knee

One of the most common knee injuries is an anterior cruciate ligament sprain or tear.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.

Anatomy

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.

normal knee anatomy

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.

complete tear of the ACL

Injured 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.

Partial tears of the anterior cruciate ligament are rare; most ACL injuries are complete or near complete tears.

Cause

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

Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports. It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other suggested causes include differences in pelvis and lower extremity (leg) alignment, increased looseness in ligaments, and the effects of estrogen on ligament properties.

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

Doctor Examination

Physical Examination and Patient History

During your first visit, your doctor will talk to you about your symptoms and medical history.

During the physical examination, your doctor will check all the structures of your injured knee, and compare them to your non-injured knee. Most ligament injuries can be diagnosed with a thorough physical examination of the knee.

Imaging Tests

Other tests which may help your doctor confirm your diagnosis include:

X-rays. Although they will not show any injury to your anterior cruciate ligament, x-rays can show whether the injury is associated with a broken bone.

Magnetic resonance imaging (MRI) scan. This study creates better images of soft tissues like the anterior cruciate ligament. However, an MRI is usually not required to make the diagnosis of a torn ACL.

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

Rebuilding the ligament. Most ACL tears cannot be sutured (stitched) back together. To surgically repair the ACL and restore knee stability, the ligament must be reconstructed. Your doctor will replace your torn ligament with a tissue graft. This graft acts as a scaffolding for a new ligament to grow on.

Grafts can be obtained from several sources. Often they are taken from the patellar tendon, which runs between the kneecap and the shinbone. Hamstring tendons at the back of the thigh are a common source of grafts. Sometimes a quadriceps tendon, which runs from the kneecap into the thigh, is used. Finally, cadaver graft (allograft) can be used.

There are advantages and disadvantages to all graft sources. You should discuss graft choices with your own orthopaedic surgeon to help determine which is best for you.

Because the regrowth takes time, it may be six months or more before an athlete can return to sports after surgery.

Procedure. Surgery to rebuild an anterior cruciate ligament is done with an arthroscope using small incisions. Arthroscopic surgery is less invasive. The benefits of less invasive techniques include less pain from surgery, less time spent in the hospital, and quicker recovery times.

Rehabilitation

Whether your treatment involves surgery or not, rehabilitation plays a vital role in getting you back to your daily activities. A physical therapy program will help you regain knee strength and motion.

If you have surgery, physical therapy first focuses on returning motion to the joint and surrounding muscles. This is followed by a strengthening program designed to protect the new ligament. This strengthening gradually increases the stress across the ligament. The final phase of rehabilitation is aimed at a functional return tailored for the athlete’s sport.

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The knee is the largest joint in your body and one of the most complex. It is also vital to movement.

Your knee ligaments connect your thighbone to your lower leg bones. Knee ligament sprains or tears are a common sports injury.

In the past, injuring more than one knee ligament would put an end to future sports activities. Today, many athletes are able to return to high level sports following multiple ligament injuries.

Normal knee anatomy

Normal knee anatomy. The knee is made up of four main things: bones, cartilage, ligaments, and tendons.

Anatomy

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.

Description

Because the knee joint relies just on these ligaments and surrounding muscles for stability, it is easily injured. Any direct contact to the knee or hard muscle contraction — such as changing direction rapidly while running — can injure a knee ligament.

Injured 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.

It is possible to injure two or more ligaments at the same time. These multiple injuries can have serious complications. They can disrupt blood supply to the leg. They can also affect the nerves that supply the muscles of the limb. In severe cases, multiple ligament injuries may lead to amputation.

The MCL is injured more often than the LCL. Due to the more complex anatomy of the outside of the knee, if you injure your LCL, you usually injure other structures in the joint, as well.

combined knee ligament tears

Tears of the anterior cruciate ligament (left) can occur along with injuries to the medial collateral ligament (right).

Treatment

The individual with a suspected multiple ligament injury needs a thorough examination by an experienced physician. Depending on the injury, the orthopaedic surgeon may call in other specialists such as a vascular surgeon or microsurgeon.

In contrast to treatment for single ligament tears, surgery for combined ligament tears is often performed soon after the injury. This is done even though early surgery — before inflammation has resolved — poses an increased risk of arthrofibrosis (a scar forming in the joint). More than one operation may be required when treating multiple ligament injuries.

Outcome

Results from multiple ligament surgery are not as consistent as single ligament injury.

In the past, a multiple ligament injury prevented people from returning to sports activities. Today, it is possible to return to high level sports, although there is no certainty of it.

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Shin splints are a common exercise-related problem. The term “shin splints” refers to pain along the inner edge of the shinbone (tibia).Shin splints typically develop after physical activity. They are often associated with running. Any vigorous sports activity can bring on shin splints, especially if you are just starting a fitness program.Simple measures can relieve the pain of shin splints. Rest, ice, and stretching often help. Taking care not to overdo your exercise routine will help prevent shin splints from coming back.

Description

Shin splints (medial tibial stress syndrome) is an inflammation of the muscles, tendons, and bone tissue around your tibia. Pain typically occurs along the inner border of the tibia, where muscles attach to the bone.

Location of pain from shin splints

Shin splint pain most often occurs on the inside edge of your tibia (shinbone).

Cause

In general, shin splints develop when the muscle and bone tissue (periosteum) in the leg become overworked by repetitive activity.

Shin splints often occur after sudden changes in physical activity. These can be changes in frequency, such as increasing the number of days you exercise each week. Changes in duration and intensity, such as running longer distances or on hills, can also cause shin splints.

