COMMON CONDITIONS OF THE KNEE
The information outlined below on common conditions and treatments is provided as a guide only and it is not intended to be comprehensive.
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COMMON CAUSES OF KNEE PAIN
SIMPLE SPRAIN OR STRAIN
If you think your pain is the result of having done more activity than you’re used to, you’ve probably just sprained or strained your knee. This means that the knee tissues have stretched, but aren’t permanently damaged. Most sprains and strains can be managed yourself using PRICE therapy (protection, rest, ice, compression and elevation) and painkillers. You can prevent future injuries by:
• always warming up before exercising and stretching to cool down after exercise
• increasing your activity levels slowly over time
• replacing your sports shoes when necessary
You can also try low-impact exercises, such as cycling and swimming, to improve your health and fitness without harming your knees.
ANTERIOR KNEE PAIN
Knee pain felt at the front of the knee, around the kneecap, is called anterior knee pain or patellofemoral pain syndrome. It’s not always obvious why this pain develops, but it’s been linked to previous injuries, overuse of your knees, muscle weakness and your kneecap being slightly out of place. The pain tends to be dull or aching and often affects both knees at the same time. It’s usually made worse by sitting for prolonged periods, squatting or kneeling, or using stairs. You can normally treat this yourself using ordinary painkillers, an ice pack and rest. Exercises to strengthen the muscles around your kneecap can also help. You may be referred to a physiotherapist, who can advise you about specific exercises to try.
DAMAGE TO THE MENISCI OR CARTILAGE
Sitting between the upper and lower leg bones at the knee joint are rubbery pads of tissue called menisci. These cushion the bones, acting as shock absorbers. A meniscus can also be torn after suddenly twisting the knee joint, resulting in pain, swelling and occasionally locking of the knee. Rarely, the torn meniscus can flip into the joint and prevent you from straightening it. A meniscus can also be torn after suddenly twisting the knee joint, resulting in pain, swelling and occasionally locking of the knee. The cartilage covering the bones of the knee joint can also be damaged by injury. These symptoms may settle down with rest, although physiotherapy can sometimes help, and in the case of menisci damage, an operation may be needed to remove or repair the torn pad of tissue.
OSTEOARTHRITIS
In older people, recurrent pain and stiffness in both knees is likely to be caused by osteoarthritis, the most common type of arthritis in the UK. Osteoarthritis causes damage to the articular cartilage (protective surface of the knee bone) and mild swelling of the tissues in and around the joints. The pain in your joints may be worse after putting weight on your knees and your knees may become stiff if you don’t move them for a while. They may also occasionally become locked or feel as though they’re going to give way. In some cases, osteoarthritis can also cause a painful fluid-filled swelling to develop at the back of the knee – this is known as a Baker’s cyst, or popliteal cyst. Less commonly, osteoarthritis can affect younger people, especially those who are overweight or have had serious injuries to the knee in the past. You should see your GP if you think your knee pain may be caused by osteoarthritis. They may recommend wearing suitable footwear to reduce the strain on your joints, using assistive devices such as a walking stick, losing weight, taking painkillers, or having physiotherapy.
TENDONITIS
Overusing or injuring the tendon that connects the kneecap to the shin bone can cause patellar tendonitis (inflammation of the tendon). This condition is sometimes called “jumper’s knee”, as it can be brought on by jumping activities such as basketball or volleyball.
As well as feeling painful and tender, your knee may also be swollen, red and warm. The pain can often be relieved with rest, ice packs and painkillers at home.
BURSITIS
Repetitive movement of the knee or kneeling for long periods can cause a build-up of fluid over the knee joint, known as bursitis or “housemaid’s knee”. This particularly affects people with certain jobs that involve kneeling (such as carpet layers), or sports players (such as footballers).
It typically causes pain in the knee that gets worse when you kneel or bend your knee fully. Your knee will also probably be swollen and may be tender, red and warm. Bursitis can often be treated at home. Resting the affected area and using an ice pack helps reduce the swelling and ordinary painkillers can help relieve the pain until your knee heals. Read more about treating bursitis. If you develop redness that spreads, a high temperature (fever), or persistent pain, this may be due to infection of the bursae. You should see your GP urgently, or go to your nearest accident and emergency (A&E) department.
