A Knee and Shoulder Handbook
For All of Us
By Alan M. Reznik, MD and
Jane Y. Reznik
Published by Jane Reznik at Smashwords
Copyright 2010 Alan Reznik
The information in this book is the authors’ best representation of the top practices and many of the most accepted treatments for common knee and shoulder problems. Practices vary by surgeon experience, location, facility and the patient’s individual medical condition. The information in this book cannot replace a good physical examination, review of tests and a full understanding of the medical history in a given case. The authors cannot be held responsible for errors or consequences from the use or misuse of the information presented in this book. The authors make no warrantees, expressed or implied, with respect to the contents of this publication. The information presented here is not a substitute for advice, opinions or instructions from a physician familiar with the specifics of the patient’s condition. It is the sole responsibility of the treating physician, with the full respect of the presenting condition, medical history and experience, to determine the best treatment options for any given patient or condition. Neither the publisher nor the authors assume any responsibility for any injury and/or damage to persons or property.
This book is dedicated to the memory of my father, Barry D. Reznik, as an engineer, an inventor and a truly self-made man. He believed that almost anything could be explained to anyone if you had a little time, a napkin and a pen. His presence is deeply missed.
Table of Contents
Doctor’s Introduction
Injuries in Children
Play It Safe!
Knee Pain in Young Children and Teenagers
Osteochondritis Dissecans
Knee
Locking, Buckling and Giving Way
“Water on the Knee” ACL Tears
Injury to Other Knee Ligaments (MCL, LCL, PCL) Torn “Cartilage” in the Knee (Meniscus Tears) Other Cartilage Defects
Kneecap Pain and Dislocations
Injury to the Knee Extensor Mechanism
Tibial Plateau Fractures
Shoulder
Frozen Shoulder (Adhesive Capsulitis) Shoulder Instability and Dislocations
Torn Cartilage in the Shoulder: “SLAP” Tears
Rotator Cuff Tears
Shoulder Pain without Tears of the Rotator Cuff
Injuries to the Biceps Tendon
The AC Joint
Clavicle Fractures
Appendix I: Q and A with Dr. Reznik
Appendix II: Making the Most of Your Office Visit
Glossary
Author’s Biography
Acknowledgment
Where does one start when thanking the people who contributed to this project? You could go back to birth and thank your parents, or stop short of that event and thank the first teacher that thought you might have potential. You may want to thank your wife for lovingly putting up with the trials that ensue once anyone starts a book of any type. These are the people who believed in me and told me to never give up, and I thank all of them. I have also grown to appreciate many others, including the clinical faculty at New York’s Mount Sinai Hospital during my Orthopaedic residency, Professor Robert Duthie and everyone on the “top floor” at Oxford University’s Orthopaedic Department, Dale Daniel, Ray Sachs, Mary Lou Stone and Don Fithian from the San Diego sports fellowship. I would also like to acknowledge the Yale Orthopedic department’s faculty, staff and residents and my current partners at The Orthopaedic Group in New Haven, CT. All of these people have taught me everything about Orthopaedic surgery and helped to shape my daily clinical practice.
I have to especially thank a former Yale resident, Ted Kenyon, MD, for telling me that the patient booklets I had written for my office inspired him to write his book and for returning the favor by inspiring me to write this one. Lastly, with pride, I am grateful to my daughter, Jane, for at age 18 thinking it wasn’t a terrible idea to work with her dad on a project that may help patients better under- stand what is wrong with their shoulder or knee and hopefully help them to a better diagnosis and a speedy recovery.
Doctor’s Introduction
Remember the Peanuts specials during the holiday season? Remember how it sounded when the adults spoke to Charlie Brown? To me, that is a fairly accurate picture of what it’s like to listen to a doctor after he says the words, “looks like you may need surgery.” I could see it in my patient’s eyes. Just like in Charlie Brown, from that point on, all they heard was “wah-wah wah-wah…” Telling anyone that surgery was an option seemed to cause both short-term memory loss and retrograde amnesia. It was worrisome. No one was listening to a thing I said. With this in mind, I started to write blurbs to give to my patients as they left the office. The “wah-wahs” sounded clearer when written down. A piece of paper with a summary of the problem they had, the possible treatment and the care afterwards was a great help. Like homework, they were to read it and write down their questions for the next visit. They were even encouraged to bring family with them to go over the answers.
