I have enjoyed my years as full-time faculty at Baylor College of Medicine having helped start the Baylor Sports Medicine Institute in the mid-90′s. However, I think that my priorities and those of Baylor have drifted apart recently, and I strongly feel I can better care for my patients going forward at Methodist. I will retain a voluntary faculty appointment at Baylor.

My office staff is committed to making this transition as seamless as possible for my patients. New office address and phone numbers will be posted here soon. The present appointment and office numbers will continue to forward patients to me.

Numerous, well- controlled studies still support non-operative treatment of most patients with a first time dislocation.  Over the age of 27, about 2 out of 3 will not have another dislocation or symptoms of instability.  The rate of recurrence, however, can be much higher in the younger, active patient.  In some studies, this recurrence rate was found to be as high as 90%.  The military academies for many years have surgically fixed these first time dislocations.  In this setting there is often an important reason a recurrence could be a serious problem.

As surgical treatment has become less invasive with arthroscopic techniques becoming just as successful as open techniques, an increased interest has arisen in perhaps fixing the younger, active athlete after a traumatic, anterior, first time dislocation.  It is my typical recommendation, though, to treat the first time dislocation conservatively with a temporary sling and shoulder rehab exercises as soon as discomfort allows.  I then allow a return to sports as tolerated.  However, if the shoulder comes out a second time, it will inevitably come out again.  Recurrence or any persistent symptoms of instability despite appropriate rehab are indications for surgical repair.

1.   Activity modification – Certain changes in lifestyle may be necessary to accommodate degenerative changes in the knee. Sometimes if more stressful impact activities stop, then other types of activities are possible without symptoms. Typically, activities like jogging, tennis, basketball, etc. are not a good idea, and these limitations may be permanent. Think of substituting biking, stationary bike, elliptical machine, and swimming instead.

2.   Non-steroidal anti-inflammatory medicines (Naprosyn, Mobic, Celebrex) – These medicines can decrease pain and inflammation in the knee. They work best if taken in blocks of time; that is, 10 days, 2 or 3 weeks at a time. Once symptoms have improved they can be stopped. Reuse again if symptoms recur.

3.   Non-narcotic pain medicine – Good for long term relief of pain due to chronic degenerative changes in the knee.

4.   Visco-supplementation (Supartz, Synvisc) – Series of injections lasting 3 to 5 weeks given into the knee. These colloid substances can coat the end of the arthritic knee and relieve symptoms. Usually helps in about 50% of patients. Variable length of improvement.

5.   Steroid shots – Intra-articular steroid shots can be used for acute flare-ups of knee inflammation and swelling.

6.   Arthroscopy – Unresponsive knee swelling and / or mechanical symptoms such as locking and catching may be amenable to operative arthroscopy. The scope doesn’t replace articular surface that has been lost, but can address loose bodies, and meniscal tears.

7.   Cartilage restoration procedures – Newer procedures to replace lost articular cartilage. Usually for strictly focal lesions. I’ll let you know if you are a candidate for one of these new procedures.

8.   Partial knee replacement (Oxford Knee) – Good procedure for arthritis limited to the medial compartment of the knee. Ligaments have to be intact too. For patients who are candidates and have significant pain despite appropriate conservative management. There is a smaller incision and shorter recovery time compared to a total knee.

10.    Total knee replacement ( Otis Med / Biomet knee) – For patients with worsening arthritis who have failed conservative treatment. Today, we are using a new Custom Fit technique where custom cutting jigs are designed by a computer based on patient anatomy. This requires a preoperative MRI.

If you’re currently suffering from knee arthritis, why not contact us today to discuss your options? We’ll help you get mobile once again.

The shoulder is a very complex piece of machinery. Its elegant design gives us the ability to do many things. This design gives the shoulder joint great range of motion but not much stability. As long as the parts of this elegant machine are in good working order, the shoulder can move freely and painlessly. An injury to the shoulder, or wear and tear in the parts of the shoulder, can lead to pain with movement or stiffness in the shoulder. Many people are probably familiar with the term bursitis. Any pain in the shoulder is sometimes mistakenly referred to as bursitis. The term bursitis really only means that the part of the shoulder called the bursa is inflamed. In reality, there are many different problems that can lead to symptoms from inflammation of the bursa, or bursitis. Impingement is one of those things that can cause bursitis. Let’s see how this machine called the shoulder is put together and what might cause a breakdown.

Anatomy

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone) and the clavicle (collarbone). The tendons of four muscles form the rotator cuff. The muscles are called the supraspinatus, infraspinatus, teres minor, and subscapularis. Tendons attach muscles to bones. Muscles are able to move bones by pulling on these tendons. This large tendon called the rotator cuff connects the humerus with the scapula (shoulder blade) and helps raise and rotate the arm. As the arm is raised, the rotator cuff also keeps the humerus tightly in the socket (glenoid) of the scapula. The part of the scapula that makes up the roof of the shoulder is called the acromion. Between the acromion and the rotator cuff tendons there is a bursa. There are many bursae all over the body where tissues must move against one another. The bursa is a lubricated sac of tissue that protects the muscles and tendons as they move against one another. The bursa simply allows the moving parts to slide against one another without too much friction.