TORN LIGAMENT OR TENDON
Knee pain may be caused by torn ligaments or tendons. Ligaments are tough bands of tissue that connect the bones at the knee joint; tendons connect the muscles to the bone. You can tear these tissues during running sports such as rugby or football. Injured tendons or knee ligaments at the side of the knee may cause pain even when the knee is at rest, which may get worse when you bend the knee or put weight on it. There may also be warmth and swelling around the knee. If you feel that your knee is also unstable or keeps “giving way”, you may have torn the anterior cruciate ligament (one of the main knee ligaments). This probably resulted from a sudden change in direction or a twisting movement, and you may have heard a pop when it happened. You should see your GP if this happens, and you may be referred to an orthopaedic specialist for advice and treatment. In some cases, surgery may be recommended.
BLEEDING INTO THE JOINT
An injury that causes significant damage to the knee joint may cause bleeding into the joint spaces, known as haemarthrosis. This can happen if a cruciate ligament is torn or if there is a fracture to one of the bones of the knee. Signs of haemarthrosis are swelling of the knee, warmth, stiffness and bruising. You should go to hospital immediately to have your knee treated if you have a badly swollen knee. Surgery may be required to repair the damage. If you take anticoagulant medication such as warfarin, bleeding into the joint can happen without any obvious damage. You should see your GP in this case as you may need treatment to reverse the effects on your medication.
OSGOOD-SCHLATTER’S DISEASE
In teenagers and young adults, pain, swelling and tenderness in the bony lump just below the kneecap could be a sign of Osgood-Schlatter’s disease. This is a where the bone at the top of the lower leg becomes damaged during a growth spurt. It’s relatively common in active children who participate in sports that involve running, jumping and repetitive bending on the knees. Reducing activity levels, taking painkillers and using ice packs can help relieve the pain in most children. The problem will normally resolve completely once your child stops having growth spurts, although occasionally it can persist into adulthood.
GOUT
If you experience sudden attacks of severe knee pain and your knee also becomes red and hot, the cause is likely to be gout, which is a type of arthritis. Gout is caused by a build-up of uric acid (a waste product) in the body, which can form crystals in the joints. These crystals cause the joints to become inflamed and painful. Gout will cause severe pain in the knee and limit movement of the joint. You may feel pain even when you’re resting, including at night. Gout can affect any joint in the body and sometimes other joints such as the joint of your big toe may be affected before your knees. You should see your GP if you think the cause of your knee pain is gout. They may recommend using ice packs and taking non-steroidal anti-inflammatory drug (NSAID) painkillers. You may also need to change your diet or receive additional treatment to prevent attacks if you experience them frequently.
SEPTIC ARTHRITIS (INFECTED KNEE)
Septic arthritis is a serious condition that causes a very painful, hot, swollen knee. You may also feel generally unwell and have a fever.
It can be mistaken for gout (see above). You should see your GP urgently, or go to your nearest accident and emergency (A&E) department if you suspect you have septic arthritis. Septic arthritis is treated by draining fluid from the knee before antibiotics are given. Occasionally arthroscopic surgery is needed to clear out the infection.
Arthritis is inflammation of one or more of your joints. Pain, swelling, and stiffness are the primary symptoms of arthritis. Any joint in the body may be affected by the disease, but it is particularly common in the knee. Knee arthritis can make it hard to do many everyday activities, such as walking or climbing stairs. It is a major cause of lost work time and a serious disability for many people.
Although there is no cure for arthritis, there are many treatment options available to help manage pain and keep people staying active.
The major types of arthritis that affect the knee are osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis.
OSTEOARTHRITIS
Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative,”wear-and-tear” type of arthritis that occurs most often in people 50 years of age and older, but may occur in younger people, too. In osteoarthritis, the cartilage in the knee joint gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone, and produce painful bone spurs. Osteoarthritis develops slowly and the pain it causes worsens over time.