In time, the papers grew into little booklets with pictures. Still, it was clear that patients had a limited understanding of what was wrong. They could not see that in using an arthroscope in surgery, dozens of different operations can be done through the same small incisions. Patients who had completely different operations would ask why it was taking them longer to heal. So I posted a few You- Tube videos for my patients. They could now see the different procedures on video (www.youtube. com/DrAReznik). My nurse and I also wrote a list of frequently asked questions (with the answers) and even an article on how to make the most of your office visit. All of these educational pieces seemed to help in a small way. However, as certain issues were solved, other issues crept in. The common complaints of knee locking, buckling and giving way were poorly reported, so I wrote an article on that. Lastly, too many children were being injured in sports. Most injuries occurred because of a lack of understanding of simple safety precautions for growing children or a lack of appreciation of what special concerns we have for injuries to growing bones. To help, a newsletter called “Playing it Safe,” based on the American Academy of Orthopedic Surgeon’s Play it Safe program, was sent out to the local pediatricians. Soon enough, it became clear that others might benefit from the collection of patient materials, but mailing them to everyone was impractical. Thus, this book was born.
Inside, you will find the articles described above, as well as articles on a series of common knee and shoulder problems. I have presented what I believe are the latest treatment concepts, tips on understanding the diagnoses and preferred treatment options. Of course, like any book on medical conditions, this cannot substitute for an exam by an experienced physician or make a diagnosis, but once a diagnosis is made, the information here may help make it easier for you to have a good understanding of your problem. In my experience, the most well educated patients can understand the reasons for their rehabilitation program and therefore participate fully in their own recovery. It is my sincere hope that this understanding, along with expert treatment by your own doctor, will improve your chances of an excellent outcome.
Alan M Reznik, MD
Injuries in Children
Play It Safe!
In the U.S. alone, there are over three quarter million ER visits each year by children under the age of 15. A major cause of this is the alarming rate of injury during sports. The “Play It Safe” pro- gram was created by the American Academy of Orthopedic Surgeons (AAOS) to increase awareness and to reduce injury to children during these sporting activities. Many studies show that the majority of injuries occur in unorganized or casual sports, like pick-up games of basketball, baseball and football. Still significant, organized league sports make up about one third of the injuries. Reducing the risk of both injury rates is a goal of the “Play it Safe” campaign. There are four topics that require special attention when it comes to children and sports:
1- Young athletes are not just small adults
2- Growing children’s injuries create special concerns
3- Diagnosis and treatment offered to children
4- Prevention
Young athletes are not just small adults
Children are growing all the time. This gives them some special advantages over adults. To start, their bones have a little more spring and bend before they break. They are typically lower to the ground and have lower body weights, making most minor falls of little consequence. At the same time, they tend to be less prepared for injury, and their sense of danger is far less than an adult’s. Children also grow at differing rates at different times during development. A sudden growth spurt or a change in limb length can create the gawky behavior that makes some children seem accident-prone. These factors alone help explain some of the injuries prevalent in child athletes.
Sports injuries I’ve seen in children vary from a child simply exceeding his or her physical limitations to an accident occurring during an unsupervised activity in an unsafe environment. Adults have to be aware of their own children’s limits. Some 14 year olds are fully-grown, while others are not. I often hear stories of children in an age-based league playing against kids who weigh 50 to 100 pounds more than them. Many coaches and parents take performance at very young ages to an extreme, and lying about a child’s age or weight for an unfair advantage is simply wrong. Worse yet, studies have shown that in the late 1990’s, up to 500,000 young athletes were using black market
steroids to increase muscle mass. The risks of these drugs are widely known, serious for children and potentially life threatening. These “performance enhancing” products should be completely avoided. Sports for children should always be fun, not unhealthy or dangerous.
Growing children’s injuries create special concerns
The bones in children grow in specialized areas near each joint called growth plates. These areas are softer than calcified bone in the middle of the limbs and therefore are more susceptible to injury. When an injury to a growth plate occurs, future growth and alignment of the limb are at risk if it is not treated properly.
Growing children’s bones can buckle and bend without breaking all the way. This creates fractures in the middle of the bone, which are often known as “green stick” fractures since they resemble what happens when you try to break a growing tree branch. These green stick fractures break, deform and stay deformed, even though part of the bone (branch) is still intact. These “incomplete” fractures or breaks also require special attention. Both growth plate and green stick fractures affect bone growth. The growing child can remodel broken bones and overcome minor disturbances in growth. The child’s age, the fracture location, the bone’s angulation (amount of bend) and the fragment’s displacement (separation) are important factors in determining how well a fracture will heal without orthopedic intervention. When it is clear that a deformity will result, prompt treatment is necessary.
