KNEE CONDITIONS & TREATMENT

Sudden pain in one of the knees is usually the result of overusing the knee or injuring it. In many cases, you don’t need to see your GP. The knee joint is particularly vulnerable to damage and pain because it takes the full weight of your body and any extra force when you run or jump. You’re more likely to experience knee pain as you get older, and people who are overweight or do lots of sports have a higher risk of damaging their knees. Some sports that involve a lot of turning, such as football, netball and skiing, carry a particularly high risk of knee injuries.

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.

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.

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.

MEDICATIONS

Paracetamol, which you can buy over the counter, is the best medicine to use if you have a knee injury. Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can help to reduce inflammation and swelling, as well as relieve pain. However, you shouldn’t take oral NSAIDs (tablets) for the first two days after your injury because they may delay healing. NSAIDs are also available as gels, creams and sprays that you can put directly onto your skin and these are OK from the time of injury.

Your GP may prescribe stronger painkillers if your pain is severe. Always read the patient information that comes with your medicine and if you have questions, ask your pharmacist or doctor for advice.

PHYSIOTHERAPY

If your injury is more severe or complex or persists for over six to eight weeks, your GP may refer you to a physiotherapist. This is a health professional who specialises in movement and mobility. You can also choose to see a physiotherapist privately. They will develop a programme of rehabilitation exercises to gradually strengthen your knee and restore its normal function. These exercises will vary depending on the type of injury you have and how severe it is.

Some people have braces or strapping to support the knee during rehabilitation, usually when an injury has been severe.

SURGICAL TREATMENT

For some types of knee injury, your GP or physiotherapist could refer you to an orthopaedic surgeon for assessment. They may recommend that you have surgery to repair the damage to your knee – especially if other forms of treatment haven’t worked.

Your surgeon is more likely to suggest surgery if you have one of the following injuries.

• You have torn your anterior cruciate ligament (ACL) and you do a lot of sport or have also torn a meniscus. ACL reconstruction involves taking a piece of tendon (usually from your patella tendon or hamstring) to replace the damaged ligament.

• Your knee remains painful or locks after an injury to your meniscus. Your surgeon may repair or partially remove your damaged meniscus.

• You have an injury to your medial collateral ligament (MCL) that hasn’t healed after three months of non-surgical treatment. Your surgeon will repair or reconstruct your MCL.

You may be able to have a type of keyhole surgery called knee arthroscopy to get to the damaged area of your knee.

Knee replacement surgery (arthroplasty) is a routine operation that involves replacing a damaged, worn or diseased knee with an artificial joint.
Adults of any age can be considered for a knee replacement, although most are carried out on people between the ages of 60 and 80. More people are now receiving this operation at a younger age.

A replacement knee usually lasts over 20 years, especially if the new knee is cared for properly and not put under too much strain.

WHEN A KNEE REPLACEMENT IS NEEDED

Knee replacement surgery is usually necessary when the knee joint is worn or damaged to the extent that your mobility is reduced and you experience pain even while resting.

The most common reason for knee replacement surgery is osteoarthritis. Other conditions that cause knee damage include:

• rheumatoid arthritis
• haemophilia
• gout
• disorders that cause unusual bone growth (bone dysplasias)
• death of bone in the knee joint following blood supply problems (avascular necrosis)
• knee injury
• knee deformity with pain and loss of cartilage

A knee replacement is major surgery, so is normally only recommended if other treatments, such as physiotherapy or steroid injections, haven’t helped reduce pain or improve mobility.

You should only consider knee replacement surgery if:

• you have severe pain, swelling and stiffness in your knee joint and your mobility is reduced
• your knee pain is so severe that it interferes with your quality of life and sleep
• everyday tasks, such as shopping or getting out of the bath, are difficult or impossible
• you’re feeling depressed because of the pain and lack of mobility
• you can’t work or have a normal social life

You’ll also need to be well enough to cope with both a major operation and the rehabilitation afterwards.

TYPES OF KNEE REPLACEMENT SURGERY

There are two main types of surgery, depending on the condition of the knee:

• total knee replacement (TKR) – both sides of your knee joint are replaced
• partial (half) knee replacement (PKR) – only one side of your joint is replaced in a smaller operation with a shorter hospital stay and recovery period

Alternative surgery

There are alternative surgeries to knee replacement, but results are often not as good in the long term. Your doctor will discuss the best treatment option with you. Alternatives may include:

• arthroscopic washout and debridement – an arthroscope (tiny telescope) is inserted into the knee, which is then washed out with saline to clear out any bits of bone or cartilage
• osteotomy – during an open operation, the surgeon cuts the shin bone and realigns it so that weight is no longer focused on the damaged part of the knee
• mosaicplasty – a keyhole operation that involves transferring plugs of hard cartilage, together with some underlying bone from another part of your knee, to repair the damaged surface

RECOVERING FROM KNEE REPLACEMENT SURGERY

You’ll usually be in hospital for three to five days, but recovery times can vary depending on the individual and type of surgery being carried out.
Once you’re able to be discharged, your hospital will give you advice about looking after your knee at home. You’ll need to use a frame or crutches at first and a physiotherapist will teach you exercises to help strengthen your knee.