RHEUMATOID ARTHRITIS
Rheumatoid arthritis is a chronic disease that attacks multiple joints throughout the body, including the knee joint. It is symmetrical, meaning that it usually affects the same joint on both sides of the body. In rheumatoid arthritis the synovial membrane that covers the knee joint begins to swell, This results in knee pain and stiffness. Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. The immune system damages normal tissue (such as cartilage and ligaments) and softens the bone.
POST TRAUMATIC ARTHRITIS
Posttraumatic arthritis is form of arthritis that develops after an injury to the knee. For example, a broken bone may damage the joint surface and lead to arthritis years after the injury. Meniscal tears and ligament injuries can cause instability and additional wear on the knee joint, which over time can result in arthritis.
SYMPTOMS
A knee joint affected by arthritis may be painful and inflamed. Generally, the pain develops gradually over time, although sudden onset is also possible. There are other symptoms, as well:
• The joint may become stiff and swollen, making it difficult to bend and straighten the knee.
• Pain and swelling may be worse in the morning, or after sitting or resting.
• Vigorous activity may cause pain to flare up.
• Loose fragments of cartilage and other tissue can interfere with the smooth motion of joints. The knee may “lock” or “stick” during movement. It may creak, click, snap or make a grinding noise (crepitus).
• Pain may cause a feeling of weakness or buckling in the knee.
• Many people with arthritis note increased joint pain with rainy weather.
TREATMENT OF KNEE ARTHRITIS
There is no cure for arthritis but there are a number of treatments that may help relieve the pain and disability it can cause.
LIFESTYLE MODIFICATIONS
Some changes in your daily life can protect your knee joint and slow the progress of arthritis.
• Minimize activities that aggravate the condition, such as climbing stairs.
• Switching from high impact activities (like jogging or tennis) to lower impact activities (like swimming or cycling) will put less stress on your knee.
• Losing weight can reduce stress on the knee joint, resulting in less pain and increased function.
PHYSICAL THERAPY
Specific exercises can help increase range of motion and flexibility, as well as help strengthen the muscles in your leg. Your doctor or a physical therapist can help develop an individualized exercise program that meets your needs and lifestyle.
ASSISTIVE DEVICES
Using devices such as a cane, wearing shock-absorbing shoes or inserts, or wearing a brace or knee sleeve can be helpful. A brace assists with stability and function, and may be especially helpful if the arthritis is centered on one side of the knee. There are two types of braces that are often used for knee arthritis: An “unloader” brace shifts weight away from the affected portion of the knee, while a “support” brace helps support the entire knee load.
Applying heat or ice, using pain-relieving ointments or creams, or wearing elastic bandages to provide support to the knee may provide some relief from pain.
MEDICATIONS
Several types of drugs are useful in treating arthritis of the knee. Because people respond differently to medications, your doctor will work closely with you to determine the medications and dosages that are safe and effective for you. Over-the-counter, non-narcotic pain relievers and anti-inflammatory medications are usually the first choice of therapy for arthritis of the knee.
Another type of pain reliever is a nonsteroidal anti-inflammatory drug, or NSAID (pronounced “en-said”). NSAIDs, such as ibuprofen and naproxen, are available both over-the-counter and by prescription.
Corticosteroids (also known as cortisone) are powerful anti-inflammatory agents that can be injected into the joint These injections provide pain relief and reduce inflammation; however, the effects do not last indefinitely. Your doctor may recommend limiting the number of injections to three or four per year, per joint, due to possible side effects.
In some cases, pain and swelling may “flare” immediately after the injection, and the potential exists for long-term joint damage or infection. With frequent repeated injections, or injections over an extended period of time, joint damage can actually increase rather than decrease.
Disease-modifying anti-rheumatic drugs (DMARDs) are used to slow the progression of rheumatoid arthritis. Drugs like methotrexate, sulfasalazine, and hydroxychloroquine are commonly prescribed. In addition, biologic DMARDs like etanercept (Embril) and adalimumab (Humira) may reduce the body’s overactive immune response. Because there are many different drugs today for rheumatoid arthritis, a rheumatology specialist is often required to effectively manage medications.
