cause of the pain and the noise is a roughness on the underside of the patella.  Normally, the joint surface of the patella is very smooth—like a slick piece of ice.  Damage to the patella produces scratches and nicks so that eventually the surface becomes rough and irregular. Think of an ice skating rink after a hockey game.  As the knee bends, the patella is pressed tighter and deeper into the knee, and this causes pain, just as rubbing a skin wound would.  The knee becomes inflamed, and swelling can result.

Why does the damage occur?  Normally, the patella moves in a straight line as the knee bends and straightens. The patella is wedge-shaped and lies in a bony groove on the top of the femur (thigh bone).  This groove holds it in proper alignment.  If an abnormality is present to disrupt this alignment, the patella can slip out of the groove as it moves, and a shearing damage to its surface can occur.  This injury may be minor each time, but over the years the damage becomes extensive.  The most common abnormality is a combination of a “knocked knee” posture of the leg and tightness of the ligaments on the outer side of the knee.  A bowstring effect occurs and pulls the patella out of line.  Other causes include deformities of the patella or shallowness of the groove. Abnormalities of the foot, and even the hip can contribute. For example ,intoeing from the hip joint or pronation of the feet can lead to patella abnormalities and can influence proper patella alignment and tracking.

Any direct injury to the patella, such as a fall or fracture, can also produce this problem.  Athletes, such as baseball catchers or football linemen, who must constantly squat or kneel can also be susceptible.

TREATMENT

As one would imagine, treatment consists of rest from running and avoidance of excessive bending.  Since hill running produces constant knee flexion, changing to a flat surface, such as a track, is advisable.  Anti-inflammatory medication is useful for this condition and can be taken for the pain.  (It is best to consult your doctor before taking frequent doses.)

The most important factor in treatment, however, is a good exercise program.  To counter the tight bowstringing ligaments which pull on the outer side, the muscles on the inside of the knee must be developed and strengthened.  The best exercise is performed while lying flat with the knee completely straight.  The leg is lifted up and held to the count of ten.  During this time, an isomeric tightening of the knee muscles can also be done.  Lower the leg, rest for a few seconds, and raise it again.  One should gradually work up to 100-150 lifts per day (in intervals).  Ankle weights can also be used starting with two pounds and increasing to ten pounds over several weeks.  Bending exercises should generally be avoided because they increase the pressure on the patella and thereby aggravate the condition.

Later, when the pain subsides, running can be resumed with a graduated program.  Ice should be applied after the run.  Knee exercises should continue and hills avoided.

If the problem persists, various knee bands or braces can be prescribed.  The most common type of brace for chondromalacia has a hole over the kneecap to hold it in place and to prevent abnormal side displacement.  If the runner has pronated feet, a shoe orthotic may help to better position the heel and take pressure off of the knee.

In severe cases of chondromalacia, the patella may partially dislocate (sublux), producing further damage and disability.  Conservative medical measures already discussed should first be initiated; but if they fail, surgery is warranted.  Operative procedures can be performed with the arthroscope through small incisions.  The tight lateral ligaments can be cut ( lateral release), and the rough surfaces of the patella can be shaved and smoothed to some extent.  This operation is frequently successful.

I remember back to my training just prior to the advent of arthroscopic surgery. Operations on the patella for this conditions consisted of an open incision to re-align the patella. Tissues were cut on one side of the knee and others, on the other side were tightened. The results were frequently dismal. Now with arthroscopic surgery, the results are much better- achieved with minor surgery. This has been a great advance in medicine.

True dislocations of the patella can occasionally occur—usually as the result of trauma. They are usually treated with a brace to allow the torn ligaments to heal. Recurrent dislocations may require surgery. Sometimes, an open reconstruction: the results are not always uniform. Therefore conservative measures or even arthroscopic surgery should first be tried.

To conclude, in all of these injuries, prompt recognition and treatment, as well as thoughtful medical and technical measures, is important to prevent permanent impairment.

Ski Injuries

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Preventing Common Ski Injuries

Once again, many are heading north to the slopes and most will return invigorated, tanned, and happy.  Some, unfortunately, will return with slings or crutches, pale and unhappy.  Here are some common ski injuries and how to avoid.

Well over half of the ski injuries involve the lower extremities, and most of these favor the knee and leg.

Knee Injuries

Knee sprains are by far the most common injuries.  The ligaments along the inside of the knee are injured when a skier catches the inner edge of a ski in the snow and the foot rotates outward as the body continues forward.  Stress is then placed on the inner side of the knee, which is forced into a “knock-knee” position as the skier falls.  The ligament will be stretched (sprained) if the force is minimal and if the bindings release.  Otherwise, the ligament can be completely torn.  Another potentially dangerous position is the “snow plow”—where both knees are knocked and the body weight is placed on the inner edge of the ski.  A fall will place direct force against the inside of the knee.