Other factors that contribute to shin splints include:

Having flat feet or abnormally rigid arches
Exercising with improper or worn-out footwear

Runners are at highest risk for developing shin splints. Dancers and military recruits are two other groups frequently diagnosed with the condition.

Photo of flat feet

Flat feet can increase stress on lower leg muscles during exercise.

Symptoms

The most common symptom of shin splints is pain along the border of the tibia. Mild swelling in the area may also occur.

Shin splint pain may:

Be sharp and razor-like or dull and throbbing
Occur both during and after exercise
Be aggravated by touching the sore spot

Doctor Examination

After discussing your symptoms and medical history, your doctor will examine your lower leg. An accurate diagnosis is very important. Sometimes, other problems may exist that can have an impact on healing.

Your doctor may order additional imaging tests to rule out other shin problems. Several conditions can cause shin pain, including stress fractures, tendinitis, and chronic exertional compartment syndrome.

Exam for shin splints

Your doctor will examine your lower leg, checking for pain and tenderness along the inner border of the tibia (shinbone).

Stress Fracture

If your shin splints are not responsive to treatment, your doctor may want to make sure you do not have a stress fracture. A stress fracture is a small crack(s) in the tibia caused by stress and overuse.

Imaging tests that create pictures of anatomy help to diagnose conditions. A bone scan and magnetic resonance imaging (MRI) study will often show stress fractures in the tibia.

Tendinitis

Tendons attach muscles to bones. Tendinitis occurs when tendons become inflamed. This can be painful like shin splints, especially if there is a partial tear of the involved tendon. An MRI can help diagnose tendinitis.

Chronic Exertional Compartment Syndrome

An uncommon condition called chronic exertional compartment syndrome causes symptoms like shin splints. Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. In chronic exertional compartment syndrome, this is brought on by exercise. Pain usually resolves soon after the activity stops.

The tests used to diagnose this condition involve measuring the pressure within the leg compartments before and after exercise.

Treatment

Nonsurgical Treatment

Rest. Because shin splints are typically caused by overuse, standard treatment includes several weeks of rest from the activity that caused the pain. Lower impact types of aerobic activity can be substituted during your recovery, such as swimming, using a stationary bike, or an elliptical trainer.

Nonsteroidal anti-inflammatory medicines. Drugs like ibuprofen, aspirin, and naproxen reduce pain and swelling.

Ice. Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin.

Compression. Wearing an elastic compression bandage may prevent additional swelling.

Flexibility exercises. Stretching your lower leg muscles may make your shins feel better.

Supportive shoes. Wearing shoes with good cushioning during daily activities will help reduce stress in your shins.

Orthotics. People who have flat feet or recurrent problems with shin splints may benefit from orthotics. Shoe inserts can help align and stabilize your foot and ankle, taking stress off of your lower leg. Orthotics can be custom-made for your foot, or purchased “off the shelf.”

Return to exercise. Shin splints usually resolve with rest and the simple treatments described above. Before returning to exercise, you should be pain-free for at least 2 weeks. Keep in mind that, when you return to exercise, it must be at a lower level of intensity. You should not be exercising as often as you did before, or for the same length of time.

Be sure to warm up and stretch thoroughly before you exercise. Increase training slowly. If you start to feel the same pain, stop exercising immediately. Use a cold pack and rest for a day or two. Return to training again at a lower level of intensity. Increase training even more slowly than before.

Surgicamel Treatnt

Very few people need surgery for shin splints. Surgery has been done in very severe cases that do not respond to nonsurgical treatment. It is not clear how effective surgery is, however.

Prevention

There are things you can do to prevent shin splints.

Wear a proper fitting athletic shoe. To get the right fit, determine the shape of your foot using the “wet test.” Step out of the shower onto a surface that will show your footprint, like a brown paper bag. If you have a flat foot, you will see an impression of your whole foot on the paper. If you have a high arch, you will only see the ball and heel of your foot. When shopping, look for athletic shoes that match your particular foot pattern.

In addition, make sure you wear shoes designed for your sport. Running long distances in court-type sneakers can contribute to shin splints.

Slowly build your fitness level. Increase the duration, intensity, and frequency of your exercise regimen gradually.

Cross train. Alternate jogging with lower impact sports like swimming or cycling.

Barefoot running. In recent years, barefoot running has gained in popularity. Many people claim it has helped to resolve shin splints. Some research indicates that barefoot running spreads out impact stresses among muscles, so that no area is overloaded. However, there is no clear evidence that barefoot running reduces the risk for any injury.

Like any significant change in your fitness regimen, a barefoot running program should be started very gradually. Begin with short distances to give your muscles and your feet time to adjust. Pushing too far, too fast can put you at risk for stress injuries. In addition, barefoot runners are at increased risk for cuts and bruises on their feet. Several brands of minimalist shoes with “toes” are available and these also require a slow working in period as your body adjusts to this different activity.

If your shin splints do not improve after rest and other methods described above, be sure to see a doctor to determine whether something else is causing your leg pain.

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Patellar Dislocation and Instability in Children (Unstable Kneecap)

Your child’s kneecap (patella) is usually right where it should be—resting in a groove at the end of the thighbone (femur). When the knee bends and straightens, the patella moves straight up and down within the groove. Sometimes, the patella slides too far to one side or the other. When this occurs — such as after a hard blow or fall — the patella can completely or partially dislocate.When the patella slips out of place — whether a partial or complete dislocation — it typically causes pain and loss of function. Even if the patella slips back into place by itself, it will still require treatment to relieve painful symptoms. Be sure to take your child to the doctor for a full examination to identify any damage to the knee joint and surrounding soft tissues.

kneecap function

(Left) The patella normally rests in a small groove at the end of the femur called the trochlear groove. (Right) As you bend and straighten your knee, the patella slides up and down within the groove.