Glucosamine and chondroitin sulfate, substances found naturally in joint cartilage, can be taken as dietary supplements. Although patient reports indicate that these supplements may relieve pain, there is no evidence to support the use of glucosamine and chondroitin sulfate to decrease or reverse the progression of arthritis.
ALTERNATIVE THERAPIES
Many alternative forms of therapy are unproven, but may be helpful to try, provided you find a qualified practitioner and keep your doctor informed of your decision. Alternative therapies to treat pain include the use of acupuncture and magnetic pulse therapy. Acupuncture uses fine needles to stimulate specific body areas to relieve pain or temporarily numb an area. Although it is used in many parts of the world and evidence suggests that it can help ease the pain of arthritis, there are few scientific studies of its effectiveness. Be sure your acupuncturist is certified, and do not hesitate to ask about his or her sterilization practices. Magnetic pulse therapy is painless and works by applying a pulsed signal to the knee, which is placed in an electromagnetic field. Like many alternative therapies, magnetic pulse therapy has yet to be proven.
SURGICAL TREATMENT
Your doctor may recommend surgery if your pain from arthritis causes disability and is not relieved with nonsurgical treatment. As with all surgeries, there are some risks and possible complications with different knee procedures. Your doctor will discuss the possible complications with you before your operation.
• Arthroscopy. During arthroscopy, doctors use small incisions and thin instruments to diagnose and treat joint problems. Arthroscopic surgery is not often used to treat arthritis of the knee. In cases where osteoarthritis is accompanied by a degenerative meniscal tear, arthroscopic surgery may be recommended to treat the torn meniscus.
• Cartilage grafting. Normal, healthy cartilage tissue may be taken from another part of the knee or from a tissue bank to fill a hole in the articular cartilage. This procedure is typically considered only for younger patients who have small areas of cartilage damage.
• Synovectomy. The joint lining damaged by rheumatoid arthritis is removed to reduce pain and swelling.
• Osteotomy. In a knee osteotomy, either the tibia (shinbone) or femur (thighbone) is cut and then reshaped to relieve pressure on the knee joint. Knee osteotomy is used when you have early-stage osteoarthritis that has damaged just one side of the knee joint. By shifting your weight off the damaged side of the joint, an osteotomy can relieve pain and significantly improve function in your arthritic knee.
• Total or partial knee replacement (arthroplasty). Your doctor will remove the damaged cartilage and bone, and then position new metal or plastic joint surfaces to restore the function of your knee.
Recovery
After any type of surgery for arthritis of the knee, there is a period of recovery. Recovery time and rehabilitation depends on the type of surgery performed. Your doctor may recommend physical therapy to help you regain strength in your knee and to restore range of motion. Depending upon your procedure, you may need to wear a knee brace, or use crutches or a cane for a time. In most cases, surgery relieves pain and makes it possible to perform daily activities more easily.
Cartilage damage is a relatively common type of injury. It often involves the knees, although joints such as the hips, ankles and elbows can also be affected. Cartilage is a tough, flexible tissue found throughout the body. It covers the surface of joints, acting as a shock absorber and allowing bones to slide over one another. It can become damaged as a result of a sudden injury, such as a sports injury, or gradual wear and tear (osteoarthritis). Minor cartilage injuries may get better on their own within a few weeks, but more severe cartilage damage may eventually require surgery.
SYMPTOMS OF CARTILAGE DAMAGE
Symptoms of cartilage damage in a joint include:
• joint pain – this may continue even when resting and worsen when you put weight on the joint
• swelling – this may not develop for a few hours or days
• stiffness
• a clicking or grinding sensation
• the joint locking, catching, or giving way
It can sometimes be difficult to tell a cartilage injury apart from other common joint injuries, such as sprains, as the symptoms are similar.
