Knee pain

ARTHROSCOPY NOT RECOMMENDED FOR DEGENERATIVE KNEE DISEASE

A recent systematic review concluded that arthroscopic surgery for degenerative knee disease (including arthritis and meniscal tears) did not result in lasting pain relief or improved function. As a result, panelists strongly recommend against arthroscopy for patients with degenerative knee disease. 

The review (Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline- May 2017) was published in BMJ.

According to the review, about 25% of people older than 50 years of age experience pain from degenerative knee disease (the percentage rises with age), and costs for arthroscopies for this condition are in excess of $3 billion per year in the United States. Furthermore, only 15% of arthroscopy patients reported a small or very small improvement in pain or function at 3 months post surgery, and those benefits were not sustained at 1 year post surgery. 

In place of arthroscopy, panelists recommend effective alternatives including an individualized regimen combining rest, weight loss as needed, a variety of treatments provided by a physical therapist, exercise, and nonsteroidal anti-inflammatory drugs.

In an interview with the New York Times, Dr Reed A.C. Siemieniuk, a methodologist at McMaster University in Hamilton, Ontario, Canada, and chairman of the panel, said, “Arthroscopic surgery has a role, but not for arthritis and meniscal tears.” The procedure, he elaborated, “became popular before there were studies to show that it works, and we now have high-quality evidence showing that it doesn’t work.”

ARTHROSCOPY NOT RECOMMENDED FOR DEGENERATIVE KNEE DISEASE, PER NEW RESEARCH

A recent systematic review concluded that arthroscopic surgery for degenerative knee disease (including arthritis and meniscal tears) did not result in lasting pain relief or improved function. As a result, panelists strongly recommend against arthroscopy for patients with degenerative knee disease in most cases. 

The review (Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline- May 2017) was published in BMJ.

According to the review, about 25% of people older than 50 years of age experience pain from degenerative knee disease (the percentage rises with age), and costs for arthroscopies for this condition are in excess of $3 billion per year in the United States. Furthermore, only 15% of arthroscopy patients reported a small or very small improvement in pain or function at 3 months post surgery, and those benefits were not sustained at 1 year post surgery. 

In place of arthroscopy, panelists recommend effective alternatives including an individualized regimen combining rest, weight loss as needed, a variety of treatments provided by a physical therapist, exercise, and nonsteroidal anti-inflammatory drugs.

In an interview with the New York Times, Dr Reed A.C. Siemieniuk, a methodologist at McMaster University in Hamilton, Ontario, Canada, and chairman of the panel, said, "Arthroscopic surgery has a role, but not for arthritis and meniscal tears." The procedure, he elaborated, "became popular before there were studies to show that it works, and we now have high-quality evidence showing that it doesn't work."

PT BEFORE SURGERY

Yes, please! 

Mild meniscal tears and moderate knee osteoarthritis send some people under the knife, when all they really need is physical therapy.

A recent study in the New England Journal of Medicine found no significant difference between individuals who received surgery and those who received physical therapy alone, thus avoiding the unnecessarily invasive procedure and related costs.

Dr Edward Laskowski, codirector of the Mayo Clinic Sports Medicine Center, told Men's Journal that physical therapy might prove equally effective for other knee injuries, including MCL, PCL, and cartilage tears (Try Physical Therapy Before Surgery - April 29, 2013).

"If you have good range of motion, physical therapy may very well settle down the symptoms over time," Laskowski said.

In a May 2, 2013, episode of Move Forward Radio, the lead physical therapist in the trial discussed the findings of the study.

Learn about physical therapist treatment of meniscal tears and osteoarthritis of the knee.

ACL TEAR TREATMENT AND RECONSTRUCTION

The treatment options following an ACL tear are individualized for each patient depending on age, activity level, and the presence or absence of injury to other structures within the knee. In general, surgery is recommended for young patients who are active and for those in whom the ACL tear is associated with injury to other structures in the knee. Nonoperative (nonsurgical) treatment may be recommended in older or more sedentary patients.