Causes

Usually, there is enough room between the acromion and the rotator cuff so that the tendons slide easily underneath the acromion as the arm is raised. But each time the arm is raised, there is a bit of rubbing on the tendons and the bursa between the tendons and the acromion. This rubbing, or pinching action, is called impingement. Impingement occurs to some degree in everyone’s shoulder, caused by day to day activities that we do using the arm above shoulder level. But continuously working with the arms raised overhead, repeated throwing activities, or other repetitive actions of the arm can cause impingement to become a problem. Raising the arm tends to force the humerus against the edge of the acromion. With overuse this can cause irritation and swelling of the bursa.

If any condition decreases the amount of space between the acromion and the rotator cuff tendons, the impingement process may get worse. Bone spurs can further reduce the space available for the bursa and tendons to move under the acromion. Wear and tear of the joint between the collarbone and the scapula, the acromioclavicular (AC) joint, is a fairly common cause of bone spurs around this joint. This joint sits right above the bursa and rotator cuff tendons and if bone spurs develop underneath the joint, this can make impingement worse.

Symptoms

Early symptoms of Impingement Syndrome include generalized aching of the shoulder, pain when raising the arm out from the side or in front of the body. Most patients complain of difficulty sleeping due to pain, especially when they roll over on the affected shoulder. A very reliable sign of impingement is a sharp pain when trying to reach into your back pocket. As the process continues, discomfort increases and the joint may become stiffer. Sometimes a “catching” sensation is felt when the arm is lowered. Weakness and inability to raise the arm may indicate that the rotator cuff tendons are actually torn.

Diagnosis

The diagnosis of impingement and bursitis is usually made on the basis of the history and physical examination. You doctor will be interested in your activities and your job, because this condition is frequently related to continuous overhead activities. Some people have an odd anatomy of the acromion, where the bone tilts too far down and reduces the space between the acromion and the rotator cuff. X-rays may be ordered to look for this abnormal type of acromion, or bone spurs from the acromioclavicular (AC) joint. The MRI scan, or arthrogram, may be performed if there is also a suspected tear of the rotator cuff tendons. An MRI scan is a special radiological test where magnetic waves are used to create pictures that look like slices of the shoulder. The MRI scan shows more than the bones of the shoulder. It can show the tendons as well, and whether there has been a tear in those tendons. The MRI scan is painless, and requires no needles or dye to be injected. The arthrogram is an older test. This test is done by injecting dye into the shoulder joint and taking several X-rays. If the dye leaks out of the shoulder joint where it was placed, it suggests that there is a tear in the rotator cuff tendons where the dye leaked out. Both tests are still widely used.

In some cases, there is a question whether or not the pain is coming from the neck or the shoulder. An injection of a local anesthetic (like novacaine) into the bursa can be used to make sure that the pain is in fact coming from the shoulder, and not coming from a problem in the neck. If the pain goes away immediately after the bursa is injected with novacaine, then most likely the pain is coming from there. Pain from a pinched nerve in the neck would not normally be removed by injecting the shoulder.

Prevention/Treatments

Rest: Your physician or therapist may prescribe a sling to provide adequate rest to the shoulder. It is crucial that the sling be removed several times daily while you perform your home exercises. This is paramount in order to prevent a stiff or “frozen” shoulder.

Ice: Ice decreases the size of blood vessels in the sore area, halting inflammation and relieving pain. Choices of application include cold packs, ice bags, or ice massage. Ice massage is an easy and effective way to provide first aid. Simply freeze water in a paper cup. When needed, tear off the top inch, exposing the ice. Rub three to five minutes around the sore area until it feels numb.

Medications: Anti-inflammatory medications may be prescribed by your physician. These include aspirin and ibuprofen. If these measures fail to improve your pain, an injection of cortisone into the bursa may reduce the inflammation and control the pain. Cortisone is a very strong anti-inflammatory medication and can reduce the inflammation in the bursa and tendons of the rotator cuff.

Physical Therapy: It is very important to maintain the strength in the muscles of the Rotator Cuff. These muscles help control the stability of the shoulder joint and strengthening these muscles can actually decrease the impingement of the acromion on the rotator cuff tendons and bursa. Long term management of this problem should also address worksite alterations to reduce the need for overhead activity. A posterior capsular stretching program and rotator cuff strengthening program may be started by your physical therapist. These programs are simply a set of exercise that will help keep the shoulder strong and flexible and help reduce the irritation from impingement. Your therapist will make sure you understand the exercises and are doing them correctly before turning you loose on your own.

Surgery

Surgery to relieve the constant rubbing of impingement is not uncommon. When surgery becomes necessary, the major goal of the surgery is to increase the space between the acromion and the rotator cuff tendons. The first thing that must be done is to remove any bone spurs under the acromion that are rubbing on the rotator cuff tendons and the bursa. Usually a small part of the acromion may be removed as well to give the tendons even more space and allow them to move without rubbing on the underside of the acromion. In patients who have an abnormal tilt to the acromion, more of the bone may need to be removed.