Cause

There are a several ways in which the kneecap can become unstable or dislocate. In many cases, the patella dislocates with very little force because of an abnormality in the structure of a child’s knee.

A shallow or uneven groove in the femur can make dislocation more likely.
Some children’s ligaments are looser, making their joints extremely flexible and more prone to patellar dislocation. This occurs more often in girls, and the problem may affect both knees.
Children with cerebral palsy and Down syndrome may have kneecaps that dislocate frequently due to imbalance and muscle weakness.
Rarely, children are born with unstable kneecaps causing dislocations at a very early age, often without pain.

patellar dislocation

Many things can cause patellar dislocation, such as a shallow groove in the femur or direct force on the knee joint.

In children with normal knee structure, patellar dislocations are often the result of a direct blow or a fall onto the knee. This incidence is more common in high-impact sports, such as football.

Dislocations can occur without contact, as well. A common example is that of a right-handed baseball player who dislocates the right patella while swinging the bat. When the right foot is planted on the ground and the torso rotates during the swing, the patella lags behind, resulting in dislocation.

Symptoms

The symptoms associated with a patellar dislocation depend on how far out of place the patella has moved and how much damage occurred when it happened.

Some general symptoms your child may experience include:

Pain
Feeling the kneecap shift or slide out of the groove
Feeling the knee buckle or give way
Hearing a popping sound when the patella dislocates
Swelling
A change in the knee’s appearance — the knee may appear misshapen or deformed
Apprehension or fear when running or changing direction.

Doctor Examination

If your child’s patella has slid back into place, you should see your doctor as soon as possible. If your child’s patella is still out of place, go to the emergency room.

Medical History and Physical Examination

During the examination, your doctor will ask you and your child about how the injury occurred and specific symptoms. Your doctor also will evaluate the range of motion, tenderness, and appearance of the knee.

Tests

Imaging tests can help your doctor diagnose patellar instability, as well as determine a treatment plan.

X-rays. These tests create clear pictures of bone. Your doctor may order x-rays to look for skeletal abnormalities in the knee, such as a shallow groove in the femur.
Magnetic resonance imaging (MRI) scans. These scans create better pictures of the soft structures surrounding the knee, like ligaments. An MRI is seldom necessary because the doctor can usually diagnose a dislocated patella through an examination and x-rays. However, if your doctor needs additional, more detailed images, he or she may order an MRI.

Sometimes a piece of bone or cartilage can dislodge or loosen when the patella dislocates. This can be seen on an x-ray or MRI scan.

x-ray of knee dislocation

In this x-ray of a bent knee taken from above, the patella is clearly out of alignment within the groove in the femur.

Treatment

Immediate Treatment

If your child’s patella remains dislocated, go to the emergency room. To put the kneecap back in place, your doctor may give your child pain medication to relax his or her knee muscles, and then gently apply pressure to move the kneecap back into place. This process is called a “reduction.”

Nonsurgical Treatment

Immobilization. Your doctor may recommend that your child wear a brace for 3 to 4 weeks. This stabilizes the knee while it heals.
Weightbearing. Because putting weight on the knee may cause pain and slow the healing process, your doctor may recommend using crutches for the first week or two after the injury.
Physical therapy. Once the knee has started to heal, your child’s doctor will recommend physical therapy to help your child regain normal motion. Specific exercises will strengthen the thigh muscles holding the knee joint in place. Your child’s commitment to the exercise program is important for a successful recovery. Typically, children return to activity 3 to 6 weeks after the injury.

Because a dislocation often damages knee tissue, the patella often remains looser, or more unstable, than it was before the injury. As a result, the patella may dislocate again. Recurrences also are common if the dislocation was caused by an irregularity in the knee structure. Ongoing exercises, such as cycling, can strengthen quadriceps muscles in the thigh and prevent future patellar dislocations.

Surgical Treatment

If your child’s patella dislocates multiple times, or continues to be unstable despite therapy and bracing, surgery may be recommended to correct the problem. The type of surgery will depend on the cause of the unstable kneecap.

Surgical treatments often involve reconstructing the ligaments that hold the patella in place. This surgery is sometimes performed arthroscopically—using a tiny camera and miniature surgical instruments inserted through small incisions.

Repeated dislocation caused by a congenital or other bone deformity may require more complex surgical treatment.

Safe Return to Play

Once the knee has returned to full motion and strength, your doctor will likely allow your child to resume normal activities. A full return to more demanding sports may take more time. It is also important that the child feels comfortable and ready to resume activity.

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Bursae are small, jelly-like sacs that are located throughout the body, including around the shoulder, elbow, hip, knee, and heel. They contain a small amount of fluid, and are positioned between bones and soft tissues, acting as cushions to help reduce friction.Pes anserine bursitis is an inflammation of the bursa located between the shinbone (tibia) and three tendons of the hamstring muscle at the inside of the knee. It occurs when the bursa becomes irritated and produces too much fluid, which causes it to swell and put pressure on the adjacent parts of the knee.Pain and tenderness on the inside of your knee, approximately 2 to 3 inches below the joint, are common symptoms of pes anserine bursitis of the knee.

Location of pain from pes anserine bursitis

Pain from pes anserine bursitis is located on the inside of the knee, just below the joint.

Cause

Bursitis usually develops as the result of overuse or constant friction and stress on the bursa. Pes anserine bursitis is common in athletes, particularly runners. People with osteoarthritis of the knee are also susceptible.

