GETTYSBURG MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
03, February, 2000

THE TROUBLESOME KNEE

Knee problems seem to span many decades. Beginning with high school athletics, knee injuries are perhaps the most common and disabling injuries that occur even into middle age. Weekend athletes and infrequent skiers often encounter damage to the knee. Past age 50, arthritic knee problems and injuries that come from falls can lead to severe disability. The discussion below will go through the injuries that can happen to the knees and the steps that can be taken to help.

Knee injuries begin in the teenage years with athletic injuries that occur in basketball and football most commonly and less commonly in baseball and track. The most common injury occurs when the knee is struck from the side causing a stretching of the ligaments on the side of the knee. These are usually of minor significance provided they are allowed to heal. Usually no permanent damage results with only brief instability of the knee. The greatest danger of this injury is not allowing adequate healing so that a worse injury happens if the person continues to strain the knee.

The second most common injury that occurs with knees involves the cartilages. The cartilages are pads that are present in the sides of the knee and cushion the pressure when a person walks or jumps. Unfortunately, the cartilages can be torn and when they are torn, they do not heal. When this occurs, the person has repeated episodes of pain when the knee is strained or if a slight misstep occurs. Sometimes the knee can “lock”. Very fortunately, this type of injury can be diagnosed with an magnetic resonance imaging scan and then arthroscopic surgery can be done to remove the tear that is in the cartilage. If this is not done and the person goes through many years of repeated slight injuries, degenerative arthritis can occur causing severe long term pain and disability.

Perhaps the most dangerous injury that occurs to a knee is when the anterior cruciate ligament is torn. This is the major ligament that holds the two long leg bones that form the knee joint together. This injury most commonly occurs with a severe twisting and distortion of the knee joint. Pain is severe and usually there is a great deal of bleeding that occurs into the knee joint within an hour or two. The knee will become very swollen and painful. Early attention to this injury by an orthopedist for surgical correction is critical for recovery of function. If this injury is not surgically corrected, long term disability and arthritic change is a predictable likelihood.

Dislocation of the knee cap is a relatively unusual injury. This tends to happen to individuals who are thin and have a toe-in type of walk. The knee cap very commonly will dislocate to the outside of the knee and can be very painful. The individual with a dislocated knee cap needs immediate medical attention to relieve the dislocation and prevent further injuries.

In middle age years, the most common abnormalities result from cartilage injuries that were not corrected at a younger age or with individuals who continue athletic endeavors but without the necessary physical conditioning. Knees and legs that are not as strong as needed to engage in athletic activities are more easily injured. Torn cartilages and anterior cruciate ligaments occur relatively commonly and need to be treated surgically also.

Beginning at about age 50, degenerative arthritic changes in the knee are very common. The tendency to neglect these with time, often leads to severe degenerative changes and pain with activity. When this occurs, there are two steps that can be taken to help deal with the pain and disability. The first of these is to use medications to help stop the pain and to modify activity. Sometimes, arthroscopic surgery can be done on the elderly individual and repair of cartilages done even after years of damage. Most often this is not as successful as would be hoped. Medications that treat the pain then become the backbone of treatment unless the individual elects to proceed with prosthetic (artificial) knee replacement.

Prosthetic knee replacement is one of the very commonly performed joint replacement operations. If the individual arrives at a point where medications are not stopping the discomfort and the disability becomes unacceptable, then consideration for joint replacement becomes a realistic alternative. The details of whether to perform this surgery and the type of surgery to do can be worked out with the orthopedic surgeon.

I am often struck by the individual who says they would never consider a knee replacement because they are too young, are too old, or they do not like surgery. They delay performing an operation for some period of time, often 10 years or more. They then put up with 10 years of disability and pain that becomes progressive, before they elect to go ahead and have the knee replacement done. I have often wondered why a person would want to put up with 10 years of pain before doing some surgery rather than doing it at an early time to get better relief?

As a last comment, the expectations from prosthetic knee surgery need to be considered. The knee you were born with will heal itself when bruised or bumped or irritated. A prosthetic artificial knee does not repair itself when injured. If it happens to be strained repeatedly, it can come loose from the normal bones to which it is attached. Thus, when an artificial knee is placed it does not allow a person to return to vigorous physical activity such as basketball or running. Rather the person can walk without pain and carry on normal activities of daily living. However, it does not provide a return to completely normal function for vigorous physical activity. Thus, the major reason to have an artificial knee placed is when the normal activities of daily living, such as walking, are too painful to carry on.

Your local clinic and the primary health care providers there can assist in evaluating knee pain, perform a preliminary evaluation, and have the person referred on to the orthopedic surgeon as needed.