Impingement may not be the only problem in a shoulder that has begun to show wear and tear due to aging and overuse. It is very common to see degenerative (wear and tear) arthritis in the acromioclavicular (AC) joint in addition to impingement. If there is reason to believe that the acromioclavicular (AC) joint is arthritic, the end of the clavicle may be removed as well. This procedure is called a resection arthroplasty. After removal of about one inch of the clavicle, scar tissue fills the space left between the clavicle and the acromion to form a false joint. This stops the arthritic pain in the acromioclavicular (AC) joint caused by bone rubbing against bone. The scar tissue that forms creates a stable, flexible connection between the clavicle and the scapula.

In some cases this can be using the arthroscope. The arthroscope is a small TV camera that can be inserted into a joint through a small incision. Through other small incisions around the joint the surgeon can insert special instruments to cut and burr away bone while he watches what he is doing on a TV screen. If your surgery is done with the arthroscope you may be able to go home the same day.

In other cases, an open incision is made to allow removal of the bone. Usually an incision about 3 or 4 inches is made over the top of the shoulder. Any bone spurs are removed and a part of the acromion is removed and smoothed by the surgeon. If necessary, the end of the clavicle is removed to perform the resection arthroplasty of the acromioclavicular (AC) joint. If your surgery is done in this way, you may have to stay a night or two in the hospital.

Recovery from shoulder surgery can be a slow process. Physical therapy will probably be needed for several weeks after your surgery. Getting the shoulder moving as fast as possible is important, but this must be balanced with the need to protect the healing muscles and tissues. You can expect the process of recovery to take several months.

Please feel free to print, download, and use/distribute this information (as long as you are not reselling it in any form). Remember, it is the property of the Medical Multimedia Group and they retain all rights regarding its educational content, graphics, and animation’s. Alteration of this document in any way is a violation of the copyright. If you would like to discuss licensing agreements for using MMG’s content in your products, contact mmg@sechrest.com.

This material does not constitute medical advice. It is intended for informational purposes only. NO ONE ASSOCIATED WITH MEDICAL MULTIMEDIA GROUP WILL ANSWER MEDICAL QUESTIONS VIA EMAIL. Please consult a physician for specific treatment recommendations.

A popliteal cyst, also called a Baker’s cyst, is a soft, often painless cyst on the back of the knee. A cyst is usually nothing more than a bag of fluid. These cyst occur most often when the knee is damaged due to arthritis, gout, an injury, or from inflammation of the joint lining. Treatment of the cyst is most successful when the underlying cause of the cyst is also treated. Otherwise, the cyst can reoccur.

Rarely, the cyst can cause pressure on blood vessels causing swelling or other problems in the leg. A ruptured popliteal cyst can be very painful. The symptoms caused by a popliteal cyst can mimic more serious problems. Therefore, careful clinical evaluation is important.

The purpose of this information is to help you understand popliteal cysts:

• The nature of disorder and the normal anatomy of the knee,
• the signs and symptoms of the disorder,
• the treatments available to you now and later,
• what you can expect from those treatments, and
• what you can expect long-term if you have this disorder.

In order to understand what is happening with your knee joint, you need to understand the basics about the normal anatomy of your knee. This includes becoming familiar with the various parts that make up the knee. Also, you should understand the function of these parts, that is, how they make your knee work. Keep in mind that no one is going to give you a test, but the more you know, the more you will be able to talk with your doctors and healthcare team in words that will help them better understand your particular disorder. It will also help you understand what they are telling you about your particular problem.

Anatomy of the Knee Joint

A joint is formed where two or more bones meet. The knee is a hinge type joint and is formed where the thighbone (femur) meets the shinbone (tibia). The thighbone is rounded on the end and rocks back and forth on the flat surface formed on the end of the shinbone. A smooth cushion of articular cartilage covers the surface ends of both of these weight-bearing bones. The articular cartilages are kept slippery by joint fluid made by the synovial membrane (joint lining). Since the cartilage is smooth and slippery, the bones move against each other easily and without pain.

In addition to bones, the knee joint is also made of “soft tissues”. These soft tissues include ligaments, tendons, muscles, and blood vessels. Tendons and ligaments are connective tissue. Bones are attached (connected) to bones by ligaments. Muscles allow us to bend and straighten the bones in our knee joint. Muscles are attached to bones by tendons. Nerves send electrical impulses to muscles, which make them, contract and relax causing the joint to bend and straighten. Blood vessels carry needed oxygen, nutrients, and fuel to the muscles to allow them to work normally – and to heal when injured.

Causes

A popliteal cyst forms when the joint lining produces too much joint fluid. The extra fluid leaks or pushes through the joint lining and forms a cyst. The cyst often “sticks out” on the back of the knee between two muscles. If the cyst ruptures, it can cause pain and swelling of the calf. A ruptured popliteal cyst is important because its symptoms are just like a much more serious problem called thrombophlebitits. Therefore, it is important to determine right away the cause of the pain and swelling in the calf.