Several factors can contribute to the development of pes anserine bursitis, including:

Incorrect training techniques, such as neglecting to stretch, doing excessive hill running, and sudden increases in mileage
Tight hamstring muscles
Obesity
An out-turning of the knee or lower leg
Osteoarthritis in the knee
Medial meniscus tear

Symptoms

The symptoms of pes anserine bursitis include:

Pain slowly developing on the inside of your knee and/or in the center of the shinbone, approximately 2 to 3 inches below the knee joint.
Pain increasing with exercise or climbing stairs

Doctor Examination

Your doctor will examine your knee and talk to you about your symptoms.

Symptoms of pes anserine bursitis may mimic those of a stress fracture, so an x-ray is usually required for diagnosis.

Treatment

Athletes with pes anserine bursitis should take steps to modify their workout program so that the inflammation does not recur.

Other treatments include:

Rest. Discontinue the activity or substitute a different activity until the bursitis clears up.
Ice. Apply ice at regular intervals three or four times a day for 20 minutes at a time.
Anti-inflammatory medication. Aspirin and nonsteroidal anti-inflammatory medication (such as ibuprofen) may ease the pain and reduce the inflammation.
Injection. Your doctor may inject a solution of anesthetic and steroid into the bursa, which often provides prompt relief.
Physical therapy. Your doctor may recommend physical therapy for specific stretching exercises, and ice and ultrasound treatments.

If your symptoms continue, your orthopaedic surgeon may recommend surgical removal of the bursa. This is typically performed as an outpatient (same-day) procedure.

If putting weight on your leg causes discomfort after the procedure, your doctor will recommend using crutches for a short time. Normal activities can typically be resumed within 3 weeks of the procedure.

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Osgood-Schlatter disease is a common cause of knee pain in growing adolescents. It is an inflammation of the area just below the knee where the tendon from the kneecap (patellar tendon) attaches to the shinbone (tibia).Osgood-Schlatter disease most often occurs during growth spurts, when bones, muscles, tendons, and other structures are changing rapidly. Because physical activity puts additional stress on bones and muscles, children who participate in athletics — especially running and jumping sports — are at an increased risk for this condition. However, less active adolescents may also experience this problem.In most cases of Osgood-Schlatter disease, simple measures like rest, ice, over-the-counter medication, and stretching and strengthening exercises will relieve pain and allow a return to daily activities.

Osgood-Schlatter disease causes pain at the tibial tubercle — the bony bump where the patellar tendon attaches to the tibia (shinbone).

Description

The bones of children and adolescents possess a special area where the bone is growing called the growth plate. Growth plates are areas of cartilage located near the ends of bones. When a child is fully grown, the tibial tubercle covers the growth plate at the end of the tibia. The group of muscles in the front of the thigh (called the quadriceps) attaches to the tibial tubercle.

When a child is active, the quadriceps muscles pull on the patellar tendon which, in turn, pulls on the tibial tubercle. In some children, this repetitive traction on the tubercle leads to inflammation of the growth plate. The prominence, or bump, of the tibial tubercle may become very pronounced.

Symptoms

Painful symptoms are often brought on by running, jumping, and other sports-related activities. In some cases, both knees have symptoms, although one knee may be worse than the other.

Knee pain and tenderness at the tibial tubercle
Swelling at the tibial tubercle
Tight muscles in the front or back of the thigh

Doctor Examination

During the appointment, your doctor will discuss your child’s symptoms and general health. He or she will conduct a thorough examination of the knee to determine the cause of the pain. This will include applying pressure to the tibial tubercle, which should be tender or painful for a child with Osgood-Schlatter disease. In addition, your doctor may also ask your child to walk, run, jump, or kneel to see if the movements bring on painful symptoms.

Your doctor may also order an x-ray image of your child’s knee to help confirm the diagnosis or rule out any other problems.

Osgood-Schlatter disease inflamed tibial tubercle

In Osgood-Schlatter disease, the enlarged, inflamed tibial tubercle is nearly always tender when pressure is applied.

Treatment

Treatment for Osgood-Schlatter disease focuses on reducing pain and swelling. This typically requires limiting exercise activity until your child can enjoy activity without discomfort or significant pain afterwards. In some cases, rest from activity is required for several months, followed by a strength conditioning program. However, if your child does not have a large amount of pain or a limp, participation in sports may be safe to continue.

Your doctor may recommend additional treatment methods, including:

Stretching exercises. Stretches for the front and back of the thigh (quadriceps and hamstring muscles) may help relieve pain and prevent the disease from returning.
Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.
Ice. Icing the inflamed area may reduce pain and swelling. Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin.

Standing quadriceps stretch.

You should feel this stretch in the front of your thigh.
Tip: Do not arch or twist your back.

Outcome

Most symptoms will completely disappear when a child completes the adolescent growth spurt, around age 14 for girls and age 16 for boys. For this reason, surgery is rarely recommended. However, the prominence of the tubercle will persist.

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Anatomy

The knee is the largest and strongest joint in the body. It is made up of the lower end of the femur (thighbone), upper end of the tibia (shinbone), and the patella (kneecap). A smooth, slippery tissue called articular cartilage covers and protects the ends of the bones where they meet to form a joint.

The knee joint is filled with a clear fluid (synovial fluid) that acts as a lubricant to help reduce friction within the joint. Small fluid-filled sacs called bursa cushion the joint and help reduce friction between the muscles and other surrounding structures.

knee anatomy The bones that make up the knee joint.

