Knee pain is one of the most common problems for people today. This can be attributed to the increasing level of activity and sports in society, simple falls and accidents in the home and workplace, and also natural wear and tear of the joint. However, as biomechanist, Sean Flanagan, PhD, states in sports medicine lectures, “The knee is trapped between the hip and the ankle and problems there can manifest in the knee. The knee then becomes the focus of the clinical work-up and the contributing factors sometimes go unaddressed”. The hip, ankle and sometimes lumbar disc protrusions should be considered in knee pain patients.
Joints are lined with a type of cartilage known as articular cartilage. There are two “C”-shaped cartilage structures in the knee. One is called the medial meniscus and the other is called the lateral meniscus. One of the most common knee injuries is a tear of these menisci. Meniscus tears can occur from rotation injuries of the knee, or can tear from friction from an arthritic knee.
As the MRI became more frequently used, we learned more about the stages of degeneration of menisci. It was very common for knee pain patients to have knee arthroscopy to remove the torn portion of the meniscus. This helped many patients but unfortunately many patients felt exactly the same after knee arthroscopy. The reason for this the meniscus tear was not the pain generator. This is another example of why we need to treat the patient and not the film. As we often state, anatomy and function do not always correlate. This is the reason the history and physical examination is more important than the MRI or x-ray. There are many structures in the knee that are capable of generating pain. The meniscus tears may, or may not, generate pain.
Anterior Cruciate Ligament (ACL)
The anterior cruciate ligament (ACL) tears are often heard mentioned on sports news with football, hockey and soccer players. This ligament is inside the knee joint and is also commonly torn by suddenly changing directions on a field. There is usually much pain and knee swelling.
There is a significant increase in the number of ACL tears in adolescent female athletes. Much research has occurred to determine the cause. Current ideas include poor motor control of the lower extremity during direction change and landing from a jump are predictable for an ACL tear. Improved motor control can be taught and this can have some degree of reduced risk of ACL tears. This also applies for those athletes who have already had one ACL reconstruction surgery. Learning improved motor control by specific rehab can reduce the risk of a re-tear of the reconstructed ligament. A more recently considered contributing factor is occult instability of the knee.
Medial Collateral Ligament (MCL)
The MCL is a ligament on the inner side of the knee and it prevents the knee from buckling inwards. A blow to the outside of the knee, which forces it to buckle inwards, typically tears this ligament. A person who has his/her leg slip out (on ice for example) can tear the MCL. The severity of the tear will determine the management of the case. Surgery is rarely performed for isolated MCL tears today.
Patellofemoral Pain Syndrome (PFPS)
Many patients have pain in, or around, their kneecap (patella). There are many reasons for patellar pain including arthritic changes, overuse, bands of connective tissue, overtraining, too much jumping, and tendonitis. Abnormal tracking of the patella is not believed to be as common as once believed. A careful clinical examination is required to differentiate these pathologies, and to assess if there are other contributing factors from the hip or ankle.
Osteochondritis dessicans (OCD)
Patients can chip off part of all of the articular cartilage in a specific point in the knee. This most often occurs in a weight bearing area. In some cases, the cartilage can have fissures and cracks from prolonged weight bearing. The cartilage can remain in place or it can flake off away from the original site. There are a variety of methods to manage this pathology.
As with the hip, occult instability is a relatively new consideration in knees that are not responding as expected. There are clinical exam tests to make this diagnosis.
The most common tests for the knee are x-rays and the MRI. If the history and clinical exam indicate the hip, ankle, or lumbar spine is contributing the knee pain, then the appropriate tests will be ordered.
The majority of care for the knee is conservative/rehabilitation. Meniscus surgery is not commonly performed anymore as most patients can rehabilitate successfully without surgery. Prevention of ACL tears is a very important component of an athlete’s training, and post-operative rehab for ACL reconstruction is equally important. The MCL tear requires conservative care unless the athlete tore the ACL and medial meniscus along with it. A referral for co-management may be indicated if a consultation of joint injections of growth factors to promote healing supports the findings. If the findings are severe enough, an orthopedic surgical consultation may be in order. Again, these decisions are made on a case-by-case basis.
The doctors at the Soft Tissue Center at DISC are knowledgeable in the diagnosis and management of knee pathologies. Exercise or training modification of popular gym exercises may be required as well. The doctors at the Soft Tissue Center can be your first step and help guide you through the process of diagnosis and the treatment plan whether the plan is rehabilitation with our group or if we need to refer you to another specialist for co-management of your hip pain.