The main reason to have surgery is to restore stability to the knee so it no longer gives out or slides too far forward, which is often painful. The other reason — perhaps the most important reason — is to protect the articular cartilage in the knee from being damaged. It is also important to protect the medial and lateral menisci in the knee.

The meniscus is a fibrous type of cartilage that sits between the ends of the tibia and femur, and is attached to the lining of the joint. There are two separate meniscal cartilages in the knee, each somewhat C-shaped: one on the inner half of the knee (the medial meniscus), and one on the outer half (the lateral meniscus). [Figure 1] The medial and lateral menisci primarily serve as shock absorbers between the ends of the bones to protect the surface or articular cartilage. With recurrent episodes of giving way, the meniscus can be damaged or torn, causing it to lose its shock-absorbing capability. Without a functioning meniscus, the articular cartilage is exposed to increased pressure and “wears” away, leading to arthritis. Additionally, the articular cartilage may be directly injured or damaged with each episode of giving way.

Nonsurgical Treatment

Nonsurgical treatment consists of physical therapy, activity modification and use of a brace. The goal of physical therapy is to strengthen the muscles around the knee to compensate for the absence of the ACL. Specifically, strengthening the muscles in the back of the thigh (the hamstrings) is helpful. Activity modification can be very successful. Sports that do not involve cutting, such as jogging, cycling or swimming, can often be performed successfully.

In addition to therapy and activity modification, use of a hinged sports brace can be attempted. While bracing may be effective in some patients, in others, instability episodes may continue despite their use.

Surgical Treatment and ACL Reconstruction

Once the ACL tears, it has usually sustained enough damage that attempts to surgically repair it are not successful. Consequently, better results are obtained if the ACL is surgically replaced or reconstructed with another tendon from around the knee. [Figure 2]There are a number of surgical options for reconstructing the ACL. The type of procedure done may vary from patient to patient depending on a specific surgeon’s preference as well as factors unique to an individual patient.

The surgical procedure is most commonly performed using arthroscopic techniques. Using one or two small incisions on the knee, the graft is taken from the patellar tendon or hamstring tendons, and a tunnel is drilled into both the tibia and femur. The graft is threaded across the knee, leaving a piece of bone in each of the tunnels and the patellar tendon in the position of the original ACL, thus reconstructing the ligament. [Figure 2] The graft is then secured in this position, most commonly by “wedging” a screw between the side of the bone and the tunnel. [Figure 3] Alternatively, the graft can be secured by other techniques — staples, sutures, buttons, etc. These fixation devices are usually left in place permanently.

In addition to the ACL reconstruction, additional procedures may be done to other structures within the knee if injury is present. A torn meniscus can be either repaired or trimmed (meniscectomy), and other ligaments can be repaired or reconstructed as well.

Figure 3

Allografts most frequently used today are of the bone-patellar tendon-bone type or from the Achilles tendon at the heel, and come from cadavers that have been screened for infectious diseases, e.g., hepatitis and AIDS. The risk of AIDS from one of these grafts is not known, but it is generally believed to be one out of 1 million. All allografts are carefully screened and tested before they are used in surgery.

How long does rehabilitation take after surgery?

The exact course of therapy may vary somewhat depending on the specific type or reconstruction done, particularly if additional meniscus or ligament surgery was done. Physical therapy is done in a supervised setting in conjunction with a trained therapist. Early in the course of recovery, visits may be two to three times per week, but later, once every week or two is often sufficient. Home exercises are done on days not scheduled for a formal therapy session.

The rehabilitation following ACL reconstruction includes essentially three phases. The first phase of rehabilitation consists of controlling the pain and swelling in the knee, regaining knee motion, and getting early return of muscle strength. The operated leg is typically placed into a brace immediately after surgery.

Initially, weight bearing is allowed with crutches and is progressed to full-weight bearing independent of crutches as swelling, motion and muscle strength allow. Most patients are on crutches for one week, although some may be on crutches longer and some shorter. This phase typically takes six to eight weeks.

The second phase emphasizes recovery of full knee motion and muscle strength. Cycling, running on the treadmill and light jogging are started in this phase. In some patients, a sport brace is obtained to replace the postoperative knee brace. This phase typically lasts from two to four months after surgery.