Cause

In adults, Baker’s cysts usually result from an injury or condition that causes swelling and inflammation inside the knee joint, such as:

Osteoarthritis
Rheumatoid arthritis
Meniscus tear
Anterior cruciate ligament (ACL) tear
Other conditions that damage the tissues inside the joint

In response to this inflammation, the knee produces excess synovial fluid, which travels behind the knee and accumulates in the popliteal bursa. The bursa then swells and bulges, forming a Baker’s cyst.

In younger patients, Baker’s cysts often have no known cause.

cyst forms when excess synovial fluid travels to the popliteal bursa at the back of the knee.

Symptoms

Some Baker’s cysts cause no symptoms and are only discovered incidentally during a physical exam or when an MRI scan is performed for some other reason. When symptoms do occur, they may include:

A feeling of fullness or a lump behind the knee
Knee pain
Stiffness or tightness at the back of the knee
Swelling in your knee and lower leg

If the cyst becomes very large, it can interfere with blood flow in the veins of your leg. This can cause pain, swelling, weakness, or even numbness if there is nerve compression. Very rarely, the cyst can even burst.

Sometimes the symptoms of a cyst may resemble those of a blood clot or deep vein thrombosis, a much more serious problem. If you have increasing pain and swelling in your calf, it is important to seek medical care right away to rule out a blood clot.

Doctor Examination

Medical History and Physical Examination

Your doctor will take a full medical history and ask you to describe your symptoms. He or she will want to know if you have had a previous knee injury.

Your doctor will then perform a careful examination of your affected knee, comparing it to your “normal” knee. During the exam, he or she will look for:

Swelling
Instability of the joint
A clicking or popping noise when you bend your knee
Joint stiffness and limited range of motion

Your doctor will also palpate (feel) the back of your knee where the cyst is located. Often, a cyst will become firm when the knee is fully extended and soft when the knee is bent.

Imaging Tests

Imaging tests may be ordered to help confirm the diagnosis and provide more information about your condition.

X-rays. X-rays provide images of dense structures, such as bone. Although a cyst cannot be seen on an x-ray, one may be ordered so that your doctor can look for narrowing of the joint space and other signs of arthritis in the joint.

normal and arthritic knee

(Left) In this x-ray of a normal knee, the space between the bones indicates healthy cartilage. (Right) This x-ray of an arthritic knee shows severe loss of joint space.

Ultrasound. This test uses sound waves to create images of structures inside the body. An ultrasound will help your doctor see the lump behind your knee in greater detail and determine whether it is solid or filled with fluid.

Magnetic resonance imaging (MRI) scans. These tests produce clear pictures of the body’s soft tissues. Your doctor may order an MRI scan to learn more about your cyst and to look for a meniscus tear or another underlying condition.

Baker's cyst

This MRI scan shows an area of fluid behind the knee, the characteristic location of a Baker’s cyst.

Treatment

Nonsurgical Treatment

Most Baker’s cysts will go away on their own. For cysts that do not disappear, initial treatment is always nonsurgical in nature and may include one or more of the following:

Observation. Your doctor may recommend simply observing the cyst over time to ensure that it does not grow larger and cause painful symptoms.
Activity modification. Decreasing your activity and avoiding high-impact activities that irritate the knee, such as jogging and aerobics, can help alleviate symptoms.
Nonsteroidal anti-inflammatory medications. Drugs like ibuprofen and naproxen can help reduce pain and swelling.
Steroid injection. Your doctor may inject a corticosteroid medication into your knee joint to reduce inflammation.
Aspiration. In this procedure, your doctor numbs the area around the cyst, then uses a needle to drain the excess fluid from the joint. Aspiration is often performed using ultrasound to guide the placement of the needle.

Surgical Treatment

Surgical treatment for a Baker’s cyst is rarely needed. However, it may be recommended if you have painful symptoms that are not relieved with nonsurgical treatment or if your cyst returns repeatedly after aspiration.

Arthroscopy. In this procedure, your doctor makes tiny incisions under anesthesia, then inserts a small camera called an arthroscope into the knee joint. The camera displays images on a video screen and your doctor uses these images to guide miniature surgical instruments.

Arthroscopy is used to treat conditions inside the knee, such as meniscus tears, that may give rise to a Baker’s cyst.

knee arthroscopy

Photo shows a camera and instruments inserted through portals in the knee.

Excision. For large cysts or those that are causing nerve and vascular problems, your doctor may perform an open surgical procedure to excise (remove) the entire cyst.

Recovery

It is very important to follow your recovery instructions to prevent the recurrence of a Baker’s cyst.

Early movement. If your cyst has been aspirated or if you have had arthroscopic surgery, you will most likely be allowed to walk right after the procedure, but you should avoid strenuous activity during your recovery.

Bracing. Your doctor may recommend that you wear a knee brace for several weeks after surgery to immobilize your knee.

Physical therapy. Specific exercises will help improve range of motion and strengthen the muscles around the knee.

The time it takes to recover from surgery varies from patient to patient, depending on whether the underlying condition in the joint was treated during the procedure. Most patients can expect a return to full activity around 4 to 6 weeks after surgery.

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Arthroscopy

Arthroscopy is a surgical procedure that orthopaedic surgeons use to visualize and treat problems inside a joint.The word arthroscopy comes from two Greek words, “arthro” (joint) and “skopein” (to look). The term literally means “to look within the joint.”In arthroscopic surgery, an orthopaedic surgeon makes a small incision in the patient’s skin, then inserts pencil-sized instruments that contain a small lens and lighting system to magnify and illuminate the structures inside the joint. Light is transmitted through fiber optics to the end of the arthroscope that is inserted into the joint.By attaching the arthroscope to a miniature camera, the surgeon is able to see the interior of the joint through this very small incision, rather than the larger incision needed for open surgery.

arthroscope

An arthroscope is a small, thin tube that is inserted into the body. A camera and light source are attached to the arthroscope.