WHEN TO GET MEDICAL ADVICE
If you’ve injured your joint, it’s a good idea to try self care measures first. Sprains and minor cartilage damage may get better on their own within a few days or weeks. More severe cartilage damage probably won’t improve on its own. If left untreated, it can eventually wear down the joint. Visit your GP or your local hospital if:
• you can’t move the joint properly
• you can’t control the pain with ordinary painkillers
• you can’t put any weight on the injured limb or it gives way when you try to use it
• the injured area looks crooked or has unusual lumps or bumps (other than swelling)
• you have numbness, discolouration, or coldness in any part of the injured area
• your symptoms haven’t started to improve within a few days of self-treatment
Your GP may need to refer you for tests such as an X-ray, MRI scan, or arthroscopy to find out if your cartilage is damaged.
TREATMENT FOR CARTILAGE DAMAGE
Self care measures are usually recommended as the first treatment for minor joint injuries.
For the first few days:
• protect the affected area from further injury by using a support, such as a knee brace
• rest the affected joint
• elevate the affected limb and apply an ice pack to the joint regularly
• take ordinary painkillers, such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs)
Get medical advice if your symptoms are severe or don’t improve after a few days. You may need professional treatment, such as physiotherapy, or possibly surgery. A number of surgical techniques can be used, including:
• encouraging the growth of new cartilage by drilling small holes in the nearby bone
• replacing the damaged cartilage with healthy cartilage taken from another part of the joint
• replacing the entire joint with an artificial one, such as a knee replacement – this is usually only necessary in the most severe cases.
Minor cartilage damage may improve on its own within a few weeks, but more severe damage will often require surgery.
INITIAL TREATMENT AND SELF CARE
If you’ve injured your joint and your symptoms aren’t too severe – for example, you’re still able to put weight on and move the joint – you can often look after yourself using PRICE therapy. PRICE stands for:
• Protection – protect the affected area from further injury by using a support, such as a knee brace
• Rest – rest the affected joint as much as possible during the first two or three days (crutches may help if you’ve injured your knee or ankle), then try gradually returning to light activity over the next few days and weeks
• Ice – apply an ice pack or a bag of frozen vegetables wrapped in a towel to the injured area for 15-20 minutes every 2-3 hours during the first two or three days
• Compression – compress or bandage the injured area to limit any swelling and movement that could damage it further; you can use a simple elastic bandage or an elasticated tubular bandage available from a pharmacy
• Elevation – keep the injured area raised and supported on a pillow whenever you can to help reduce swelling
If your joint is painful, take ordinary painkillers such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs). Visit your GP if your symptoms haven’t started to improve after a few days of PRICE therapy.
PHYSIOTHERAPY
Physiotherapy can be helpful if you have difficulty moving the affected joint. Your GP may be able to refer you to a physiotherapist, or you may choose to pay for private treatment. A physiotherapist can teach you exercises to help strengthen the muscles surrounding or supporting your joint. This may help reduce pain and pressure on the joint. Physiotherapy can also be useful when you’re recovering from the surgical procedures described below.
SURGERY
Severe cartilage damage doesn’t tend to heal very well on its own, so surgery is often necessary in these cases. Surgery is usually performed using arthroscopy – a type of keyhole surgery where special instruments are inserted into the joint through small cuts (incisions) – although sometimes larger incisions need to be made. It’s normally carried out under general anaesthetic, where you’re asleep.
Some of the main procedures are:
• lavage and debridement – the joint is cleaned out to remove any loose tissue, and the edges of the damaged area are trimmed to make them smooth; it may sometimes be possible to repair the damage at the same time
• marrow stimulation (microfracture) – tiny holes are made in the bone beneath the damaged cartilage, which releases bone marrow into it; the marrow cells then begin to stimulate the production of new cartilage
• mosaicplasty – small plugs of healthy cartilage from non-weightbearing areas of a joint, such as the side of the knee, are removed and used to replace small areas of damaged cartilage
• osteotomy – the alignment of the leg is altered slightly to reduce pressure on the damaged area and improve pain; this usually involves adding or removing a wedge of bone from the shin or thigh bone, and the bone is fixed with a plate until it heals
• joint replacement – replacing the whole joint with an artificial one, such as a knee replacement or hip replacement, is occasionally necessary if the damage is particularly severe
Talk to your surgeon about which type of surgery they think is best for you, what the possible risks are, and how long they expect it will take you to recover. You’ll usually need to take things easy for at least a few weeks after surgery, and you may not be able to return to strenuous activities and sports for several months.