Most people can stop using walking aids around six weeks after surgery, and start driving after about eight to 12 weeks.

Full recovery can take up to two years as scar tissue heals and your muscles are restored by exercise. A very small amount of people will continue to experience some pain after two years.

RISKS OF KNEE REPLACEMENT SURGERY

Knee replacement surgery is a common operation and most people don’t experience complications. However, as with any operation, there are risks as well as benefits. Complications are rare but can include:

• stiffness of the knee
• infection of the wound
• deep infection of the joint replacement, needing further surgery
• unexpected bleeding into the knee joint
• ligament, artery or nerve damage in the area around the knee joint
• blood clots or deep vein thrombosis (DVT)
• persistent pain the in the knee
• fracture – a break in the bone around the knee replacement during or after the operation

In some cases, the new knee joint may not be completely stable and further surgery may be needed to correct it.

If you tear the anterior cruciate ligament (ACL) in your knee, you may need to have reconstructive surgery. The ACL is a tough band of tissue joining the thigh bone to the shin bone at the knee joint. It runs diagonally through the inside of the knee and gives the knee joint stability. It also helps to control the back-and-forth movement of the lower leg.

ACL INJURIES

Knee injuries can occur during sports such as skiing, tennis, squash, football and rugby. ACL injuries are one of the most common types of knee injuries, accounting for around 40% of all sports injuries. You can tear your ACL if your lower leg extends forwards too much. It can also be torn if your knee and lower leg are twisted.

Common causes of an ACL injury include:

• landing incorrectly from a jump
• stopping suddenly
• changing direction suddenly
• having a collision, such as during a rugby/football tackle

If the ACL is torn, your knee may become very unstable and lose its full range of movement. This can make it difficult to perform certain movements, such as turning on the spot. Some sports may be impossible to play.

RECONSTRUCTIVE ACL SURGERY

A torn ACL can’t be repaired by stitching it back together. However, it can be reconstructed by grafting (attaching) new tissue onto it. The ACL can be reconstructed by removing what remains of the torn ligament and replacing it with a tendon from another area of the leg, such as the hamstring or patellar tendon. The patellar tendon attaches the bottom of the kneecap (patella) to the top of the shinbone (tibia).

After you’ve been anaesthetised, the surgeon will carefully examine the inside of your knee, usually with a medical instrument called an arthroscope (see below). Your surgeon will check that your ACL is torn and look for damage to other parts of your knee. Any other damage found might be repaired during the surgery to your ACL or after your operation.

After confirming that your ACL is torn, your surgeon will remove the graft tissue, ready for relocation.

Graft tissue

A number of different tissues can be used to replace your ACL. Tissue taken from your own body is known as an autograft. Tissue taken from a donor is known as an allograft. A donor is someone who has given permission for parts of their body to be used after they die by someone who needs them. Before your operation, your surgeon will discuss the best option with you. Tissues that could be used to replace your ACL are listed below.

• A strip of your patellar tendon – this is the tendon running from the bottom of the kneecap (patella) to the top of the shin bone (tibia) at the front of your knee.
• Part of your hamstring tendons – these run from the back of your knee on the inner side, all the way up to your thigh.
• Part of your quadriceps tendon – this is the tendon that attaches the patella to the quadriceps muscle, which is the large muscle on the front of your thigh.
• An allograft (donor tissue) – this could be the patellar tendon or Achilles tendon (the tendon that attaches the back of the heel to the calf muscle) from a donor.
• A synthetic graft – this is a tubular structure designed to replace a torn ligament.

The most commonly used autograft tissues are the patellar tendon and the hamstring tendons. Both have been found to be equally successful. Allograft tissue may be the preferred option for people who aren’t going to be playing high-demand sports, such as basketball or football, as these tendons are slightly weaker.

Synthetic (man-made) tissues are currently used in certain situations, such as revision surgery and multi-ligament injuries. The graft tissue will be removed and cut to the correct size. It will then be positioned in the knee and fixed to the femur (thigh bone) and tibia (shin bone). This is usually carried out using a technique known as a knee arthroscopy.

