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Knee injuries, frequent in sportsmen and older adults, are a common cause of visits to the orthopaedic specialist. These knee injuries include ligament sprains, cartilage tears, overuse injuries and arthritis.
Ligament injuries
The knee has four ligaments, or tough bands of tissues, that stabilise the joint. The most commonly injured ligament is the anterior cruciate ligament (ACL). Preventing abnormal sideways motion of the knee are the collateral ligaments – the medial collateral ligament (MCL) and the lateral collateral ligament (LCL), which are located on the inside and outside respectively, of the knee.
1. Anterior Cruciate Ligament (ACL)
Causes
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The ACL is the most commonly injured ligament of the knee. It is usually injured because of a rapid or abnormal twisting motion such as when the knee stops or changes direction suddenly.
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The ACL can also be injured when the knee twists on landing, or as a result of a direct contact or collision, such as during a soccer tackle.
Symptoms
- Immediate pain right after injury.
- Swelling of the affected knee within 4 to 12 hours.
- A popping sound when the ligament ruptures.
- Difficulty with knee movement.
- Walking with a painful limp.
- Feeling of instability, with the knee giving way during sports or daily activities.
Diagnosis
- Usually made on history and clinical examination.
Treatment
- An x-ray of the knee will rule out associated fractures.
- An MRI may also be ordered to rule out other injuries to the meniscus or cartilage.
2. Posterior Cruciate Ligament (PCL)
Causes
- Injury to the PCL occurs when direct force is applied to the front of the knee when the knee is bent, such as when the bent knee hits the dashboard in a car accident.
- The ligament may also be pulled or stretched in a twisting or hyper-extension injury.
Symptoms
- Initial pain and swelling right after the injury.
- Pain in the front or inner side of the knee.
- Instability not a major complaint unless there is injury to other ligaments.
Diagnosis
- Usually made on history and clinical examination.
Treatment
- An x-ray of the knee will rule out associated fractures.
- An MRI may also be ordered to rule out other injuries to the meniscus or cartilage.
3. Collateral ligaments
Causes
- Injuries to the collateral ligaments, like the medial collateral ligament (MCL) and lateral collateral ligament (LCL), are usually caused by a direct blow to the side of the knee, or a twisting injury. It may occur in isolation or together with ACL or PCL injuries.
Symptoms
- Pain and swelling at the site of the injury.
- Knee may feel unstable.
Diagnosis
- Usually made on history and clinical examination.
Treatment
- Non-surgical treatment includes rest, elevation and ice therapy of the affected limb.
- Crutches to take some weight off the knee, and braces to support the knee, may also be prescribed.
- Physiotherapy to strengthen the supporting muscles and increase the range of motion will normally be part of the treatment.
- Depending on your situation, your doctor may recommend you undergo surgery for ligament repair or reconstruction.
Cartilage injuries
The cartilage is a connective tissue that acts as a shock absorbing structure and provides a smooth surface for the knee joints. There are two types of cartilage in the knee – meniscus and articular.
1. Meniscus injuries
The meniscus acts as a shock absorber during weight-bearing activities and helps to maintain knee joint stability. It is a commonly injured part of the knee.
Causes
- A meniscus tear can be caused during a contact or non-contact activity when a weight-bearing knee moves or twists suddenly.
- It can also occur as a result of wear and tear.
Symptoms
- Knee pain.
- Swelling of the knee.
- Locking of the knee.
- Inability to straighten or bend the knee fully.
- Difficulty walking due to pain.
Diagnosis
- Made on case history and clinical examination.
- An MRI may also be useful for diagnosing tears of the meniscus.
Treatment
- Non-surgical treatment includes rest, elevation and ice therapy of the affected limb.
- Crutches can help take the weight off the affected limb, and physiotherapy, after the pain subsides, can help improve the range of motion and strengthen the muscles around the knee.
- If the meniscus does not heal by itself, surgical repair or excision of the meniscus may be needed if you continue to experience persistent pain, locking of the knee, or are unable to achieve the full range of motion.
2. Articular cartilage injury
The articular cartilage is the smooth covering at the end of the bones that allows for frictionless gliding of one
bone against another. It also acts as a shock absorber.
Causes
- The surface can be damaged by direct trauma or through chronic wear and tear.
Symptoms
- Recurrent pain.
- Swelling of the knee.
- May experience difficulty straightening or bending the knee.
- There may be audible ‘clicks’ on knee movement.
Diagnosis
- An x-ray and MRI may be useful in the diagnosis.
Treatment
- Rest, ice and compress should be the first course of treatment upon injury.
- Crutches can also be used to ease pressure on the sore knee, followed by physiotherapy, when the pain subsides, to strengthen the muscles and for range of motion.
- Medications such as non-steroidal anti-inflammatory drugs are useful for pain relief and reducing inflammation.