Catching the outer edge of the ski may injure the ligament that lies along the outside of the knee.  This can occur if the tips of the skis accidentally cross and the skier falls sideways.  The leg on the side of the fall will twist inward and will remain straight.  Stress is placed on the outer ligaments.

The new shorter, shaped skis place more stress on the knees than the former, longer skis.

Especially stress on the medial collateral ligiment(MCL).

Prevention of these injuries mainly centers around adequate bindings.  It has been reported that a high percentage of lower extremity injuries result from a failure of bindings to release.  Quality bindings properly mounted and maintained will prevent many knee injuries.  Various knee braces can also be worn and, to some extent, can provide protection.  A brace with metal sidings and hinges can comfortably be worn under ski pants and allow an acceptable degree of knee mobility.

Fractures

Another common injury is the tibial fracture—or broken leg.  This occurs when the leg is forced against the hard boot top during a fall.  The leg can also break when the bindings fail to release and the leg is twisted.  This torque can snap the bone.  Again, proper bindings are the best insurance against this unfortunate and incapacitating injury.

Shoulder Dislocations

If inadequate bindings are a cause of knee and leg injuries, faulty pole technique can contribute to upper extremity injuries—specifically the shoulder or thumb.

Shoulder dislocations are very commonly treated at base clinics.  The shoulder can dislocate when a backwards force is applied to the outstretched arm and the shoulder is levered forward.  Thus, a skier who falls on his outstretched (abducted) arm may sustain this injury.  Frequently, however, the arm is levered by a planted pole; as the body continues forward, the arm is forcibly stretched and rotated outward, aggravating the injury and making a dislocation more likely.  Slalom racers who grasp too long on their planted poles are especially susceptible to this type of injury.

A shoulder dislocation is very painful and requires immediate setting to relocate the joint.  Multiple dislocations can eventually produce a damaged, unstable shoulder, and surgery will frequently be required to repair it.  One way to avoid this injury is to be aware of the mechanism and try to eliminate excessive pole planting.  Poles with strapless hand grips, which release better from the skier’s hand, may also prevent this injury.  If a skier has a dislocated shoulder, he or she might consider a brace to check excessive shoulder stretching.  These braces are custom made, but they are light, comfortable, and usually don’t interfere with normal skiing.  They can be worn inconspicuously under the ski jacket. ( I have personal experience on this matter, as I dislocated my shoulder twice while skiing—once on a bunny trail at Stratton-when I first learned to ski—but again, and less embarrassingly, on a real black diamond trail—Nosedive—at Stowe, a few years later. I successfully skied down Nosedive without falling and ,of course, at the bottom on level terrain, slipped and fell. I had a custom made brace made which I wore thereafter and never again dislocated my shoulder.) 

Thumb Injuries 

The other notorious injury caused by ski poles is damage to the ligament on the inside of the thumb.  Since the pole is grasped between the thumb and the index finger, sudden force along the pole can jam the handle of the pole into the base of the thumb and injure the ligament.  This is a serious injury which is treated with a cast and perhaps surgery.   Pole straps incorrectly positioned can result in greater risk of this accident.  A strap held around the palm just below the base of the thumb can be stretched.  The strap should properly lie around the wrist, well away from the thumb.  The risk of thumb injuries may also be decreased—although not eliminated—by using poles with a strapless type of hand grip.

Finally, here are five useful tips for prevention of ski injuries:

  1. Service your bindings at the start of each ski season.
  2. Stay fit prior to the ski vacation.
  3. Do warm-up exercises before you go out.
  4. Quit whenever you feel tired.
  5. Don’t be a daredevil.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Knee Replacements

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Joint replacements without question are one of the major medical innovations of the past hundred years.

A Total Knee Replacement (TKR) replaces an arthritic knee joint. The femoral (thigh) component is metal; The lower tibial (upper leg ) component is high grade polyethylene plastic; Commonly, the arthritic knee cap surface is also replaced with a plastic button.Thus, the new joint is metal bearing on plastic. While some TKR’s are designed for bony ingrowth to secure them to the bone, most are attached with a medical acrylic cement.

The arthritic joint surfaces are removed -by cutting the old joint out with a power saw. We use guides to insure accurate cuts and the above components fit into these cuts -held by the cement.

Total Knee Replacements  have evolved over my career. During my formal orthopedic training and my fellowship in Joint Replacement Surgery at Boston’s Massachusetts General Hospital, this procedure was relatively new and the technique was not as streamlined as it is today. For example, then, many of the saw cuts to remove bone were eyeballed and were made freehanded. Today the cutting guides are much better perfected and easier to use ,so that the cuts are much more accurate and components fit much better than in the past. This leads to better fitted and more secure components, thus resulting in better longevity.