Symptoms

Symptoms are things that you feel. The symptoms caused by a popliteal cyst are usually mild. You may have aching or tenderness with exercise or your knee may give way. Sometimes, there is pain from the underlying cause of the cyst, such as arthritis, an injury, or a mechanical problem with the knee. Along with these symptoms, you may also see or feel a bulge on the back of your knee. Anything that causes swelling of the knee and more fluid in the knee joint can make the cyst larger. It is common for a popliteal cyst to swell and shrink over time.

Sometimes a cyst will suddenly rupture, or burst underneath the skin, causing a lot of pain and swelling in the calf. The fluid inside the cyst simply leaks into the calf and is absorbed by the body. In this case, you will no longer be able to see or feel the cyst. However, the cyst will probably return in a short time.

Diagnosis

You doctor will ask you to tell him the history of your problem, such as how long have you had the problem, have you noticed it getting worse, and how has it kept you from doing your daily activities, what makes it worse, or what makes it better. He will ask if you have any pain. Then he will examine your knee and leg. He will ask you to bend and straighten your knee to see if he can feel or see the cyst. Most often, a physical exam is all that is needed to diagnose a popliteal cyst. Unless the cyst has ruptured, further testing is usually not needed.

If the cyst has ruptured, additional test will be needed. Regular x-rays will not show the cyst since it is a soft tissue and regular x-rays show mostly bones. A cyst can be seen with a sonogram, or arthroscopy.

Treatment

There are two types of treatment for popliteal cysts: surgical and non-surgical. Whether or not the cyst has ruptured, how painful the cyst has become, or how much it interferes with the normal use of your knee will determine which is the best course of treatment for you. In adults, the treatment is most often non-surgical. If surgery is needed, it is usually done on an out patient basis. Unless there is a lot of discomfort from the cyst surgery is rarely indicated.

Non-surgical:

Drawing the fluid out with a needle and syringe can reduce the size of the cyst. Then, cortisone can be injected into the affected area to reduce inflammation. Non-surgical treatment also includes rest and keeping your leg propped up for several days. If non-surgical treatment fails, then complete removal of the cyst may be needed. Many people – once they are reassured that the cyst is not dangerous – simply ignore the problem unless it becomes very painful.

Surgical Treatment:

The goal of surgery is to remove the whole cyst and repair the hole in the joint lining where the cyst pushed through.

Anesthesia

Surgery can be slow and take over an hour to complete. Surgery is usually done under a general anesthetic, where you are completely asleep during surgery, or spinal anesthesia, where the lower half of the body is numbed. With spinal anesthesia you may be awake during the surgery, but you won’t be able to see the surgery.

Surgery

Once you have anesthesia, your surgeon will make sure the skin of knee your is free of infection by cleaning the skin with a germ killing solution. An incision will be made in the skin over the cyst. The cyst is located and then separated from the surrounding tissues. The area of the joint capsule where the cyst appears to be coming from is identified. A synthetic patch may be sewn in place to cover the hole in the joint capsule left by the removal of the cyst. Special care is taken not to damage nearby nerves and blood vessels.

Your knee will be bandaged with a well-padded dressing and a splint for support. Your surgeon will want to check your knee within 5 to 7 days. Stitches will be removed after 10 to 14 days. Most of your stitches will be absorbed into your body. You may have some discomfort after surgery. You will be given pain medicine to control the discomfort you have.

You should keep your knee propped up for several days to avoid swelling and throbbing. Keep it propped up on a stack of pillows when sleeping or sitting up. Take all medicines exactly as prescribed by your physician. Be sure to keep all follow up appointments.

Complications

You should expect complete healing without complications in about 4 weeks. The most common possible complication after surgery is infection of the incision. If infection occurs, your surgeon may prescribe antibiotics to fight infection or surgery may be needed to drain the infection. After surgery, keep 24-hour phone numbers handy. Call you surgeon’s office if you feel your knee is not healing as it should. Check your incision as instructed by your doctor. If you think you have a fever take your temperature. If you have signs of infection or other complications, call your surgeon right away.

These are warning signs of infection or other complications:

• Pain in your knee that is not relieved by your medicine
• Smelly discharge coming from your incision
• Red, hot, swollen incision
• Chills or fever over 100.4 F
• You notice bright red blood coming from the incision
• If you have side effects from your medicine

Baker’s cysts form very near the major nerve and blood vessels of the leg. It is possible that these structures can be injured during surgery. If an injury happens, it can be a serious complication. Injury to the nerves can cause numbness or weakness in the foot and lower leg. Injury to the blood vessels may require surgery to repair the blood vessels.

In addition, it is uncommon but possible that another cyst can occur.

Rehabilitation

After your surgery you can resume daily activities and work as soon as you are able. Your doctor may want you to use crutches or a cane for awhile. Avoid vigorous exercise for 6 weeks after surgery. You should be able to resume driving 2 weeks after surgery. You may need a short course of physical therapy to regain the strength in your leg.