Surgical options
As the ability of the cartilage to heal by itself is limited, your surgeon may recommend that you undergo resurfacing procedures. Some of the surgical options include:
- Arthroscopic microfracture techniques to help fill the defect with blood clot and stem cells.
- Osteochondral autograft transfer techniques where plugs of cartilage, together with the supporting bone foundation, are taken from a less critical part of the knee and transplanted to cover the defect.
- Autologous cartilage implantation techniques where cartilage cells are harvested from the knee, grown and multiplied in the laboratory, and subsequently implanted back into the joint to cover the defect.
Knee cap injury
Patello-Femoral Syndrome (PFS)
PFS is a common cause of knee pain. It is an overuse injury common amongst runners, jumpers, and other athletes such as skiers, cyclists, and soccer players who put repetitive stress on their knees.
Causes
- Structural alignment and muscle weakness or imbalance may cause the patella (kneecap) to track improperly on the femur (thigh bone) during movement. This results in excessive wear and tear on the undersurface of the kneecap in contact with the thigh bone, leading to pain around the kneecap.
Symptoms
- Pain behind the kneecap or in front of the knee. The pain is worsened by activities that involve knee bending such as running, squatting or climbing of stairs.
- There may be swelling of the knee.
- Sensation of grinding and audible crepitus may be present.
Diagnosis
- Usually made on history and clinical examination.
- An x-ray of the knee may be useful to assess the position of the kneecap and to rule out other conditions.
Treatment
- Includes avoiding activities that will place more stress on the knee, and medication to reduce pain, swelling and inflammation.
- Physiotherapy, when the pain lessens, may be recommended, particularly exercises to strengthen quadricep muscles.
- Other non-surgical treatments include the use of a knee support or brace during sports participation. You may return to your usual level of exercise and sport gradually.
- Your surgeon may explore the option of surgery should your symptoms not improve.
Tendon injuries and disorders
Patellar tendinitis
Patellar tendinitis is an injury that affects the tendon connecting your kneecap (patella) to your shinbone. The patellar tendon helps your muscles extend your lower leg so that you can kick a ball, pedal your bicycle and jump up in the air.
Causes
- Commonly known as jumper's knee, patellar tendinitis is most common in athletes who are involved in frequent jumping, running or kicking.
- Patellar tendinitis is a common overuse injury as a result of repeated stress on your patellar tendon. The stress results in tears that, as they become more numerous, cause inflammation in your tendon.
Symptoms
- Pain is the first symptom of patellar tendinitis. It worsens with physical activity.
- Pain is usually relieved with rest but may be persistent in severe cases.
- Swelling may be present.
Diagnosis
- Usually made on history and clinical examination.
Treatment
- The conservative approach to treating patellar tendinitis aims to reduce strain on the tendon and to gradually build up the tendon's strength.
- Your doctor may suggest that you avoid running and jumping and recommend physiotherapy to stretch the tendon and quadriceps, with the aim of returning to your previous level of exercise intensity.
- Medications to reduce pain, swelling and inflammation may also be given.
- A patellar tendon strap that applies pressure to your patellar tendon to distribute force away from the tendon may be given to relieve pain.
Osteoarthritis of the knee
Osteoarthritis (OA) of the knee is the most common type of OA and a common cause of disability. Early diagnosis and treatment can help to manage the symptoms of knee OA.
Treatment
For the treatment of knee OA, your doctor may sometimes recommend a steroid injection into or around the joint. The pain relief is usually only temporary, and your doctor will limit the number of steroid injections that you can receive.
Another type of injection therapy is called visco-supplementation. This involves the injection of hyaluronic acid derivatives into the joint. Hyaluronic acid is a normal component of joint fluid. However, the response to hyaluronic acid injection, as with steroid injection, is variable and usually temporary.
Surgery
Surgery is usually only offered for severe cases that have not responded to other forms of therapy. Both the type of surgery and the decision for surgery are made following careful discussions between you and your doctor. Some of the more common types of surgery include:
Arthroscopy
- This is suitable for early OA of the knee, and is considered a minor procedure during which the orthopaedic specialist uses an ‘arthroscope’ to look inside the joint.
- This is a form of ‘keyhole surgery’. During the procedure, the surgeon will be able to clean up damaged portions of the joint, or stimulate repair in areas where the cartilage has been lost.
Osteotomy
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This procedure is suitable for younger patients (generally less than 50 years of age) with limited OA of the knee. During this procedure, the bones around the joint are cut to allow the alignment of the joint to be corrected. Symptom relief can sometimes be achieved for up to 10 years following this procedure.
Joint replacement
- In late stages of OA, the joint becomes so damaged that the best treatment is to replace it with an artificial one, which is typically made of a metal alloy together with a plastic component. The entire joint may be replaced (total joint replacement), or if OA is limited to only one part of the joint, then the surgeon may choose to only replace that part (unicompartmental/partial joint replacement).
Ref: W09
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