Our knees are extremely complex and subject to extreme stress on a daily basis so they can suffer from a variety of conditions – all of which are treatable if diagnosed correctly.
Meniscal tears can either result due to sporting injuries or due to wear and tear in the menisci which makes them soft. Meniscal tears cause pain and clicking in the knee. They can also cause mild instability and a severe tear can cause the knee to lock.
The tears are assessed by thorough clinical examination utilising special tests. MRI scanning confirms the diagnosis and further delineates the severity of the tear. In certain cases with a very high index of clinical suspicion, arthroscopy is used for both diagnosis and treatment.
Some meniscal tears are amenable to non-surgical treatment and resolve with physiotherapy and modified activity. If the tears are complex, they require surgical intervention in the form of arthroscopy (keyhole surgery). They are treated by either repairing the meniscus or resecting the torn edges (partial meniscectomy). If a repair is carried out, the patient may have restrictions on weight bearing. The surgery is followed by brief outpatient physiotherapy.
Meniscal cysts form due to exudation of synovial fluid into tears of the meniscus, usually seen in degenerative tears. Treatment is aimed at management of the tears and achieved arthroscopically. Occasionally the cysts may be large and may require open surgery for complete resolution.
Articular cartilage is the tough smooth tissue which covers the ends of bones, forming joints. The cartilage can be damaged due to trauma and sporting injuries. It can also be damaged due to a selective wear and tear process. In children, a cartilage lesion can occur secondary to a minor trauma due to condition called osteochondritis dissecans (literally meaning ‘drying up of the cartilage’).
The assessment includes examination followed by further MRI imaging. Quite often, arthroscopy is required to precisely diagnose the severity of damage. These are difficult problems to treat and there are multiple treatment methods. They are all known as cartilage regeneration procedures.
There are two cruciate ligaments in the knee. The cruciate ligaments are very strong ligaments and can withstand huge amounts of strain before rupturing.
The cruciate ligaments are damaged due to sporting accidents and other high energy trauma. Sports requiring pivoting on the knee such as football, netball, skiing or rugby are the usual culprits.
Cruciate injury presents as a painful swollen knee due to bleeding in the joint. Subsequently, the patient is left with a weak knee which gives way even with normal activities. It becomes difficult to participate in sports. Since the knee becomes unstable, other structures in the knee remain at risk of further trauma.
Management involves examination and imaging with MRI scan. Depending on the findings, the cruciate ligament injury can be treated non-surgically with specific rehabilitation or surgically via reconstruction.
Our choice of reconstruction is the all-arthroscopic technique, using hamstring tendon from the same leg. This allows us to rehabilitate patients early and the graft site has minimal morbidity.
These are strong ligaments on either side of the knee. The medial collateral ligament (MCL) lies on the inner aspect and the lateral collateral ligament (LCL) lies on the outer aspect. They provide stabilisation in sideways stress in the knee.
The MCL is one of the most commonly injured ligaments and is a predominant sporting injury, though it can be injured in other trauma as well. The LCL is less commonly involved in isolation and is usually in association with other ligament injuries. The ligaments are sprained as a result of forced stretching of the ligaments. There may be other injuries in the knee that need meticulous evaluation.
Clinical examination remains the mainstay for diagnosing these injuries. Further imaging is important to estimate the severity and to identify any other damage to the knee. MRI scanning is a very useful assessment tool.
The MCL injuries can be classified into 3 grades according to the extent of damage. Treatment is planned on the grade of injury and after assessing other factors like concomitant injury to other stabilising structures.
Less severe injuries of the MCL are managed non-surgically in a hinged knee brace with controlled early mobilisation protocol. Severe injuries are treated with repair of the ligament or reconstruction. The LCL injuries, if isolated, can be treated non-surgically.
Some other important ligaments in the knee are the posterolateral ligament complex and the posteromedial ligament complex. These are anatomically complex structures which can be injured as a result of high energy trauma. These are often associated with knee dislocations. These injuries cause instability symptoms and are managed surgically with reconstruction. The procedure is quite complex and requires use of multiple ligament/tendon grafts.
The medial patellofemoral ligament is a structure which helps the patella (kneecap) to track congruently in the trochlear notch. It is injured after patella dislocation. Reconstruction of this ligament is done to help instability and recurrent dislocation of the patellofemoral joint.
Arthritis causes painful joints. It restricts movements. The pain is activity related in the early stages but can gradually be a constant feature. The pain and stiffness causes significant limitation to how joints work and hence is a major factor affecting quality of life. In later stages of arthritis, the affected joint deforms.