Summary

While a popliteal cyst is not a life-threatening problem, a ruptured cyst can mimic one and can be cause for concern until a diagnosis is made. It is important to know that these cysts are always limited to the knee. The cysts are not cancerous and will not become cancer.

Removal of the entire cyst, if necessary, will usually give a very good result. The cure is often permanent, but preventing further cyst depends a great deal on the success of treating the underlying cause.

Please feel free to print, download, and use/distribute this information (as long as you are not reselling it in any form). Remember, it is the property of the Medical Multimedia Group and they retain all rights regarding its educational content, graphics, and animation’s. Alteration of this document in any way is a violation of the copyright. If you would like to discuss licensing agreements for using MMG’s content in your products, contact mmg@sechrest.com.

This material does not constitute medical advice. It is intended for informational purposes only. NO ONE ASSOCIATED WITH MEDICAL MULTIMEDIA GROUP WILL ANSWER MEDICAL QUESTIONS VIA EMAIL. Please consult a physician for specific treatment recommendations.

Osteoarthritis is a common problem for many people after middle age. Osteoarthritis is sometimes referred to as degenerative, or wear and tear arthritis.

Anatomy

What is osteoarthritis?

The main problem in osteoarthritis is degeneration of the articular cartilage that covers the joint. This results in areas of the joint where bone rubs against bone. Bone spurs may form around the joint as the body’s response.

Causes

How does osteoarthritis occur?

Osteoarthritis may result from an injury to the knee earlier in life. Fractures involving the joint surfaces, instability from ligament tears, and meniscal injuries can all cause abnormal wear and tear of the knee joint. Not all cases of osteoarthritis are related to prior injury, however. Research has shown that some people are prone to develop osteoarthritis, and this tendency may be genetic.

Symptoms

What does osteoarthritis feel like?

Osteoarthritis develops slowly over several years. The symptoms of osteoarthritis are mainly pain, swelling, and stiffening of the knee. The pain of osteoarthritis is usually worse after activity. Early in the course of the disease, you may notice that your knee does fairly well while walking, then after sitting for several minutes the knee becomes stiff and painful. As the condition progresses, pain can interfere with even simple daily activities. In the late stages, the pain can be continuous and even affect sleep patterns.

This pain probably does not come from the covering of the joint, the articular cartilage, because this tissue does not have a nerve supply. There is still some confusion about where the pain in osteoarthritis actually comes from.

Sources of pain may be due to:

• Inflammation in the lining of the joint, called the synovium.
• Small fractures in the bone under the cartilage, the subchondral bone.
• Pressure from blood in the area.
• Stretching of nerve endings over a bone spur (osteophyte).

Diagnosis

How do we look into this problem?

The diagnosis of osteoarthritis can usually be made on the basis of the initial history and examination. X-Rays are very helpful in the diagnosis and may be the only special test required in the majority of cases. In some cases of early osteoarthritis, the X-rays may not show changes typical of osteoarthritis. It is not always clear where the pain is coming from. Knee pain from osteoarthritis may be confused with other common causes of knee pain such as a torn meniscus or kneecap problems. Sometimes, a MRI scan may be ordered to look at the knee more closely. A MRI scan is a special radiological test where magnetic waves are used to create pictures that look like slices of the knee. The MRI scan shows more than the bones of the knee. It can show the ligaments, articular cartilage, and menisci as well. The MRI scan is painless, and requires no needles or dye to be injected.

If the diagnosis is still unclear, arthroscopy may be necessary to actually look inside the knee and see if the joint surfaces are beginning to develop changes from wear and tear. Arthroscopy is a surgical procedure where a small fiberoptic television camera is inserted into the knee joint through a very small incision, about a 1/4 inch. The surgeon can then move the camera around inside the joint while watching the pictures on a TV screen. The structures inside the joint can be poked and pulled with small surgical instruments to see if there is any damage.

Treatment

What can be done for your knee pain?

Non-Surgical Treatment

Osteoarthritis (OA) is a condition which progresses slowly over a period of many years. Osteoarthritis cannot be cured. Treatment is directed at decreasing the symptoms of the condition, and slowing the progress of the condition. First, realize you are not alone. OA of the knee is a condition many people face. But thanks to continued advances in medicine, there are now many treatment options available. Recent information now shows that your condition may be maintained, and in some cases it may even improve. So let’s look at some ways to get your knee feeling better, to get it in tiptop shape, and to keep it that way!

Our first goal, then, will be to help reduce pain in the knee. Your physician may prescribe acetaminophen (Tylenol), a mild analgesic, as an excellent first-line pain reliever in this problem. Some people may also get relief of pain with anti-inflammatory medication, such as ibuprofen and aspirin. In either case, medications should be used in combination with physical therapy.