The camera attached to the arthroscope displays the image of the joint on a video monitor, allowing the surgeon to look, for example, throughout the knee. This lets the surgeon see the cartilage, ligaments, and under the kneecap. The surgeon can determine the amount or type of injury and then repair or correct the problem, if it is necessary.

Arthroscopic surgery

In this photo of arthroscopic surgery, the surgeon views the inside of the patient’s knee on a video monitor.

When is arthroscopy used?

Your bones, cartilage, ligaments, muscles, and tendons can all be damaged by disease and injury. To diagnose your condition, your doctor will take a thorough medical history, perform a physical examination and order imaging studies — usually x-rays. For some conditions, an additional imaging study — such as a magnetic resonance imaging (MRI) scan or a computerized tomography (CT) scan — may also be needed. After making a diagnosis, your doctor will determine the most appropriate treatment choice for your condition.

Conditions

Conditions that are commonly treated with arthroscopic procedures include:

Inflammation. For example, synovitis is a condition that causes the tissues surrounding the knee, shoulder, elbow, wrist, and ankle joint to become inflamed.
Acute or chronic injuries, including:
- Rotator cuff tendon tears
- Shoulder impingement
- Recurrent dislocation in the shoulder
- Meniscal (cartilage) tears in the knee
- Chondromalacia (wearing or injury of the cartilage cushion in the knee)
- Anterior cruciate ligament (ACL) tears with instability in the knee
- Carpal tunnel syndrome in the wrist
- Loose bodies of bone and/or cartilage, particularly in the knee, shoulder, elbow, ankle, or wrist

Some problems associated with arthritis can also be treated arthroscopically.

Procedures

The procedures below are performed either with arthroscopy or with a combination of arthroscopic and open surgery:

Rotator cuff repair
Repair or resection of torn cartilage (meniscus) from the knee or shoulder
Reconstruction of the anterior cruciate ligament (ACL) in the knee
Removal of the synovium in the knee, shoulder, elbow, wrist, or ankle
Release of the carpal tunnel in the wrist
Repair of torn ligaments
Removal of loose bone or cartilage in the knee, shoulder, elbow, wrist, or ankle

Although the inside of nearly all joints can be viewed with an arthroscope, six joints are most frequently examined with this instrument. These are the knee, shoulder, elbow, ankle, hip and wrist. As advances are made in fiberoptic technology and new techniques are developed by orthopaedic surgeons, other joints may be treated more frequently in the future.

Arthroscopic view of shoulder joint

The parts of the shoulder joint as seen through an arthroscope: the rotator cuff (RC), the head of the humerus (HH), and the biceps tendon (B).

How is arthroscopy performed?

Arthroscopic surgery, although much easier in terms of recovery than open surgery, still requires the use of anesthetics and the special equipment in a hospital operating room or outpatient surgical suite. You will be given a general, spinal, or a local anesthetic, depending on the joint or suspected problem.

A small incision (about the size of a buttonhole) will be made to insert the arthroscope. Several other incisions may be made to see other parts of the joint or insert other instruments.

Corrective surgery is performed with specially designed instruments that are inserted into the joint through accessory incisions. Originally, arthroscopy was simply a diagnostic tool used for planning standard open surgery. However, with the development of better instrumentation and surgical techniques, many conditions can now be treated with arthroscopic techniques.

After arthroscopic surgery, the small incisions will be covered with a dressing. You will be moved from the operating room to a recovery room. Many patients need little or no pain medication.

Trimming a torn meniscus

The surgeon inserts miniature scissors to trim a torn meniscus.

Before being discharged, you will be given instructions on caring for your incisions, what activities to avoid, and which exercises you should do to aid your recovery. During the follow-up visit, the surgeon will inspect your incisions; remove sutures, if present; and discuss your rehabilitation program.

The amount of surgery required and recovery time will depend on the complexity of your problem. Occasionally, during arthroscopy, the surgeon may discover that the injury or disease cannot be treated adequately with arthroscopy alone. More extensive open surgery may be performed while you are still anesthetized, or at a later date after you have discussed the findings with your surgeon.

What are the possible complications?

Although uncommon, complications do occur occasionally during or after arthroscopy. Infection, blood clots of a vein (also called deep vein thrombosis or DVT), excessive swelling or bleeding, damage to blood vessels or nerves, and instrument breakage are the most common complications; however, these occur in far less than 1 percent of all arthroscopic procedures.

What are the advantages?

Although arthroscopic surgery has received a lot of public attention because it is often used to treat well-known athletes, it is an extremely valuable tool for all orthopaedic patients and is generally easier on the patient than open surgery. Most patients have their arthroscopic surgery as outpatients and are home several hours after the surgery.

What is recovery like after arthroscopy?

The small puncture wounds take several days to heal. The operative dressing can usually be removed the morning after surgery and adhesive strips can be applied to cover the small healing incisions.

Although the puncture wounds are small and pain in the joint that underwent arthroscopy is minimal, it takes several weeks for the joint to maximally recover. A specific activity and rehabilitation program may be suggested to speed your recover and protect future joint function.

It is not unusual for patients to go back to work or school or resume daily activities within a few days. Athletes and others who are in good physical condition may, in some cases, return to athletic activities within a few weeks. Remember, though, that people who have arthroscopy can have many different diagnoses and preexisting conditions, so each patient’s arthroscopic surgery is unique to that person. Recovery time will reflect that individuality.