Less common surgical procedures
There are also a number of alternative surgical techniques sometimes used to treat cartilage damage, including:
• allograft osteochondral transplantation (AOT) – similar to mosaicplasty, but the replacement cartilage is obtained from a recently deceased donor, and it’s used to repair larger damaged areas
• autologous chondrocyte implantation (ACI) – the surgeon first takes a small sample of cartilage cells from the joint; these are then used to grow more cells in a laboratory and the new cells are used to replace the damaged cartilage
• artificial scaffolds – a special patch or gel is used to repair the damaged cartilage; it may be used in combination with marrow stimulation or on its own
Avascular necrosis is the death of bone tissue due to a lack of blood supply. Also called osteonecrosis, avascular necrosis can lead to tiny breaks in the bone and the bone’s eventual collapse. The blood flow to a section of bone can be interrupted if the bone is fractured or the joint becomes dislocated. Avascular necrosis is also associated with long-term use of high-dose steroid medications and excessive alcohol intake.
Anyone can be affected by avascular necrosis. However, it’s most common in people between the ages of 30 and 60. Because of this relatively young age range, avascular necrosis can have significant long-term consequences.
SYMPTOMS OF LIGAMENT TEARS
Many people have no symptoms in the early stages of avascular necrosis. As the condition worsens, your affected joint may hurt only when you put weight on it. Eventually, the joint may hurt even when you’re lying down. Pain can be mild or severe and usually develops gradually. Pain associated with avascular necrosis of the hip may be focused in the groin, thigh or buttock. In addition to the hip, the areas likely to be affected are the shoulder, knee, hand and foot. Some people develop avascular necrosis bilaterally — for example, in both hips or in both knees.
CAUSES OF AVASCULAR NECROSIS
Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. Reduced blood supply can be caused by:
• Joint or bone trauma. An injury, such as a dislocated joint, might damage nearby blood vessels. Cancer treatments involving radiation also can weaken bone and harm blood vessels.
• Fatty deposits in blood vessels. The fat (lipids) can block small blood vessels, reducing the blood flow that feeds bones.
• Certain diseases. Medical conditions, such as sickle cell anemia and Gaucher’s disease, also can cause diminished blood flow to bone.
For about 25 percent of people with avascular necrosis, the cause of interrupted blood flow is unknown.
RISK FACTORS
Risk factors for developing avascular necrosis include:
• Trauma. Injuries, such as hip dislocation or fracture, can damage nearby blood vessels and reduce blood flow to bones.
• Steroid use. High-dose use of corticosteroids, such as prednisone, is the most common cause of avascular necrosis that isn’t related to trauma. The exact reason is unknown, but one hypothesis is that corticosteroids can increase lipid levels in your blood, reducing blood flow and leading to avascular necrosis.
• Excessive alcohol use. Consuming several alcoholic drinks a day for several years also can cause fatty deposits to form in your blood vessels.
• Bisphosphonate use. Long-term use of medications to increase bone density may be a risk factor for developing osteonecrosis of the jaw. This complication has occurred in some people treated with these medications for cancers, such as multiple myeloma and metastatic breast cancer. The risk appears to be lower for women treated with bisphosphonates for osteoporosis.
• Certain medical treatments. Radiation therapy for cancer can weaken bone. Organ transplantation, especially kidney transplant, also is associated with avascular necrosis.
Medical conditions associated with avascular necrosis include:
• Pancreatitis
• Diabetes
• Gaucher’s disease
• HIV/AIDS
• Systemic lupus erythematosus
• Sickle cell anemia
TREATMENT OF AVASCULAR NECROSIS
The goal is to prevent further bone loss. Specific treatment usually depends on the amount of bone damage you already have.
MEDICATIONS AND THERAPY
In the early stages of avascular necrosis, symptoms can be reduced with medication and therapy. Your doctor might recommend:
• Nonsteroidal anti-inflammatory drugs. Medications, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others) may help relieve the pain and inflammation associated with avascular necrosis.