Arthroscopy

An arthroscopy is a type of keyhole surgery. It uses a medical instrument called an arthroscope, which is a thin, flexible tube with bundles of fibre-optic cables inside that act as both a light source and camera. Your surgeon will make a small incision on the front of your knee and insert the arthroscope. The arthroscope will illuminate your knee joint and relay images of your knee to a television monitor. This will allow the surgeon to see the inside of your knee clearly. Additional small incisions will be made in your knee, so that other medical instruments can be inserted. The surgeon will use these instruments to remove the torn ligament and reconstruct your ACL.

Your surgeon will make a tunnel in your bone to pass the new tissue through. The graft tissue will be positioned in the same place as the old ACL, and held in place with screws or staples that will remain in your knee permanently.

Final examination

After the graft tissue has been secured, your surgeon will test that there’s enough tension in it (that it’s strong enough to hold your knee together). They’ll also check that your knee has the full range of motion and that the graft keeps your knee stable when it’s bent or moved. When the surgeon is satisfied that everything is working properly, they’ll use stitches to close the incisions and apply dressings. After the procedure, you’ll be moved to a hospital ward to begin your recovery.

RISKS OF ACL SURGERY

ACL surgery fully restores the functioning of the knee in over 80% of cases. However, your knee may not be exactly like it was before the injury, and you may still have some pain and swelling. This may be because of other injuries to the knee, such as tears or injuries to the cartilage, which happened at the same time as or after the ACL injury.

As with all types of surgery, there are some small risks associated with knee surgery, including infection, a blood clot, knee pain, and knee weakness and stiffness.

RECOVERING FROM ACL SURGERY

After having reconstructive ACL surgery, a few people may still experience knee pain or instability. Recovering from surgery usually takes around six months. However, it could be up to a year before you’re able to return to full training for your sport.

An arthroscopy is a type of keyhole surgery used both to diagnose and treat problems with joints. An arthroscopy involves the use of a device called an arthroscope to examine the joints. This is a thin, metal tube about the length and width of a drinking straw that contains a light source and a camera. Images are sent from the arthroscope to a video screen or an eyepiece, so the surgeon is able to see inside the joint. It’s also possible for tiny surgical instruments to be used alongside an arthroscope to allow the surgeon to treat certain joint conditions.

As the equipment used during an arthroscopy is so small, only minor cuts need to be made in the skin. This means the procedure has some potential advantages over traditional, “open” surgery, including:

• less pain after the operation
• faster healing time
• lower risk of infection
• you can often go home the same day
• you may be able to return to normal activities more quickly

An arthroscopy might be recommended if you have problems such as persistent joint pain, swelling or stiffness, and scans have not been able to identify the cause. An arthroscopy can also be used to treat a range of joint problems and conditions. For example, it can be used to:

• repair damaged cartilage
• remove fragments of loose bone or cartilage
• drain away any excess fluid
• treat conditions such as arthritis

WHAT HAPPENS DURING AN ARTHROSCOPY

The arthroscope is inserted through a small cut in the skin made next to the joint. Further small incisions may also be made to allow an examining probe or surgical instruments to be inserted. Your surgeon will then examine the inside of the joint using the arthroscope and, if necessary, remove or repair any problem areas. This will usually be done under general anaesthetic, although sometimes a spinal or local anaesthetic is used.

The procedure is usually performed as a day case, which means you’ll normally be able to go home on the same day as the surgery.

RECOVERING FROM AN ARTHROSCOPY

The time it takes to recover from an arthroscopy can vary, depending on the joint involved and the specific procedure you had. It’s often possible to return to work and light, physical activities within a few weeks, but more demanding physical activities such as lifting and sport may not be possible for several months.

Your surgeon or care team will advise you how long it’s likely to take to fully recover and what activities you should avoid until you’re feeling better. While you’re recovering, you should contact your surgical team or GP for advice if you think you may have developed one of the complications mentioned below.

RISKS OF AN ARTHROSCOPY

An arthroscopy is generally considered to be a safe procedure, but like all types of surgery it does carry some risks. It’s normal to experience short-lived problems such as swelling, bruising, stiffness and discomfort after an arthroscopy. These will usually improve during the days or weeks following the procedure.

For more information on knee arthroscopy procedures please do not hesitate to get in touch with Mr Luscombe through our appointments page.

Total knee replacement is one of the most successful procedures in all of medicine. In the vast majority of cases, it enables people to live richer, more active lives free of chronic knee pain. Over time, however, a knee replacement may fail for a variety of reasons. When this occurs, your knee can become painful and swollen. It may also feel stiff or unstable, making it difficult to perform your everyday activities.