Years ago, we told patents that the TKR would only last around a dozen years. Today, a TKR could last 25-30 years.

The surgery is major and patients need to stay in the hospital for several days. Physical Therapy are recommended for 2-4 weeks and full recovery may take several months. Like any surgery there are potential, albeit,rare complications. But most people do very well and ultimately are very pleased . With a relatively pain free knee, they can get their lives back.

Who needs a Knee Replacement ? Usually people who are at least in their 50’s.  In rare circumstances, younger people with severe arthritis may need a TKR, but we try told hold off on older patients as the components do not last forever. In younger patients, the likelihood of a second revision operation later in life is likely where as it is less likely in a 60 year old. Obviously, one should have advanced arthritis and joint destruction on an x-ray.(see photo below )

Knee with severe Osteoarthritis

But, the main  indications are pain and limited function. Unable to walk more than a few blocks or around a Mall without increased pain is the usual indication.

I have been performing Total Knee Replacements for years and most of my patients have been very happy with my care and with the results. If you think that you need one, come in to see me and I will discuss the operation in greater detail.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

ACL

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ACL ( ANTERIOR CRUCIATE  LIGAMENT ) INJURIES

Several years ago, I saw a middle aged patient for a second opinion regarding his knee. Another orthopedist told him that he needed surgery to replace a torn anterior cruciate ligament (ACL). I examined his knee –everything appeared normal. There was no laxity or looseness. What sort of problems are you having with it, I inquired? “None,” he replied.

“Then why do you want surgery?” I responded.

“Because it is torn”.  The other doctor warned him that he might have future problems.

In a situation like this, I always wonder who is loonier –doctor or patient. Not everyone who tears an ACL needs reconstructive surgery, but more about this later.

The cruciate ligaments –anterior and posterior – are important central ligaments within the knee joint ( see diagram below). Like a cruciate screw head, they are in the center of the knee and they add stability. The ACL prevents the tibia (leg bone) from translating forward on the femur (thigh bone). The ends of these two bones form the knee joint. The PCL prevents backward instability. Also, the ACL restrains abnormal knee rotation.

The ACL is more commonly injured. The trauma is usually substantial-not from a minor sprain. Tears can occur from pivoting on one foot while running, decelerating, changing direction, or after landing from a jump. Blunt trauma like a clip in a football game while the victum’s foot is planted can do it as well. Or a ski injury—a twist to the knee or a fall– as the ski bindings fail to release.

A pop is commonly felt and may be heard. Swelling gradually occurs and the knee can blow up. If the knee is drained with a needle, blood is removed. This combination of a pop and bleeding tells me that the knee injury is more serious than a slight sprain.

On exam, we may find a positive drawer sign. The tibia displaces forward just like a dresser drawer is pulled out.

X-rays need to be performed to rule out a fracture and sometimes a chip fracture can be diagnosed. The ligament is not visualized on a routine x-ray and therefore, the next step is an MRI to make the diagnosis. We need to learn if the cruciate is indeed torn or if there is an associated meniscus tear. And,  if the ACL is torn: to what extent and where?

“us” above-middle – is the ACL : from an early 20th Century German Textbook. 

If it is torn right off of the bone in children, it is frequently directly repairable.Surgery should be performed fairly soon (it is no emergency, though). Frequently, when the injury occurs  lower down on the ligament at the tibial attachment, a sizable chunk of bone is broken off and this should be –and can be fairly easily – surgically repaired. This ligament fracture  is more common in children, but can be seen in teens or adults.

The most common problem is an ACL tear through the mid-portion of the ligament. Here the blood supply is frequently skimpy. Think of the ACL circulation as an hour glass. It is better at the top and bottom, but thin in the middle. Thus, repairing the ligament is this level will commonly not succeed. Most ACL tears are in the mid portion of the ligament and not repairable. I do not recommend attempting to repair the ligament if it is torn here. Moreover, the arthroscopic appearance of the torn ligament is that of a rag mop, and it would be like trying to stitch together scrambled eggs—an exercise in futility!

So, given that most people tear the ACL in an area that is unrepairable—what to do? The ACL reconstruction is a great operation. Performed mainly arthroscopically, a graft is inserted through a tunnel in the tibia into the knee joint and secured with a screw into the femur –thus replacing the torn and functionless ligament. But the operation is not without potential risks-infection, stiffness, graft failure, etc. and the recuperation is relatively lengthy. Athletes who have this operation are out for the remainder of the season.