If the symptoms continue, a cortisone injection may be used to bring the inflammation under better control and ease your pain. Cortisone is a very powerful anti-inflammatory medication, but does have secondary effects that limit its usefulness in the treatment of osteoarthritis. The major drawback in the use of multiple injections of cortisone is the fact that it may actually speed up the process of degeneration when used repeatedly. Repeated injections also increase the risk of developing a knee joint infection, called a septic arthritis. Any time a joint is entered with a needle, there is the possibility of an infection. Most physicians use cortisone sparingly, and avoid multiple injections unless the joint is already in the end stages of degeneration where the next step is an artificial knee replacement.

Recently, a new type of injectable medication has become available in the US. Hyaluronic acid preparations have been used in Europe and Canada for several years and seem to be beneficial in decreasing the symptoms in knees that have mild to moderate osteoarthritis changes. The medication requires 3 to 5 injections given over a one month period. The medication seems to reduce symptoms in many patients for 6-8 months.

In the Beginning…

Limit pain: Your physical therapist has several tools, or modalities, to help control the acute symptoms caused by osteoarthritis of the knee. Sources of heat, like a moist hot pack, ultrasound, or diathermy, can help reduce discomfort by stimulating blood flow and overriding pain sensation. Joint mobilization may be chosen for its ability to provide nutrition and lubrication to the joint surfaces. It is also helpful for overriding the transmission of pain to the brain. Another helpful treatment to reduce pain is transcutaneous nerve stimulation (TENS for short), which uses a mild electrical impulse to block pain. Certain topical ointments (such as Capsaicin) can also help limit pain.

Increase range of motion: By improving knee movement, you may find that pain symptoms ease. Another benefit of gaining more motion is that it keeps the joint surfaces healthy. And finally, it helps prepare your knee for higher levels of activity. Range of motion can be gained with a pool exercise program, gentle stretching by your therapist, or with the use of a stationary bike.

Increase strength: In the early stages, strengthening may be done using isometric exercise. These are exercises in which the muscles contract, but the joint stays in one position. Isometrics help restore strength while protecting you from further pain and irritation. As your muscles gain strength, you may notice less pain in the knee while feeling a sense of ease with walking and doing general activities.

Practice Joint Protection…

Muscular control: Sometimes the knee gets an extra jolt when you accidentally miss a stair or when you stub your toe. Untrained leg muscles are slow to respond in protecting the knee joint, and these jolting forces do more damage to the softer bone under the cartilage. A trained muscle will generate force quickly. Conditioning exercises help knee muscles generate forces more quickly, acting as shock absorbers in protecting the knee joint.

Walking aids: A cane or walker may be suggested by your physical therapist. Using a walking aid can take some of the stress off the joint, protecting it from undue stress and strain.
Shock absorption: A good pair of shoes will help reduce shock. Also, if you choose walking as your primary exercise, choose a walking surface like cinder or grass. Avoid cemented or other hard surfaces. If you find that increasing your walking speed irritates your knee, limit your speed. Other exercises that prevent high impact shock include stationary biking and swimming.

Alignment: When the knee is not properly aligned, extra pressure may develop on one side of the knee joint. In these cases, a special shoe insert, or orthotic, with a heel wedge can help relieve pressure and pain. Sometimes an osteoarthritis knee brace may be chosen. These braces are designed to unload the pressure, whether on the inside or outside of the knee joint.

Daily activities: Here are some helpful hints to use during the day to limit strain on your knee.

• Avoid standing for greater than 10 minutes; instead use a high stool or take frequent rests.
• Limit stair climbing; take the elevator, escalator, or ramp.
• Avoid bending and squatting; keep items at waist level, or use a reacher.
• Park close to your destination.
• Avoid low beds, chairs, and toilets; elevate them when possible.

As Your Treatment Progresses…

Daily exercise: Your joint surfaces can remain healthier by consistently working your leg through a full range of motion and using safe, load-bearing exercises. Use exercise to keep the hip, knee, and ankle muscles strong. Avoid pain by working in a pain-free arc of movement, limiting walking speeds, and overstressing the knee. In the presence of pain, use static, isometric exercise.

General fitness: The Surgeon General recommends that everyone get 30 minutes of moderate activity a day for as many as seven days a week. Along with reducing the risk of heart disease, lowering stress, managing body weight, and prolonging life, a general fitness program can also assist you in managing OA of the knee. Before undertaking such a program, consult your physician. Moderate activity can include walking, swimming, stationary biking, or low impact aerobics.

Exercise progression: Your exercise program will be advanced cautiously to include strengthening, balance, endurance, and functional activities. Your program will address key muscle groups of the buttock and hips, thigh, and calf. Several exercise choices can further stabilize and control the knee. Finally, a select group of exercises can be used to simulate day-to-day activities like raising up on your toes or standing from a raised stool. Specific exercises may then be chosen to simulate work or hobby demands.

Long Term Management…

Here are some long-term solutions to help manage OA of the knee:

• Control pain and inflammation.
• Reduce shock by using a walking aid, wearing good shoes, choosing soft surfaces, and keeping the leg muscles conditioned for unexpected stresses.
• Exercise daily to maintain range of motion, strength, and cardiovascular fitness.
• Use a shoe orthotic with a heel wedge for better alignment.
• Take precautions with daily activities to avoid stressing the knee.