Diagnosis and treatment offered to children
Occasionally, because the growth plates are not calcified, a diagnosis can be much more difficult to make. The cartilage and growth plates cannot be seen directly on normal X-rays. In these cases, a precise history of the injury (force involved, position of the limb, direction of impact and anatomic location of the injury) helps in making the correct diagnosis. Many times, there is no substitute for an examination by experienced hands because findings on an x-ray are often only seen once the healing process is well underway. Sometimes a missed diagnosis becomes a missed opportunity for a simpler treatment.
In children, some injuries can be treated with a sling, splint or cast while others require perfect reduction to realign the growth plate or the joint space. The goal of all treatment should be to use the least invasive method to allow a child’s bones to heal with the lowest risk of future deformity or loss of future growth.
Prevention
Young athletes should be encouraged to play in organized or supervised sports. They should
have training or specific stretching and exercise programs to prepare them for the sport. The sport itself with or without preparation should not be their only exercise. A child’s coach and parents should take into account the child’s age, height and weight before matching them in age-only based sports. Parents should be sure the coaches have appropriate training and qualifications to coach their children. The children must have access to a safe playing area and appropriate, well-maintained equipment. Field conditions, weather conditions and available supervision should always be a factor when deciding to have a competition. In hot weather, parents should be sure their children are well hydrated and be aware of the risks of hyperthermia on very hot and humid days.
Children should warm up and stretch before participating in sports. They should drink plenty of fluids. They should have appropriate fitting equipment. They should tell the supervising adult when they are hurt instead of trying to play through painful injuries. Safety rules for growing athletes, such as pitch counts, should be strictly followed, and children should not be played in multiple leagues in the same sport in the same season to “get around” these rules, no matter how great the parents think they are. The rules are designed to protect growing children from injury; ignoring the rules will risk serious growth injury and only shorten their playing careers. Children should never be given “performance enhancing” drugs or supplements.
Protective gear is also important and sports specific. Helmets for biking, skiing and roller-skating are no longer optional. Mouth guards, shin guards and plastic face guards have helped to reduce injuries and should be used. Elbow pads and wrist protectors should be worn for inline skating, even on pathways designed for skating. Binding releases for skis should be calibrated to the child’s skill level, height and weight each season.
The AAOS promotes the idea that “youth sports should always be fun. The ‘winning at all costs’ attitude of coaches, parents, professional athletes and peers can lead to injury.” Remember, having unrealistic expectations can lead a child to continue play despite warning signs of injury. This puts a child at increased risk. Lastly, the AAOS reminds us, “Coaches and parents can prevent injuries by fostering an atmosphere of healthy competition that emphasizes self-reliance, confidence, cooperation and a positive self-image.”
Pitching
limits for growing
children
and young adults
We have all heard the expressions: “His arm is burned out.” and “Be careful, or you might throw your arm out.” But what is this all about? In a young athlete, a “thrown out arm” could be a result of overthrowing due to an overzealous coach, parent or even the athlete him or herself trying to get around pitch counts. Sadly, this practice is wide spread. After all, who doesn’t want to win a tough game? Everyone thinks, “Why not use your best pitcher in a ‘pinch?’” “How can it hurt?”
Yet it can hurt. All young athletes are growing, and there are very delicate special areas of the bone that provide this growth. Immature cartilage expands and swells, and these cells are eventually replaced by new bone. This special area of bone is called the growth plate. It is vulnerable to stress and repetitive motion. If damaged, growth can be stopped or stunted. The soft cartilage around the growth plate can also crack and fail causing loose bodies (like OCD in the knee. See the chapter on loose bodies in the knee). These injuries can ruin even a bright pitching future and, in most of these cases, overthrowing or ignoring the pitch count is the major culprit.
What are some basic pitching rules?
No curve balls before age fourteen. No more than 75 pitches per game.
For younger players, no more that 5.5 pitches per year of age per game (a good rule of thumb). In young players, no more than 1000 per full season.
For older players (with more mature bones), no more that 2000 pitches per full season. No more than 8 months of pitching per year.
