Joint & Braces Information
Symptoms
Arthritis
Arthritis of the knee is most often osteoarthritis. In this disease, the cartilage in the joint gradually wears away. In rheumatoid arthritis, which can also affect the knees, the joint becomes inflamed and cartilage may be destroyed. Arthritis not only affects joints; it can also affect supporting structures such as muscles, tendons, and ligaments.
Osteoarthritis may be caused by excess stress on the joint from deformity, repeated injury, or excess weight. It most often affects middle-aged and older people. A young person who develops osteoarthritis may have an inherited form of the disease or may have experienced continuous irritation from an unrepaired torn meniscus or other injury. Rheumatoid arthritis often affects people at an earlier age than osteoarthritis.
Signs and Diagnosis
Someone who has arthritis of the knee may experience pain, swelling, and a decrease in knee motion. A common symptom is morning stiffness that lessens as the person moves around. The doctor may confirm the diagnosis by performing a physical examination and examining X-rays. Blood tests may be helpful for diagnosing rheumatoid arthritis, but other tests may be needed too. Analyzing fluid from the knee joint may be helpful in diagnosing some kinds of arthritis. The doctor may use arthroscopy to directly see damage to cartilage, tendons, and ligaments and to confirm a diagnosis, but arthroscopy is usually done only if a repair procedure is to be performed.
Treatment
Most often osteoarthritis of the knee is treated with pain-reducing medicines, such as aspirin or acetaminophen (Tylenol); nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin, Nuprin, Advil); and exercises to restore joint movement and strengthen the knee. Losing excess weight can also help people with osteoarthritis.
Rheumatoid arthritis of the knee may require physical therapy and more powerful medications. In people with arthritis of the knee, a seriously damaged joint may need to be replaced with an artificial one.
Chondromalacia
Chondromalacia refers to softening of the articular cartilage of the knee cap. This disorder occurs most often in young adults and can be caused by injury, overuse, parts out of alignment, or muscle weakness. Instead of gliding smoothly across the lower end of the thigh bone, the knee cap rubs against it, roughening the cartilage underneath the knee cap. The damage may range from a slightly abnormal surface of the cartilage to a surface that has been worn away to the bone. Chondromalacia related to injury occurs when a blow to the knee cap tears off either a small piece of cartilage or a large fragment containing a piece of bone.
Symptoms and Diagnosis
The most frequent symptom is a dull pain around or under the knee cap that worsens when walking down stairs or hills. A person may also feel pain when climbing stairs or when the knee bears weight as it straightens. The disorder is common in runners and is also seen in skiers, cyclists, and soccer players. A patient's description of symptoms and a follow-up X-ray usually help the doctor make a diagnosis. Although arthroscopy can confirm the diagnosis, it's not performed unless the condition requires extensive treatment.
Treatment
Many doctors recommend that patients with chondromalacia perform low-impact exercises that strengthen muscles, particularly the inner part of the quadriceps, without injuring joints. Swimming, riding a stationary bicycle, and using a cross-country ski machine are acceptable as long as the knee doesn't bend more than 90 degrees. Electrical stimulation may also be used to strengthen the muscles. If these treatments don't improve the condition, the doctor may perform arthroscopic surgery to smooth the surface of the cartilage and "wash out" the cartilage fragments that cause the joint to catch during bending and straightening. In more severe cases, surgery may be necessary to correct the angle of the knee cap and relieve friction with the cartilage or to reposition parts that are out of alignment.
Meniscus Injuries
The meniscus is easily injured by the force of rotating the knee while bearing weight. A partial or total tear may occur when a person quickly twists or rotates the upper leg while the foot stays still (for example, when dribbling a basketball around an opponent or turning to hit a tennis ball). If the tear is tiny, the meniscus stays connected to the front and back of the knee; if the tear is large, the meniscus may be left hanging by a thread of cartilage. The seriousness of a tear depends on its location and extent.
Symptoms
Generally, when people injure a meniscus, they feel some pain, particularly when the knee is straightened. If the pain is mild, the person may continue moving. Severe pain may occur if a fragment of the meniscus catches between the femur and the tibia. Swelling may occur soon after injury if blood vessels are disrupted, or swelling may occur several hours later if the joint fills with fluid produced by the joint lining (synovium) as a result of inflammation. If the synovium is injured, it may become inflamed and produce fluid to protect itself. This makes the knee swell. Sometimes, an injury that occurred in the past but was not treated becomes painful months or years later, particularly if the knee is injured a second time. After any injury, the knee may click, lock, or feel weak. Although symptoms of meniscal injury may disappear on their own, they frequently persist or return and require treatment.
Diagnosis
In addition to listening to the patient's description of the onset of pain and swelling, the doctor may perform a physical examination and take X-rays of the knee. The examination may include a test in which the doctor bends the leg, then rotates the leg outward and inward while extending it. Pain or an audible click suggests a meniscal tear. An MRI may be recommended to confirm the diagnosis. Occasionally, the doctor may use arthroscopy to help diagnose and treat a meniscal tear.
Treatment
If the tear is minor and the pain and other symptoms go away, the doctor may recommend a muscle-strengthening program. Exercises for meniscal problems are best started with guidance from a doctor and physical therapist or exercise therapist. The therapist will make sure that the patient does the exercises properly and without risking new or repeat injury. The following exercises after injury to the meniscus are designed to build up the quadriceps and hamstring muscles and increase flexibility and strength.
Warming up the joint by riding a stationary bicycle, then straightening and raising the leg (but not straightening it too much).
Extending the leg while sitting (a weight may be worn on the ankle for this exercise).
Raising the leg while lying on the stomach.
Exercising in a pool (walking as fast as possible in chest-deep water, performing small flutter kicks while holding onto the side of the pool, and raising each leg to 90 degrees in chest-deep water while pressing the back against the side of the pool).
If the tear is more extensive, the doctor may perform arthroscopic or open surgery to see the extent of injury and to repair the tear. The doctor can sew the meniscus back in place if the patient is relatively young, if the injury is in an area with a good blood supply, and if the ligaments are intact. Most young athletes are able to return to active sports after meniscus repair.
If the patient is elderly or the tear is in an area with a poor blood supply, the doctor may cut off a small portion of the meniscus to even the surface. In some cases, the doctor removes the entire meniscus. However, osteoarthritis is more likely to develop in the knee if the meniscus is removed. A grafted meniscus is fragile and will shrink and tear easily.
Recovery after surgical repair takes several weeks, and postoperative activity is slightly more restricted than when the meniscus is removed. Nevertheless, putting weight on the joint actually fosters recovery. Rehabilitation usually includes walking, bending the legs, and doing exercises that stretch and build up leg muscles. The best results of treatment for meniscal injury are obtained in people who do not show articular cartilage changes and who have an intact ACL.
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