There are also braces on the market now that can reduce the pressure on the side of the knee that is most involved. These braces have been designed mainly for the more common condition of early wear and tear in the medial compartment of the knee. A brace may help with your pain and is worth experimenting with.

Surgical Treatment

Arthroscopy

Arthroscopy is sometimes useful in the treatment of osteoarthritis of the knee. Looking directly at the articular cartilage surfaces of the knee is the most accurate way of determining how advanced the osteoarthritis is. Arthroscopy also allows the surgeon to debride the knee joint. Debridement essentially consists of cleaning out the joint of all debris and loose fragments. During the debridment any loose fragments of cartilage are removed and the knee is washed with a saline (salt) solution. The areas of the knee joint which are badly worn may be roughened with a burr to promote the growth of new cartilage – a fibrocartilage material that is similar scar tissue. Debridement of the knee using the arthroscope is not 100% successful. If successful, it usually affords temporary relief of symptoms for somewhere between 6 months – 2 years.

Proximal Tibial Osteotomy

Osteoarthritis usually affects the inside half (medial compartment) of the knee more often than the outside (lateral compartment). This can lead to the lower extremity becoming slightly bowlegged, or in medical terms, a genu varum deformity. The result is that the weight bearing line of the lower extremity moves more medially (towards the medial compartment of the knee). (It’s really all in the physics of the situation!) The end result is that there is more pressure on the medial joint surfaces, which leads to more pain and faster degeneration.

In some cases, re-alligning the angles in the lower extremity can result in shifting the weight-bearing line to the lateral compartment of the knee. This, presumably, places the majority of the weight-bearing force into a healthier compartment. The result is to reduce the pain and delay the progression of the degeneration of the medial compartment.

The procedure to re-align the angles of the lower extremity is called a Proximal Tibial Osteotomy. In this procedure a wedge of bone is removed from the lateral side of the upper tibia. This converts the extremity from being bow-legged to knock-kneed. This procedure is not always successful, and generally will reduce your pain, but not eliminate it altogether. The advantage to this approach is that very active people still have their own knee joint, and once the bone heals there are no restrictions to activity level.

The proximal tibial osteotomy in the best of circumstances is probably only temporary. It is thought that this operation buys some time before ultimately needing to perform a total knee replacement. The operation probably lasts for 5-7 years if successful.

Total Knee Replacement

The ultimate solution for osteoarthritis of the knee is to replace the joint surfaces with an artificial knee joint. The decision to proceed with a total knee replacement is usually only considered in people over the age of 60, (although younger patients sometimes require the surgery simply because no other acceptable solution is available to treat their condition). The main reason that orthopedic surgeons are reluctant to perform the surgery on younger individuals, is that the younger the patient, the more likely the artificial joint will fail during the patient’s lifetime. Replacing the knee again, a process called a revision, is much harder, has more potential complications and is less likely to be successful.

Artificial knee joints last about 12 years in an elderly population. Younger patients are more active and place more stress on the artificial joint. This can lead to loosening and failure of the artificial knee earlier after surgery. Obviously, younger patients are also more likely to outlive their artificial joint, and will almost surely require a revision at some point down the road. It is for these reasons that orthopedic surgeons are usually reluctant to recommend a total knee replacement in the younger patient until there are simply no other options.

Please feel free to print, download, and use/distribute this information (as long as you are not reselling it in any form). Remember, it is the property of the Medical Multimedia Group and they retain all rights regarding its educational content, graphics, and animation’s. Alteration of this document in any way is a violation of the copyright. If you would like to discuss licensing agreements for using MMG’s content in your products, contact mmg@sechrest.com.

This material does not constitute medical advice. It is intended for informational purposes only. NO ONE ASSOCIATED WITH MEDICAL MULTIMEDIA GROUP WILL ANSWER MEDICAL QUESTIONS VIA EMAIL. Please consult a physician for specific treatment recommendations.

The meniscus is a commonly injured structure in the knee. The injury can occur in any age group. In younger people, the meniscus is fairly tough and rubbery, and tears usually occur as a result of a fairly forceful twisting injury. In older people, the meniscus grows weaker with age, and meniscal tears occur as a result of a fairly minor injury, even from the up and down motion of squatting.

Anatomy

What is the meniscus and what does it do?

There is a meniscus on either side of the knee joint. The meniscus acts like a gasket between the femur and the tibia to spread out the weight being transferred from the femur above to the tibia below. The knee anatomy section points out that articular cartilage covers the ends of the bones that make up the joint. The articular cartilage surface is a tough, very slick material that allows the surfaces to slide against one another without damage to either surface. This ability of the meniscus to spread out the force on the joint surfaces as we walk is important because it protects the articular cartilage from excessive forces occurring in any one area on the joint surface. Without the meniscus, the concentration of force into a small area on the articular cartilage can damage the surface, leading to degeneration over time.