• Osteoporosis drugs. Medications, such as alendronate (Fosamax, Binosto), may slow the progression of avascular necrosis, but the evidence is mixed.
• Cholesterol-lowering drugs. Reducing the amount of cholesterol and fat in your blood may help prevent the vessel blockages that can cause avascular necrosis.
• Blood thinners. If you have a clotting disorder, blood thinners, such as warfarin (Coumadin, Jantoven), may be recommended to prevent clots in the vessels feeding your bones.
• Rest. Reducing the weight and stress on your affected bone can slow the damage. You might need to restrict your physical activity or use crutches to keep weight off your joint for several months.
• Exercises. You may be referred to a physical therapist to learn exercises to help maintain or improve the range of motion in your joint.
• Electrical stimulation. Electrical currents might encourage your body to grow new bone to replace the area damaged by avascular necrosis. Electrical stimulation can be used during surgery and applied directly to the damaged area. Or it can be administered through electrodes attached to your skin.
SURGICAL AND OTHER PROCEDURES
Because most people don’t start having symptoms until avascular necrosis is fairly advanced, your doctor may recommend surgery. The options include:
• Core decompression. The surgeon removes part of the inner layer of your bone. In addition to reducing your pain, the extra space within your bone stimulates the production of healthy bone tissue and new blood vessels.
• Bone transplant (graft). This procedure can help strengthen the area of bone affected by avascular necrosis. The graft is a section of healthy bone taken from another part of your body.
• Bone reshaping (osteotomy). In this procedure, a wedge of bone is removed above or below a weight-bearing joint, to help shift your weight off the damaged bone. Bone reshaping might allow you to postpone joint replacement.
• Joint replacement. If your diseased bone has already collapsed or other treatment options aren’t helping, you might need surgery to replace the damaged parts of your joint with plastic or metal parts. An estimated 10 percent of hip replacements in the United States are performed to treat avascular necrosis of the hip.
• Regenerative medicine treatment. Bone marrow aspirate and concentration is a novel procedure that in the future might be appropriate for early stage avascular necrosis of the hip. Stem cells are harvested from your bone marrow. During surgery a core of dead hip bone is removed and stem cells inserted in its place, potentially allowing for growth of new bone.
Knee injuries are common, especially when you’ve been taking part in sport. Injuries to soft tissues, such as ligaments, cartilage and tendons are the most likely. In some cases, you may need surgery to correct your knee injury. But the good news is that many knee injuries get better with rest and simple treatments you can carry out at home.
There are many different structures inside and outside your knee joint. These include:
• ligaments, which connect your bones together
• articular cartilage, which covers the ends of your shin bone and thigh bone, as well as the back of your kneecap (patella)
• two crescent-shaped cartilage discs called menisci, which act as ‘shock absorbers’ and help to stabilise your knee
• tendons, which connect your muscles to your bone
Injury to your knee can damage any one or more of these structures.
KNEE LIGAMENT INJURIES
Your knee ligaments help to keep your knee stable by holding the bones together. You have two sets of ligaments in your knee. The collateral ligaments run down either side of your knee, while the cruciate ligaments lie inside your knee. Each can get damaged.
• Collateral ligament injuries – the medial collateral (MCL) is on the inner side of your knee and the lateral collateral ligament (LCL) is on the outer side. They limit the amount your knee can move from side to side. You can sprain or tear your MCL if your lower leg gets forced outwards; for example, if you’re tackled in rugby or when you’re skiing. Your LCL is less commonly injured but may be damaged if your lower leg gets forced inwards. Both ligaments may also be damaged if your knee twists too far outwards.
• Cruciate ligament injuries – cruciate means cross-shaped. Your anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) form a cross inside your knee. They help to keep your knee stable by controlling its movement backwards and forwards. ACL injuries are one of the most serious types of knee injury. They often happen when you twist your knee, for instance when you land on your leg then quickly turn. You might get this type of injury while playing football or basketball. Your PCL may get damaged if you fall on your knee while it’s bent. Another typical way of damaging your PCL is when your knees hit the dashboard during a car accident.
If you’ve injured one or more of your knee ligaments, a doctor will investigate and may grade your injury according to how severe the damage is.