No dual seasons (pitching for more than one team in the same season, this is much more common than one may expect).
So with these rules, why are kids still getting hurt? Everyone likes to believe that his or her kid will become the next Tom Seaver, Nolan Ryan or Roger Clemens. The coaches know this and are taking their cue from the excited parents who truly believe his or her is kid is superman (or some other invincible comic character). The result is that they all want to illegally get around the rules, even when the leagues are highly supervised. So coaches and parents let them pitch all year round, “forget” the date of the last full game they pitched or worse, they stop pressing the pitch count button some place in the middle of the game so the count can be extended (this last one I would not believe if I had not seen it myself during a heated game between two local rival teams).
So what can we tell those parents and coaches? They need to know that the average age that most professional pitchers start pitching is 17.3 years old and many don’t even pitch before the end of high school or early in college. Over-pitching a promising ten year old has never resulted in a major-league star. Knowing this, dual seasons should be outlawed. A season off allows recovery of the growing areas of bone. In more mature players, above age 14, light lifting in season helps strengthen other muscles and prevent some injuries. But remember, heavy lifting can stunt growth and creates more slow twitch fibers as opposed to fast twitch muscle, which will decrease throwing speed. You can overdo lifting! Core and balance exercises are key to good form and help transfer force from the ground to the ball. This takes stress off the arm, elbow and shoulder (Tom Seaver’s legs were said to be like tree trunks). If form is an issue, have a pitching coach check it and make the needed corrections. Always pull pitchers if a pitch hits the ground in front of the plate or they throw over the backstop. These are certain signs the star pitcher is getting tired and an injury is right around the corner.
Knee Pain in Young Children and Teenagers
Pain in the front of the knee is one of the most common problems seen in young children and adolescents. The symptoms of possible knee injuries range from constant pain to pain only with heavy activity. The potential causes range from tendonitis to a growth plate injury. In this chapter, we will look at a number of these problems and their treatment.
Osgood Schlatter's disease
This is one of the more common causes of anterior knee pain in a growing child. It is likely to occur during sports that include running and jumping. It is most common in basketball because of the fast starts, quick stops and frequent jumps. These repetitive motions put weight on the kneecap (patella), the tendon attached to it (patella tendon) and its attachment to the tibia (the tibial tubercle). In children, the tibial tubercle is directly above a part of growing bone called a “growth plate”. The constant traction provided by some sports on this area can injure the growth plate under the tubercle. Repetitive injury causes the growth plate to stretch or enlarge, and the bone at the tendon attachment enlarges as well. When the growth plate is injured, the enlarged bone can be tender, and the plate itself can hurt when weight is put on it. This explains why going up or down stairs, kneeling, running or jumping can increase knee pain. The problem is caused by microscopic fractures in the growth plate. Furthermore, and with enough force, the tubercle can break on rare occasions. Sometimes a small part can break off, causing a separate piece of bone to form within the patella tendon. This can also be painful.
Treatment for Osgood Schlatter's (OS) disease
In general, early treatment for this problem is based on the level of symptoms present. If there is no bump, and it is only mildly tender over the tubercle, rest, ice and NSAIDs may be enough treatment. The patient can safely return to sports when his or her symptoms are gone. While the area is tender, the youth should avoid all activities that cause pain. This includes squatting, kneeling, running, stair climbing (particularly as an exercise), and jumping. The adage, “no pain, no gain,” does not apply here. In more moderated cases, there is a bump and a gap or a widening of the growth plate that can be seen on an X-ray. In these cases, the patient may benefit from immobilization with a knee immobilizer, then a rest period and a slow return to sports. In severe cases, when ambulation is painful, X- rays should be reviewed to be sure that there is no fracture. The exam should focus on the integrity of the patella tendon’s attachment to the bone. If this is compromised, it may need to be fixed, although
repair runs the risk of an early closure of the anterior growth plate and a slight risk of a back bowing of the tibia (recurvatum). Early treatment in all cases is best, and the patient’s vitamin and calcium intake should be reviewed as part of the history. Supplements should be given if his or her intake is poor, in order to help with the healing process. Chronic, recurrent cases of OS may require casting to rest the tissues and allow them to heal. In some of the cases in which it is a chronic problem, a small piece of bone may have broken off and embedded in the tendon. Later, and even as an adult, this fragment may become even more problematic. Removal of this fragment is occasionally needed.
