I promised to talk a bit about some of the more common knee injuries as part of the series on weekend warriors. I’d say that half of my practice deals with treating knees. Half again of those are arthritic knees who eventually need knee replacements (arthroplasty). That leaves 25% of my practice focused on the patient with knee trauma.
The Knee is More Than a Hinge
The Knee is a rather simple joint when compared to other joints, like the elbow for example, but it is not a simple hinge joint as you might expect. It bends, but also rolls back. It pivots, and it opens laterally and medially a bit as well.
The structures that allow these movements are called ligaments, and to some extent, the cartilage cushioned called menisci (or meniscus for one–we have two in each knee). The ligaments on the sides of the knee are the collaterals (medial and lateral) and in the middle of the knee are the cruciates (anterior and posterior).
The joint surfaces, on the ends of the femur and tibia bones which make up the weight bearing parts of the knee are coated with hyaline cartilage like on the end of a chicken bone. These surfaces, coated by a slippery substance called synovial fluid, create the articulation where the actions occur–similar to the contact between a ball-bearing in an engine, or a piston, coated with oil.
Internal Derangements of the Knee
Any of these structures can be damaged or injured during a twist, fall, contusion or a pull. If the bone on either side of the joint don’t break, then the ligaments, menisci and even some of the tendons from the large leg and thigh muscles which pass by the knee can tear.
I typically see meniscal tears and ligament injuries. Occasionally we see fractures of the top of the tibia, knee cap (patellar) or end of the femur either alone or less commonly associated with the soft tissue injuries.
A meniscal tear usually results from a twisting injury or some type of force to the knee outside of the normal anatomic mechanical motions that happen when we walk, run, climb, kneel, crawl or jump. Forces which result in injuries may be minor–the perfect twist–or major as in a soccer collision, a motor vehicle accident or a major fall from height.
Meniscal injuries can be left alone in young people if they occur in an area of good supply–and that’s really limited to the back of the medial meniscus. Unfortunately most meniscal injuries, even in young patients, do not heal and may go on to create early-onset degenerative osteoarthritis in the knee if they act as an irritant to the hyaline cartilage surfaces, particularly in the area of the tear. They may require repair (if in an area of good blood supply) or excision, where we trim out the torn area using a minimally invasive procedure called arthroscopy.
Some ligament injuries require surgery, some are better left alone to heal. A medial collateral ligament–the ligament on the medial or inner side of the knee–will typically heal if braced to avoid stress. An anterior cruciate ligament injury–if completely ruptured and causing instability of the knee–usually needs to be reconstructed. Lateral collateral ligaments and posterior cruciate ligaments may or may not need repair/reconstruction and generally depend on the patient’s lifestyle, age, and the surgeon’s experience and clinical examination.
I probably reconstruct at least 4 to 6 anterior cruciate ligaments each month–sometimes more, sometimes less. We use the small hamstrings of the thigh or the middle third of the tendon that attaches the knee cap (patella) to the leg (tibia) in order to create a new ligament. Bracing, cryotherapy, and a significant course of physical therapy are required to recover from this injury in most patients.
The Knee of the Weekend Warrior
A typical weekend warrior injury is a twist that results in pain, swelling, stiffness and decreased weight bearing tolerance. If this does not clear up with rest, ice, gentle ,movement and elevation of the leg after 2 or 3 days, then you should see your doctor for a physical examination. Xrays, ultrasound and clinical findings can diagnose most major knee issues that would require immediate attention. MRI’s are typically reserved for unresolving symptoms that do not get better over a few days or a short number of weeks in spite of a good effort at nonoperative therapies.
An MRI will help to better identify hidden fractures, ligament tears and meniscal tears.
To book a visit with Dr. Smith Auguste, please ask your family doctor to send a referral to fax: 416 352 5123.