Knee Conditions

Arthritis of Knee:

Occurs when there is wearing away or destruction of the cartilage either as a degenerative process or an inflammatory or traumatic process. Types: Osteoarthritis (OA) or Inflammatory arthritis (eg Rheumatoid arthritis RA) or post traumatic arthritis.

In OA of the knee the cartilage wears away leading to the rough bone ends which tend to rub against each other leading to pain and stiffness. In RA the immune system attacks its own normal tissues (cartilage and ligaments) causing damage. The synovial membrane gets inflamed leading to pain and stiffness.

Post traumatic arthritis occurs when there is cartilage injury after a fracture or due to cartilage damage. It can also occurs after ligament and meniscus injury which lead to instability and further wear of the joint.

Symptoms:

•    Pain
•    Stiffness
•    Crepitus
•    Reduced walking distance
•    Difficulty climbing stairs
•    Joint swelling
•    Joint instability

Treatments:

Non Surgical:

•    Activity restriction/modification
•    Medications (including anti-inflammatories, DMARD’s for RA, Joint Nutarceuticals)
•    Walking aids
•    Braces & footwear modification
•    Braces & footwear modification
•    Physical Therapy
•    Intra-articular injections: Steroid and/or Visscosuplementation, PrP injections
•    Alternative therapy

Surgical treatment:

Knee Preservation Surgery:

•    Arthroscopy to correct ligament, meniscal and cartilage injury
•    Cartilage graft procedures
•    Knee Osteotomy

Knee Replacement Surgery:

•    Partial Knee replacement
•    Total Knee replacement

Ligament injuries:

The 4 major ligaments supporting the knee are :

•    Anterior Cruciate Ligament (ACL)
•    Posterior Cruciate Ligament (PCL)
•    Medial Collateral ligament
•    Lateral Collateral Ligament

The usual mode of injury to these ligaments is traumatic in nature. Depending on the activity at the time of injury, position of the leg and knee and direction of force, one or more than one ligament may be injured or torn with or without injury to other knee structures.

ACL Injury:

Cause: Changing direction abruptly, rapidly; Incorrect landing mechanics after a jump, direct contact injury.

Collateral Ligament Injuries:

They lie to the side of the knee and control the sideways motion

Cause: Usually by a force that pushes the knee sideways.

PCL Injuries:

Uncommon compared to other ligaments.

Cause: Direct blow to front of the knee or hyperextension injury.

Grading of Ligament Injuries:

Mild Sprain (Grade 1) to Complete Tear (Grade 3)

Symptoms:

•    Pain
•    Instability
•    Swelling
•    Inability/ Difficulty in walking
•    Limping
•    Reduced movement
•    Arthritis in later stages

Treatment:

Non surgical:

•    Activity modification
•    Rest
•    Medications
•    Braces
•    Intense Physical Therapy Protocol

Surgical

•    Arthroscopy Reconstruction
•    Open Repair or Reconstruction
•    Combined Reconstructions

Meniscus Injuries:

Meniscus is a C shaped disc which acts a shock absorber between the leg bone and thigh bone. It helps stabilize the knee and provide for smooth kinematics. It can get injured due to sudden acute twisting or can be degenerative in nature due to gradual wearing out.

Symptoms:

•    Pain
•    Catching. Clicking, Locking
•    ‘Giving way’ sensation
•    Instability
•    Stiffness
•    Joint Swelling

Treatment:

Depends on nature, type and location of tear

Non Surgical treatment:

•    Activity modification
•    Rest
•    Ice
•    Bracing
•    Physical Therapy

Surgical Treatment

•    Arthroscopy Repair
•    Arthroscopy partial menisectomy

Kneecap (Patella) dislocation and pain:

Pain specifically located in the kneecap can cause acute symptoms at the time of injury but can also lead to chronic knee pain.

•    Chondromalacia patella
•    Knee cap dislocation
•    Fractured knee cap
•    Bursitis

•    Patellar dislocation & recurrent instability
•    Patellar Fractures
•    Patellar Tendon ruptures/tendinitis
•    Patellofemoral Arthritis
•    Patellar pain syndrome (including malalignment)

Patellar dislocation can be due to trauma (direct injury or fall) or due to muscle imbalance. Either situation can lead to recurrent instability. Pain is the predominant symptom followed by bucking, instability and knee swelling.

Non Surgical treatment: Immobilization ,protected weight bearing and physical therapy.

Surgical Treatment: in cases of recurrent disclocation or failure to respond to non surgical treatment surgery is needed. This incudes MPFL reconstruction, bony osteotomy and realignment procedures.

Patellofemoral arthritis: Pain in front of the knee. Difficulty in squatting, kneeling and staircase climbing. The cartilage on the undersurface of thse patella and overlying the trochlea wears away. This can occur due to malalignment of the patella, trauma or due to dysplasia of the trochlea. Non Surgical treatment includes activity modifications, rest, medications, physical therapy, bracing, injections

Surgical treatment:

•    Chondroplasty – trimming and smoothening roughened arthritic surfaces
•    Cartilage grafting procedures – done for small areas of cartilage defects
• - Realignment surgery – soft tissue and bony osteotomy surgery (eg tibial turberosity transfer). These procedures help to reduce the pressure over the arthritic areas and help relieve pain.
•    Patellofemoral Replacement: The arthritic surfaces are replaced under the knee cap and over the trochlea with metal and polyethylene components.
•    Total Knee Replacement

Other Non Arthritic Knee Conditions:

•    Bursitis: There are multiple bursae around the knee joint. These can get inflamed and swollen due to various reasons like overuse, excessive rubbing etc. Treatment for bursitis follows RICE principles and settles down with appropriate non surgical therapy.
•    Osteochondritis Dissecans: Occurs in children and adolescents when a segment of bone with overlying cartilage begins to separate due to lack of blood supply. This can loosen and float in the knee as a loose body or can be stable at the site of defect. In growing children stable lesions heal well with a period of immobilization and then physical therapy. In young adults with large lesions these may need to be drilled or fixed with a screw in the defect arthroscopically. In case of loose body it needs to be arthroscopically removed from the knee

Cartilage injuries or tears:

These injuries are seen in both young and older populations and can be a common cause of knee pain.

•    Medial and lateral meniscus tears
•    Articular cartilage injuries

Can be traumatic in nature or secondary to degenerative process The cartilage cover at the ends of the bone may be injured leading to loose body formation or an unstable chondral flap. In these conditions fixing the cartilage defect, debriding the chondral flap or arthroscopy excision of the loose body need to be done. In some cases cartilage reconstructive procedure may be necessary. Non-Surgical treatment can be done for degenerative cartilage problems by modifying activity and physical therapy.

Adolescent injuries:

Young adults can suffer from genetic malformations that cause knee pain but are also at an increased risk for knee trauma due to athletic injuries.

• Osgood-Schlatter disease
• Osteochondritis dissecans