Who requires this operation? Certainly athletes involved in high school, college, or professional sports or athletes who have to cut, pivot, or jump. Or, older patients who participate in intense sports. Also, people who have a very prominent drawer sign with pain or people who later develop a trick knee that buckles and gives way— at risk for producing a new injury.

So getting back to our friend in the first paragraph, should you have the ACL reconstruction because—like Mount Everest—it is there ? ( the surgery is available ) Or are there alternatives. In this respect—and again this is my opinion – I tend to be more conservative than some of my colleagues.

Not everyone requires the operation. And, this is not just my opinion, but a stated fact in the orthopaedic literature. In a study in 1993 involving almost 300 patients, 62 were able to function satisfactorily without an ACL.

This has clearly been my experience with my patients. Many patients with an ACL tear have stable knees as other surrounding structures of the knee  may also provide stability. If these patients have reasonably stable knees and, like the man above, few or no symptoms, I do not encourage reconstructive surgery. Instead, I rehab their knee with an intense exercise and strengthening program –emphasizing the hamstring muscles and a custom made brace for sports that stabilizes the knee. Most patients consider this brace to be comfortable and it worn by many athletes. I have had many patients who have returned to various sports and skiing after this treatment and most have done very well. For example, an attorney friend that I treated about twenty years ago, has had no long term trouble and has long since returned to skiing black diamond trails while wearing his brace.

After an ACL injury is diagnosed by an MRI, I do recommend standard arthroscopic surgery to evaluate the knee. Basic arthroscopy is a relatively minor procedure and the recovery is quick. I want to see the extent of the tear or if the ACL is repairable. Sometimes the MRI is incorrect and the tear is not as bad as reported. Sometimes there is an associated meniscal tear which I treat. I also believe that washing our the knee and removing blood clots and the scarred damaged rag mop of a ligament relieves pain and hastens recovery and rehab. This has been my overwhelming experience. If the ACL is completely torn and un-repairable, it is of absolutely no use. A wad of scar tissue forms-we call it the ACL stump- and it can probably produce some knee discomfort. Therefore, I remove the scarred stump as it is functionless.

Next, I sent my patients for PT to rehab their knee. Most feel better after this minor operation and are walking normally within two weeks. A brace is custom made and eventually they return to sports and, hopefully, a normal lifestyle. They are watched carefully. If their knee loosens up; if they re-injure their knee; if they simply do not do well –if their knee still goes out or buckles, I recommend a reconstruction. One valid criteria –for me – is how do they do during normal, daily activity. If a patient can, say, ski successfully while wearing a brace, but if his or her knee constantly buckles while going up steps, this is unacceptable. One realistically cannot constantly wear a brace. So, this patient should consider an ACL reconstruction.

Again, 60-70 % of these patients can avoid this operation. If someone is middle aged, a weekend athlete-golf or doubles tennis, etc. – or has a sedentary job, it is certainly reasonable to first try the conservative approach. Especially if their knee is fairly stable.

What patients do I recommend have a reconstruction early on ? A young athlete. Perhaps someone in their late teens or in their 20’s – 30’s who plays organized contact sports, skis, or plays competitive tennis. Someone who has 60 years ahead of them probably should have the surgery. Or, a policeman, fireman, or construction worker who may not be able to wear a brace and who may perhaps be in harm’s way if they cannot rely on their knee function.

Thus, every individual case needs to have treatment recommendations tailored to their medical exam findings and their future requirements.

Why do some doctors believe that everyone (outside of the elderly population) should have an ACL reconstruction? There is a feeling that re-injuries will occur and eventually lead to the development of osteoarthritis of the knee. While, this view may be valid, I do not believe that this is always the case. Many of my patients have done well with rehab/bracing and have not re-injured their knees. Nor, have follow-up x-rays years later demonstrated arthritis. Moreover, whenever I do a total knee replacement on someone –with severe arthritis: obviously–I almost always find an intact ACL. So, if isolated ACL tears always lead to osteoarthritis, why don’t more people undergoing total knee replacements have absent ACL’s ? Finally, some recent studies have shown that ACL reconstructive surgery does not necessarily prevent osteoarthritis in the long term.

Again, the above opinions are mine and do reflect my bias, albeit based on thirty years of experience in treating these injuries. Medicine can be in art and sometimes there is no right or wrong opinion.

But if you injure your ACL at least be informed about your condition and your options. Possibly seek a second opinion before rushing into reconstructive surgery. And remember, an ACL reconstruction is not an emergency operation in most cases. In fact, many orthopedists recommend delaying the procedure for a few weeks after an injury so that the knee swelling can decrease and the knee can somewhat recover from the insult. So, in most cases, there is no rush.Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.