When arthritis is in the early stages, treatment is directed towards managing pain. This includes lifestyle modification to avoid impact exercises, physiotherapy to improve muscle strength and co-ordination and analgesics as required.
The next step can be surgical procedures such as realignment osteotomy and cartilage debridement. At this stage, the arthritis is usually affecting only a partial area of the joint and treatment is aimed to offload the painful area and weight bear the relatively normal area.
In advanced stages, the joint is not salvageable and joint replacement is the option for treatment.
Partial joint replacement is the procedure where only the arthritic area of the joint is replaced, and the normal area left intact. This helps to preserve more structures in the knee and gives patients a better proprioception. Total joint replacement involves replacing the entire joint. It helps to completely relieve the pain and improve mobility.
Osteochondritis Dissecans is the loss of blood supply to a part of bone just adjacent to the cartilage, with associated cartilage involvement. It is seen most commonly in the knee but can be found in other joints of the body as well. The most common site is the lateral portion of the medial femoral condyle. It can be secondary to repetitive trauma, but an acute injury may or may not be present.
It affects adolescents with a growing skeleton but can occasionally be seen in adults.
Knee pain and locking in the knee are the main features of this condition. The knee can get swollen especially after sports or increased activity.
Clinical examination and radiological assessment usually gives a provisional diagnosis. An MRI scan is helpful in confirming the diagnosis, as well as quantifying the severity and healing potential of the lesion. A bone scan may be sometimes required to know about the vascularity of the area.
Prognosis is better in adolescents and therefore the goal of treatment is to obtain lesion healing before physeal closure (skeletal maturity). Factors considered before treatment are the age of patient, size of the fragment and stability of the fragment.
Non operative treatment involves anti-inflammatory medication, restricted weight bearing if the knee is irritable and avoidance of all impact loading activities. This is quite successful in children of 12 years and younger with a small stable fragment.
Operative treatment is generally required in older children (12 years and older). The various surgical options available are:
* Drilling through the fragment if the overlying cartilage is intact.
* Reduction and fixation of the fragment if the fragment is unstable. This can be achieved using screws or pins.
* If the lesion is large and unstable other methods like chondroplasty, microfracture, autologous chondrocyte implantation can be used.
A Baker’s Cyst itself rarely causes symptoms but the underlying pathology such as arthritis or meniscal tear can cause pain. If large, the cyst can cause restriction to movements because of the size. Rarely, the cyst may rupture and cause calf pain due to fluid extravasation.
Clinical examination is usually sufficient to diagnose this condition. Most diagnostic imaging modalities are directed towards finding the cause of the cyst. MRI scanning is preferred due to its high sensitivity and specificity. In the case of a cyst rupture, Doppler scanning is required to differentiate it from deep vein thrombosis (blood clots in the leg).
Treatment is directed at treating the cause. More often, a non-surgical treatment is adopted.
If the swelling is large and causing symptoms due to size, aspiration is tried but re-filling of the cyst is quite common. As recurrence rate is high after this surgery, surgery is usually the last resort.
Inflammation of the bursae is termed bursitis and caused due to overuse. It is often seen in people who must kneel to do their occupation. Bursitis can sometimes be infected and form an abscess.
Bursitis causes swelling and pain in the joint. It has to be differentiated from infection in the knee joint. If the bursa is infected, it can cause general symptoms like fever and malaise.
Treatment for inflamed bursae is non-surgical. Rest and anti-inflammatory medication are advised. If the bursa is infected, it needs incision and drainage.
This is a condition where there is pain and decreased function of the tendons around the knee. The condition affects tendons close to their insertion and may be related to reduced blood supply and degenerative process.
All tendons around the knee can be affected. Commonly, the patellar tendon and the quadriceps tendon are involved. It is also seen in the hamstring tendons. Patients present with pain in the region of tendon insertion. The pain is proportional to activity but may be also present at rest.
It affects the patient’s ability to participate in sports.
Treatment is conservative in most cases. Physiotherapy, stretching and strengthening usually resolve symptoms. The treatment may take a long time. Sometimes, the injection of a steroid and anaesthetic are used to expedite the resolution.
This is a general term used to indicate multiple problems affecting the patellofemoral joint and the entire extensor mechanism. As the name suggests, the pain is perceived in the front of the knee. The patella is a bone in the quadriceps tendon which articulates with the trochlea (which is the part of femur shaped like a trough). It is sometimes difficult to identify the exact cause of pain and hence treatment can be quite difficult.
The various pathologies considered are arthritis of the patellofemoral joint (PFJ), mal-tracking of the PFJ, subluxation/dislocation of the PFJ, dysplasia (abnormal development) of the trochlea, patella tendonitis and quadriceps tendonitis.