• Grade 1 is a stretch of the ligament without tearing.
• Grade 2 is a partial tear of the ligament.
• Grade 3 is a complete tear through the ligament.
The knee ligaments that you’re most likely to damage are your MCL and your ACL.
OTHER SOFT TISSUE INJURIES
There are other soft tissues around your knee that can be injured (soft tissue means any tissue in your body that isn’t bone). These include cartilage and tendons.
• Cartilage injuries – tearing a meniscus (one of the wedge-shaped pieces of cartilage lying inside your knee) is one of the most common knee injuries. It’s what people usually mean when they say they have a ‘torn cartilage’ in their knee. You can damage a meniscus if you play a sport that involves twisting, such as football or basketball, but it can also happen to runners, tennis players and skiers. As you get older, your menisci may become worn. This makes them more likely to tear during your normal daily activities. Your knee also has cartilage covering the parts of your bones which lie inside the joint. This articular cartilage can become damaged too, often at the same time as damage happens to the other soft tissues.
• Tendon injuries – if you’re a regular runner or take part in sports where you jump a lot, you may damage the tendons that attach muscles to your knee. You can irritate or tear the tendon that connects your kneecap (patella) to your thigh muscle. This tendon is called the quadriceps tendon. Or you may irritate soft tissue around your kneecap, including the patellar tendon, which is just below your kneecap (jumper’s knee).
SYMPTOMS OF LIGAMENT TEARS
The symptoms for most ligament injuries are similar. These include pain, swelling and instability – you may feel like your knee is giving way. You may feel or hear a popping or snapping when the injury happens. You may also find that you can’t put your full weight on the injured leg.
If you injure a meniscus in your knee, you may feel severe pain and it may swell after a few hours. In addition, your knee may ‘lock’ so that you can’t move it in the usual way. You’ll probably still be able to walk a little on your injured leg. If you’ve torn your tendons, as well as pain and swelling you may find that your kneecap is lying higher or lower than it should. You won’t be able to straighten your knee. If you’ve injured your knee and the pain is mild or moderate or has come on gradually, visit your GP. Seek advice if it’s very painful or swollen, giving way, clicking painfully, locking or you can’t put your full weight on it. If you’ve hurt your knee in an accident, are in severe pain, or the knee is severely swollen, go to your nearest A&E department.
TREATMENT OF LIGAMENT TEARS
There are different types of treatment that a healthcare professional may suggest, depending on the type and severity of the damage to your knee. It’s frustrating, but it’s important to be patient when recovering from a knee injury – your injury may take time to fully repair itself. You may not be able to do all the things you’re used to doing for some time. Even after your knee injury has recovered, there’s still a risk that you may get arthritis in that knee in the future. This is called post-traumatic or degenerative arthritis. It usually occurs around five to 10 years after the initial injury. After a more severe injury, it can come on more quickly. Different injuries require different rehabilitation, so it’s best to talk to your GP.
There’s a lot you can do to help yourself if you have a knee injury. You should follow the PRICE procedure for any soft tissue injury to your knee. PRICE stands for the following.
• Protect your knee from further harm.
• Rest your knee for the first two to three days, possibly by using crutches. Then reintroduce movement so that your knee doesn’t become stiff and you don’t lose muscle strength.
• Ice the painful area with a cold compress, for example ice or a bag of frozen peas wrapped in a towel. Do this for 20 minutes every two hours during the day for the first two to three days. Don’t apply ice directly to your skin as it can damage it.
• Compress the joint with a simple elastic bandage or elasticated tubular bandage to support the knee and help decrease swelling. Don’t leave the bandage on while you sleep.
• Elevate your knee by resting it above the level of your heart, keeping it supported.
There are certain things you shouldn’t do in the first three days after your injury so you don’t damage your knee further. You can remember these as HARM.
• Heat – don’t take hot baths, showers or saunas, or use a heat pack.
• Alcohol – don’t drink alcohol because it can increase bleeding and swelling in the affected area.
• Running or other forms of exercise – these may cause further damage.
• Massaging the injured knee – this can cause more swelling or bleeding.
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