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LCL RECONSTRUCTION

What is a Lateral Collateral Ligament?

Lateral collateral ligament (LCL) is a thin set of tissues present on the outer side of the knee, connecting the thighbone (femur) to the fibula (side bone of lower leg). It provides stability as well as limits the sidewise rotation of the knee. Tear or injury of LCL may cause instability of the knee that can be either reconstructed or repaired to regain the strength and movement of the knee.

The knee is the largest joint of the body and is stabilized by a set of ligaments. In the knee, there are four primary ligaments viz. anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and lateral collateral ligament.

LCL Reconstruction

Causes of LCL Injuries

Lateral collateral ligament may tear due to trauma, sports injuries, or direct blow on the knee. Torn LCL may result in pain, swelling and even instability of the knee.

Diagnosis of LCL Injuries

LCL injuries and torn LCL can be diagnosed through physical examination and by employing imaging techniques such as X-rays or MRI scan.

Treatment of LCL Injuries

The treatment of the torn LCL include non-surgical interventions such as rest, ice, elevation, bracing and physical therapy to help reduce swelling, and regain activity as well as strength and flexibility of the knee. Surgery is recommended if non-surgical interventions fail to provide much relief. Surgical interventions include repair and reconstruction of the torn ligament. Based on the severity and location of the injury, repair or reconstruction of the LCL is recommended. In case the ligament is torn from the upper or lower ends of attachment, then repair of the LCL is done with sutures or staples. If the ligament is torn in the middle or if the injury is older than 3 weeks, LCL reconstruction is recommended.

LCL Reconstruction Procedure

LCL reconstruction involves replacement of the torn ligament with healthy strong tissue or graft. The tissue or graft can be taken either from the tissue bank (called allograft) or from the patient’s body (called autograft). The type of graft used, depends upon the condition of the patient and choice of your surgeon. Hamstring tendons are commonly used as autograft, as removal of such tendons does not affect the strength of the legs and effectively stabilizes the knee. A small incision is made on the lateral side of the knee to perform the LCL reconstruction. The procedure is done through an open incision and not arthroscopically. The thighbone and fibula bones are drilled precisely and accurately with specialized instruments to form tunnels. The ends of the tendon graft are passed through tunnels and are fixed by using screws, metal staples or large sutures. The knee undergone LCL reconstruction surgery is braced for 6-8 weeks.

Post-operative care following LCL Reconstruction

The common Post-operative instructions for LCL reconstruction are:

Use crutches to avoid weight on the knee for at least 6 weeks
Use ice and the prescribed medications to reduce swelling
Avoid lifting heavy weight or vigorous exercise
Follow the specific instruction given by your surgeon
Follow rehabilitation programs or physical therapy to regain the motion and strength of the knee

Risks and complications of LCL Reconstruction

Some of the possible risks and complication associated with LCL reconstruction include:

Chronic pain
Knee weakness
Knee instability
Peroneal nerve injury

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MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION

What is Medial Patellofemoral Ligament Reconstruction?

Medial patellofemoral ligament reconstruction is a surgical procedure indicated in patients with more severe patellar instability. Medial patellofemoral ligament is a band of tissue that extends from the femoral medial epicondyle to the superior aspect of the patella. Medial patellofemoral ligament is the major ligament which stabilizes the patella and helps in preventing patellar subluxation (partial dislocation) or dislocation. This ligament can rupture or get damaged when there is patellar lateral dislocation. Dislocation can be caused by direct blow to the knee, twisting injury to the lower leg, strong muscle contraction, or because of a congenital abnormality such as shallow or malformed joint surfaces.

Medial Patellofemoral Ligament Reconstruction

Medial patellofemoral ligament reconstruction using autogenous tissue grafts is done by following the basic principles of ligament reconstruction such as:

Graft Selection: Strong and stiff graft should be selected
Location: The graft should be located isometrically
Correct tension: The tension set in the graft should be appropriate
Secure Fixation: Stable fixation of the graft should be achieved
Avoid condylar rubbing or impingement: The graft should not rub against condyle or cause impingement

Medial Patellofemoral Ligament Reconstruction Procedure

The surgical procedure of medial patellofemoral ligament reconstruction involves the following steps:

Graft Selection and Harvest:

Your surgeon will make a 4-6 cm skin incision over your knee, at the midpoint between the medial epicondyle and the medial aspect of the patella (kneecap). The underlying subcutaneous fat and fascia are cut apart to expose the adductor tendon. The tendon is then stripped using a tendon stripper and its free end is sutured. The diameter of the tendon graft is measured using a sizer.

Alternatively, a graft can be harvested from the quadriceps tendon.

Location of the Femoral Isometric Point:

The graft should be placed isometrically to prevent it from overstretching and causing failure during joint movements. A transverse hole measuring 2.5 mm is made through the patella. Then a small incision is made over the lateral side of the patella and a strand of Vicryl suture material is inserted through the hole. Over this strand, a 2.5 mm Kirschner wire (K-wire) is passed and then inserted into the bone besides the medial epicondyle.

An instrument called pneumatic isometer is inserted into the hole made in the patella and the Vicryl isometric measurement suture material is also passed along. The knee is taken through its full range of motion and any changes happening in the length between the medial epicondylar K-wire and the medial aspect of the patella is recorded on the isometer. The position of the K-wire will be adjusted until no deviations are read on the isometer during full range of motion. Once the isometric point is identified, a tunnel is drilled starting from the insertion of the adductor tendon uptil the isometric point is reached. The graft is pulled through this tunnel, then exits at the medial condyle and again passed through another tunnel that is made through the patella.