The final phase consists of graduated return to full activity. Normal muscle strength, coordination and the absence of swelling are required for successful return to activity. A brace may be recommended early in the return to cutting and pivoting sports. This phase occurs at four to eight months after surgery, depending on the particular patient and the nature of his or her activities.

A patient’s rehabilitation is monitored closely by both the therapist and surgeon for evidence of potential problems. Most significantly, patients are cautioned not to attempt a too premature return to full activity, which may cause the knee to be inflamed or reinjured. In every patient, the graft must both heal into place and be incorporated into the knee. Too much stress too soon may increase the risk of graft failure.

What are the potential complications after surgery?

Most patients experience no complications and return to full activity between six and eight months after surgery. However, the most common complications include pain in the front of the knee and loss of knee motion.

Pain in the front of the knee occurs in 10 to 20 percent of patients. Fortunately, it can usually be controlled by modification in the physical therapy protocol. Loss of motion occurs in less than 5 percent of patients and is most common in patients with limited motion before surgery. In some individuals, intermittent pain and swelling occur with activity despite a successful ligament reconstruction. This is often related to the amount of meniscal or cartilage injury that was present and identified at the time of surgery.

In the absence of identifiable causes, a small percentage of patients will end up with a persistent detectable increased amount of motion in their knee (a “loose” graft). This may be related to stretching of the graft over time or due to an additional injury.

Will I be able to return to my previous sporting activities?

Approximately 85 percent of patients return to their previous level of activity without restrictions. In the other 15 percent, full return may be limited by a number of causes: pain, swelling, persistent laxity, change in lifestyle related to age, intentional choice or other unidentifiable causes.

7 EXERCISES YOU CAN DO NOW TO SAVE YOUR KNEES LATER

1. You have healthy knees – and you’d like to keep it that way. That’s not a job you can tackle sitting down, though getting into a 90-degree position could help. First, though, you’ll want to heed a simple but central lesson roughly adapted from age-old song lyrics: “The hip bone’s connected to the knee bone.” Physical activities that strengthen your hips, quads, calves, and ankles are also good for your knees, while weakness in any of those areas can increase knee strain and risk of injury. So think “holistic” leg health.

 

2. Indelicate squat discussion first. You’re going to be doing that kind of loading on the knee joint just to get on and off the toilet. It’s important to do exercises that prepare the knee for regular day-to-day activities. Squatting really affects all the muscles around the knee joint, including strengthening the muscles around the knee joint. Haven’t done squats in a while – or ever? Start by doing at least 8-12 reps with just your weight, going down to just above 90 degrees, or right at 90 degrees if you don’t have any discomfort, injuries or issues that prevent that. Alternative: try leg press if you have back problems or other issues preventing you from doing squats.

 

3. Like squats, lunges can also be an excellent exercise to improve strength in your quads and butt o help support your knees. With both exercises, he notes, make sure you’re in good position – feet firmly planted. So that you’re not coming too far forward and putting more stress on the joint. Talk to your doctor before doing lunges if you’re concerned about a preexisting issue, like osteoarthritis or a knee injury, to keep from exacerbating it.

 

4. Whether you’re familiar with step-ups or not, you get the general idea. You’re lifting your body weight using one hip, one leg to get that weight, like you’re going up the stairs. Keeping the hip joint muscles strong and well-conditioned along with muscles around the ankle strong and well-conditioned will help minimize the risk of injury at the knee joint. To get started with step-ups, place your foot on a high step, weight bench or plyo boxes, so that your leg is bent at about a 90-degree angle. Then bring your other foot up onto the surface. Repeat for 12-15 reps, and add weight as you’re able.

 

5. A weak back and stomach can put extra stress on the joints that support your body. A good core strengthening program is important and paramount to the health of your knees, hips, and lower extremities. It’s important to do plenty of back and abdominal strengthening exercises. A range of activities can help in core strengthening, experts say, while improving flexibility, balance, stability, which are also protective of joint strength.