If your knee replacement fails, your doctor may recommend that you have a second surgery—revision total knee replacement. In this procedure, your doctor removes some or all of the parts of the original prosthesis and replaces them with new ones.

Although both procedures have the same goal—to relieve pain and improve function—revision surgery is different than primary total knee replacement. It is a longer, more complex procedure that requires extensive planning, and specialised implants and tools to achieve a good result.

During primary total knee replacement, the knee joint is replaced with an implant, or prosthesis, made of metal and plastic components. Although most total knee replacements are very successful, over time problems such as implant wear and loosening may require a revision procedure to replace the original components.

There are different types of revision surgery. In some cases, only one implant or component of the prosthesis has to be revised. Other times, all three components—femoral, tibial, and patellar—need to removed or replaced and the bone around the knee needs to be rebuilt with augments (metal pieces that substitute for missing bone) or bone graft.

Damage to the bone may make it difficult for the doctor to use standard total knee implants for revision knee replacement. In most cases, he or she will use specialized implants with longer, thicker stems that fit deeper inside the bone for extra support.

WHEN REVISION TOTAL KNEE REPLACEMENT IS RECOMMENDED

IMPLANT LOOSENING AND WEAR

In order for a total knee replacement to function properly, an implant must remain firmly attached to the bone. During the initial surgery, it was either cemented into position or bone was expected to grow into the surface of the implant. In either case, the implant was firmly fixed. Over time, however, an implant may loosen from the underlying bone, causing the knee to become painful.

The cause of loosening is not always clear, but high-impact activities, excessive body weight, and wear of the plastic spacer between the two metal components of the implant are all factors that may contribute. Also, patients who are younger when they undergo the initial knee replacement may “outlive” the life expectancy of their artificial knee. For these patients, there is a higher long-term risk that revision surgery will be needed due to loosening or wear.

In some cases, tiny particles that wear off the plastic spacer accumulate around the joint and are attacked by the body’s immune system. This immune response also attacks the healthy bone around the implant, leading to a condition called osteolysis. In osteolysis, the bone around the implant deteriorates, making the implant loose or unstable.

INFECTION

Infection is a potential complication in any surgical procedure, including total knee replacement. Infection may occur while you are in the hospital or after you go home. It may even occur years later. If an artificial joint becomes infected, it may become stiff and painful. The implant may begin to lose its attachment to the bone. Even if the implant remains properly fixed to the bone, pain, swelling, and drainage from the infection may make revision surgery necessary. Revision for infection can be done in one of two ways, depending on the type of bacteria, how long the infection has been present, the degree of infection, and patient preferences.

• Debridement. In some cases, the bacteria can be washed out, the plastic spacer can be exchanged, and the metal implants can be left in place.

• Staged surgery. In other cases, the implant must be completely removed. If the implant is removed to treat the infection, your doctor will perform the revision in two separate surgeries. In the first surgery, he or she will remove the implant and place a temporary cement spacer in your knee. This spacer is treated with antibiotics to fight the infection and will remain in your knee for several weeks. During this time, you will also receive intravenous antibiotics. When the infection has been cleared, your doctor will perform a second surgery to remove the antibiotic spacer and insert a new prosthesis. In general, removing the implant leads to a higher chance of curing the infection, but is associated with a longer recovery.

INSTABILITY

If the ligaments around your knee become damaged or improperly balanced, your knee may become unstable. Because most implants are designed to work with the patient’s existing ligaments, any changes in those ligaments may prevent an implant from working properly. You may experience recurrent swelling and the sense that your knee is “giving way.” If knee instability cannot be treated through nonsurgical means such as bracing and physical therapy, revision surgery may be needed.

STIFFNESS

Sometimes a total knee replacement may not help you achieve the range of motion that is needed to perform everyday activities. This may happen if excessive scar tissue has built up around the knee joint. If this occurs, your doctor may attempt “manipulation under anesthesia.”

In this procedure, you are given anesthesia so that you do not feel pain. The doctor then aggressively bends your knee in an attempt to break down the scar tissue. In most cases, this procedure is successful in improving range of motion. Sometimes, however, the knee remains stiff. If extensive scar tissue or the position of the components in your knee is limiting your range of motion, revision surgery may be needed.

FRACTURES

A periprosthetic fracture is a broken bone that occurs around the components of a total knee replacement. These fractures are most often the result of a fall, and usually require revision surgery.

In determining the extent of the revision needed, your doctor will consider several factors, including the quality of the remaining bone, the type and location of the fracture, and whether the implant is loose. When the bone is shattered or weakened from osteoporosis, the damaged section of bone may need to be completely replaced with a larger revision component.