Correct Tension:

The tension is set in the graft with your knee flexed up to 90^o and the tension should be appropriate enough to control lateral excursion.

Secure Fixation:

After bringing the tendon graft from the medial to the lateral side through the bone tunnel, it turned onto the front surface of the patella where it is sutured.

Avoid Condylar Rubbing and Impingement:

After graft fixation, the range of motion is checked to make sure there are no restrictions in patellar or knee movements. The graft should not impinge or rub against the medial femoral condyle. If it is detected, the graft is replaced into proper position.

Post-operative Care after Medial Patellofemoral Ligament Reconstruction

A knee brace should be used during walking in the first 3-6 weeks after surgery. Avoid climbing stairs, squatting and stretching your leg until there is adequate healing of the tendon. Rehabilitation exercises, continuous passive motion and active exercises will be recommended.

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TIBIAL TUBERCLE OSTEOTOMY

What is Tibial Tubercle Osteotomy?

Tibial tubercle osteotomy is a surgical procedure which is performed along with other procedures to treat patellar instability, patellofemoral pain, and osteoarthritis. Tibial tubercle transfer technique involves realignment of the tibial tubercle (a bump in the front of the shinbone) such that the kneecap (patella) traverses in the center of the femoral groove. The patellar maltracking is corrected by moving the tibial tubercle medially, towards the inside portion of the leg. This removes the load off the painful portions of the kneecap and reduces the pain.

Tibial Tubercle Osteotomy

Indications ofTibial Tubercle Osteotomy

Surgical treatment is indicated when physical therapy and other nonsurgical methods have failed and there is history of multiple knee dislocations.

Tibial Tubercle Osteotomy Procedure

The procedure is performed under general anesthesia and you will be completely unaware of the surgery until you wake up in the recovery room. At first, knee arthroscopy will be performed to inspect the inside portions of the knee joint. It involves small incisions or portals through which small instruments are passed and a video camera is used to visualize the anatomy of the knee joint, evaluate patella cartilage and assess patella tracking.

Tibial tubercle osteotomy and transfer is done through an incision made in the front of your leg just below the patella. In osteotomy procedure, a periosteal incision of 8-10 cm length is made at 1cm medial to the tibial tubercle. With the help of an oscillating saw, a cut is made medial to the tuberosity and a distal cut is also made. The tapered design of the distal cut avoids the risk of tibial fracture. Similarly, a proximal cut is made using appropriate instruments such as curved osteotome or reciprocating saw. Then an osteotomy through the bone cortex is performed without cutting off the lateral periosteum. The lateral periosteum serves as a point of attachment for the osteotomy segment. By doing this, a tibial tubercle segment which is more than 2 cm in width, more than 1 cm in thickness and 8-10 cm length can be obtained. It should include all portions of insertion of the patellar tendon. The segment from the tibia is then levered using osteotome to provide access to the medullary canal of the tibia.

The osteotomy segment is then moved under direct vision into a position that assures proper tracking of the patella. The tracking pattern can be confirmed arthroscopically. The mobilized bone is then fixed into its new place using screws, which can be removed later if they cause irritation.

Post-surgery Care for Tibial Tubercle Osteotomy

You may have minimal to moderate knee discomfort for several days or weeks after the surgery. Oral pain medications will be prescribed that helps control your pain. Keep the operated leg elevated and apply ice bag over the area for 20 minutes. This decrease swelling as well as pain. You will have a leg brace which may be removed only while sitting with your leg elevated and when using the continuous passive motion (CPM) unit. Physical therapy exercises should be done as it helps in regaining mobility. Eat healthy food and drink plenty of water.

Risks and Complications of Tibial Tubercle Osteotomy

This is a quite safe procedure and provides excellent access and surgical exposure during a difficult primary or revision total knee arthroplasty. Risks following tibial tubercle osteotomy surgery are rare but may include compartment syndrome, deep vein thrombosis, infections and delayed bone healing.

Dr. Ujjval Deliwala

Arthroscopic Surgeon

Problems ( ગોઠણ ની તકલીફો)

Treatments (ઉપલબ્ધ સારવાર)

Anatomy

Collateral Ligaments

Cruciate Ligaments

Description

Cause

Symptoms

Doctor Examination

Physical Examination and Patient History

Imaging Tests

Treatment

Nonsurgical Treatment

Surgical Treatment

Rehabilitation

Anatomy

Description

Cause

Symptoms

Doctor Examination

Treatment

Nonsurgical Treatment

Surgical Treatment

Rehabilitation

Anatomy

Description

Cause

Symptoms

Doctor Examination

Physical Examination

Imaging Tests

Treatment

Nonsurgical Treatment

Surgical Treatment

Recovery

Anatomy

Description

Types of Discoid Meniscus

Discoid Meniscus Injuries

Cause

Symptoms

Doctor Examination

Medical History and Physical Examination

Imaging Tests

Treatment

Surgical Treatment

Rehabilitation

Recovery

Anatomy

Collateral Ligaments

Cruciate Ligaments

Description

Treatment

Outcome

Anatomy

Description

Osteoarthritis

Rheumatoid Arthritis

Posttraumatic Arthritis

Symptoms

Doctor Examination

Physical Examination

Imaging Tests

Laboratory Tests

Treatment

Nonsurgical Treatment

Surgical Treatment

Recovery

Description

Cause

Symptoms

Doctor Examination

Stress Fracture

Tendinitis

Chronic Exertional Compartment Syndrome

Treatment

Nonsurgical Treatment