Remember also that the meniscus helps with the stability of the knee joint. The meniscus converts the tibial surface into a shallow socket. A socket configuration is more stable than a flat surface. Without the meniscus, the round femur would be free to slide on top of the flat tibial surface.

The meniscus can be torn in several ways. The entire inner rim of the medial meniscus can be torn in what is called a buckethandle tear. The meniscus can also have a flap torn from the inner rim, or the tear can be a degenerative type tear where a portion of the meniscus is frayed and torn in multiple directions.

Causes

How does the meniscus cause problems in the knee?

Meniscus injuries can occur in any age group, but the causes are somewhat different for each age group. In younger people, the meniscus is a fairly tough and rubbery structure. Tears in the meniscus in patients under the age of thirty usually occur as a result of a fairly forceful twisting injury. In the younger age group, meniscal tears are more likely to be caused by a sport activity.

In older people, the meniscus grows weaker with age. The tissue that makes up the meniscus becomes degenerative and is much easier to tear. Meniscal tears in the older age group occur as a result of a fairly minor injury, even from the up and down motion of squatting. Degenerative tears of the meniscus are commonly seen as a part of the overall condition of osteoarthritis of the knee in the older population. In many cases, there is no one associated injury to the knee that leads to the meniscal tear.

Symptoms

What does a torn meniscus feel like?

The most common problem caused by a torn meniscus is pain . The pain may be felt along the joint line where the meniscus is located or may be more vague and involve the whole knee. If the torn portion of the meniscus is large enough, locking may occur. Locking simply refers to the inability to completely straighten out the knee. Locking occurs when the fragment of torn meniscus gets caught in the hinge mechanism of the knee and will not allow the leg to straighten completely. (Imagine sticking a pencil between the hinges in a door and trying to close it.)

There are long term effects of a torn meniscus as well. The constant rubbing of the torn meniscus on the articular cartilage may cause wear and tear on the surface, leading to degeneration of the joint. The knee may swell with use and become stiff and tight. This is usually because of fluid accumulating inside the knee joint – sometimes called water on the knee. This is not unique to meniscus tears, but occurs whenever the knee becomes inflamed.

Diagnosis

How do we look into this problem?

Diagnosis begins with a history and physical. The examination will try to determine where the pain is located, whether or not locking has occurred, and if you have any clicks or pops as the knee is moved. X-rays will not show the torn meniscus. X-rays are mainly useful to determine if other conditions are present. The MRI scan is very good at showing the meniscus. The MRI (Magnetic Resonance Imaging) machine uses magnetic waves rather than x-rays, to show the soft tissues of the body. With this machine, we are able to “slice” through the area we are interested in very clearly. Usually, this test is done to look for injuries, such as tears in the menisci or ligaments of the knee. This test does not require any needles or special dye, and is painless. Here the MRI scan shows a tear in the meniscus. If there is a uncertainty in the diagnosis following the history and physical examination, or if other injuries in addition to the meniscal tear are suspected, the MRI scan may be suggested.

If the history and physical examination strongly suggest that a torn meniscus is present, then arthroscopy may be suggested to confirm the diagnosis and treat the problem at the same time. Arthroscopy is a type of an operation where a small fiberoptic TV camera is placed into the knee joint, allowing the orthopedic surgeon to look at the structures inside the knee joint directly. The arthroscope allows your doctor to actually look into the knee joint and see the condition of the articular cartilage, the ligaments and the menisci .

Treatment

How do we treat this problem?

Initial treatment for a torn meniscus usually is directed towards reducing the pain and swelling in the knee. Your physician may recommend crutches for resting the knee for several days and suggest ice to reduce the pain and swelling. If the knee is locked and cannot be straightened out, surgery may be recommended as soon as reasonably possible to remove the torn portion that is caught in the knee joint. Once a meniscus is torn, it will most likely not heal on its own.

If the symptoms continue, surgery will be required to either remove the torn portion of the meniscus or to repair the tear. Most meniscus surgery today is done using the arthroscope. Small incisions are made in the knee to allow the insertion of a small TV camera into the joint. Through another small incision, special instruments are used to remove the torn portion of meniscus while the arthroscope is used to see what is happening. In some cases, the meniscus tear can be repaired. The arthroscope is used to view the torn meniscus. Sutures are then placed into the torn meniscus until the tear is repaired. Repair of the meniscus is not possible in all cases. Young people with relatively recent meniscal tears are the most likely candidates for repair. Degenerative type tears in older people are not usually repairable.

Please feel free to print, download, and use/distribute this information (as long as you are not reselling it in any form). Remember, it is the property of the Medical Multimedia Group and they retain all rights regarding its educational content, graphics, and animation’s. Alteration of this document in any way is a violation of the copyright. If you would like to discuss licensing agreements for using MMG’s content in your products, contact mmg@sechrest.com.

This material does not constitute medical advice. It is intended for informational purposes only. NO ONE ASSOCIATED WITH MEDICAL MULTIMEDIA GROUP WILL ANSWER MEDICAL QUESTIONS VIA EMAIL. Please consult a physician for specific treatment recommendations.