 

6. Running has taken a pounding for the pounding it can take on the knees. For most people, it’s a safe activity. It’s easy, low cost, and we’re all designed to run for the most part. IT’s just being smart about what you can tolerate. That goes for not ramping up too quickly to longer distances or pushing through the pain of an injury – and taking time off to heal as needed. While some who have arthritis in their knees are still able to run, experts say it’s important to talk with a physician about any existing knee issues to determine what’s safe, including when walking might be more appropriate.

 

7. Whether you’re biking with friends or riding alone, racing the clock or just catching a cool breeze, taking to two wheels can strengthen your quads and calves – and even improve overall leg strengthening to bolster the knee health. Cycling is also a low-impact activity. The circular, rhythmic pedaling is easy on the knees and it can provide a great aerobic workout to boot.

 

8. Though many do just fine running on a treadmill, trying alternating an elliptical machine for an aerobic workout that works the legs while being easy on the knees. With your foot planted against a platform, there’s not repetitive impact that leads to the degredation of cartilage over time. And! It can help maintain muscular endurance.

 

9. While certain exercises target muscles are the joint, at the end of the day any strength training or aerobic exercise that helps you maintain a healthy weight reduces pressure on your knees. When you stand on one foot, 5-8x your body weight goes through your knee joint. If you gain 5 pounds, that’s an extra 25-40 pounds of pressure going through your knee joint. If for no other reason, exercise to keep your weight in check to decrease the stress on joints. That goes for knee-friendly exercises ranging from the elliptical machine to cycling, experts say, and anything else that gets you moving. 

YOUR CHILD WAS DIAGNOSED WITH OSGOOD-SCHLATTER DISEASE... NOW WHAT?

What is it? 
Osgood-Schlatter disease refers to a condition occurring during adolescence that causes pain, swelling and soreness on an area of the upper shinbone, just below the knee, called the tibial tuberosity. The condition commonly occurs during the period of adolescent growth spurt where the tibial tuberosity is vulnerable to overuse in an active teenager who is involved in a lot of running and jumping activities. The quadriceps’ (muscles of the front of the thigh) tendon attaches to the tibial tuberosity and with repetitive activity can cause traction of this growth center and cause inflammation to the upper shinbone. Osgood-Schlatter disease is caused by repetitive activities in growing teenagers who do not allow enough time in between activities to allow the inflammation that occurs at the tibial tuberosity to heal.

Symptoms
• The main symptom of Osgood-Schlatter disease is pain at the bump below the knee with activity or after a fall.
• There may be swelling and enlargement of this bump on the upper shinbone.
• Forceful contraction of the thigh muscle can also cause pain.
• One or both knees may be affected.
• The bump on the shinbone may be very tender.

Sports Medicine Evaluation and Treatment
The diagnosis of Osgood-Schlatter disease is typically made by history, physical examination and at times, x-rays of the knee, if deemed necessary by the sports medicine physician.

Treatment:
• The primary focus of treatment is to control the pain as well as tension of the thigh muscle tendon where it attaches to the upper shinbone.
• In severe cases, young athletes may need to have a period of rest from their sport.
• Activity modification, ice and non-steroidal anti-inflammatory drugs (NSAIDs) may also help with pain and swelling.
• A strap placed between the bump and the kneecap may help reduce tension of the tendon on the upper shinbone attachment site.
• Improving the flexibility of the thigh and hamstring muscles.

Injury Prevention
• Early recognition of the symptoms of Osgood-Schlatter disease by young athletes, coaches and parents can allow
early intervention to prevent severe inflammation.
• Young athletes should not try to push through this pain should they start experiencing it.
• Referral to a sports medicine physician can offer the best opportunity for education, intervention and monitoring for the young athlete.

Return to Play
• Prior to starting sports-specific activity, the athlete should have a pain-free single leg squat.
• There should be minimal pain with squatting, jumping and then a progression through sports-specific movements
prior to full return to sport.
• If the athlete experiences pain or limping during this sequence, he/she should continue the treatment and attempt a return to sports after a discussion with the sports medicine physician.
 

AMSSM Member Authors: Neeru Jayanthi, MD and Mark Riederer, MD