Jumper’s knee
This is a similar problem occurring on the patella side, as opposed to the tibial tubercle side, of the knee. In this case, the traction causes the lining on the patella (its growth plate) to pull off the bone, causing pain and weakness. The traction causes new bone to form, just as it does in Osgood Schlatter's disease, only now on the tip of the kneecap. It is treated according to the symptoms as explained above. In rare cases, it can also be associated with a fracture, called a “sleeve fracture”. This is when a small fragment of bone with a sleeve of periosteum (membrane that lines the outer surface of the bone) pulls off the kneecap, weakening the attachment of the tendon and making use of the knee impossible. Operative repair is needed in severely displaced cases.
Patella tendonitis
This is the lesser of anterior knee pain problems. In this problem, the tendon that connects the tibial tubercle and the patella is inflamed. Once again, rest, ice and NSAIDs may be enough for treatment, and patients can safely return to sports when their symptoms are gone.
Growing pains
This is the term used by many to explain any knee pain in children. I believe in “growing pains” as its own diagnosis since rapid bone growth can cause pain as the soft tissues, tendons and ligaments try to catch up with it, particularly during a growth spurt. However, this diagnosis should only be used after a complete exam, including X-rays yields no concrete findings, like those mentioned in this chapter. NSAIDs, ice, rest and gentle stretching can help ease the pain.
Kneecap or patella femoral pain is discussed in the “Kneecap Pain and Dislocations” chapter.
Osteochondritis Dissecans
In Osteochondritis Dissecans (OCD), a fragment of bone below the joint surface loses its blood supply and, along with the cartilage covering it, separates from the rest of the bone. The bone fragment with its cartilage cover is referred to as the osteochondritis lesion. Without blood flowing, the bone under the surface is not viable. The synovial fluid of the joint can continue to nourish a broken fragment, and it may enlarge. The fragment can then cause locking of the joint, pain and swelling. Treatment of this problem depends on several factors: the age of the patient, the size of the lesion, its location, the condition of the bone base it came from and the extent it is still attached to the bone.
The most common place for OCD is the knee. The bottom of the thighbone (femur) is made up of two curved surfaces next to each other with a notch for the ACL and PCL in between. These surfaces are called the medial and lateral femoral condyles. The medial condyle is on the inner side of the knee, and the lateral is on the outer side. The condyles are covered with articular cartilage to ensure the smooth movement of the joint. OCD can occur in the lateral condyle or on the patella. However, the most common place in the knee is the lateral side of the medial femoral condyle, more towards the middle of the joint. This is because the inside of the knee bears more weight. The involved area is near a raised spot on the tibia called the tibial eminence. It is believed that loading and twisting causes the tibial eminence and femur to hit each other and microscopic fracturing to occur. If the injured area is under constant stress from weight bearing, running or repetitive trauma, it won’t have time to heal. The blood supply to the area fails, and the fragment loosens.
Still, even with a good theory, the exact reason for this disease and the associated bone break- down in any specific individual is often unknown. Most doctors believe that it is due to repetitive trauma, but an underlying vascular problem in the local bone under the lesion may have a role. It could also be from an unnoticed injury, steroid use, elevated blood fats or a genetic predisposition. It occurs commonly in older children or adolescents who participate in sports. Doctors also believe that the repetitive motion in sports can cause a small segment of the bone to fatigue and fracture under the surface. If there is continued micro-trauma from repetitive loading (for example, running on an already injured knee), it will prevent the defect from healing and again, loosen the bone fragment. This loose fragment causes swelling and pain. If the fragment comes off completely, it’s called a loose body. Loose bodies could get trapped in between the joint and cause locking of the knee. The defect, without the cartilage present, is not smooth, so the bones rubbing against each other could cause arthritis over time.
How will I know I have OCD?
If you have OCD, you will feel pain in the knee, especially after being active, and have some swelling. You may experience catching or locking and difficulty with full extension of the leg. If the fragment breaks free or enlarges, symptoms will only get worse over time. Eventually, it may become too painful to put any weight on the leg at all.
OCD is usually diagnosed with X-rays (including a special notch view). To stage a lesion and see if there is any bone damage or if there is fluid under the lesion itself, an MRI may be ordered. If there is fluid present, the cartilage is loose and surgery is required. Sometimes OCD is recognized when you are being tested for something else. In growing children, an early lesion that is not loose could heal with crutches, rest and a brace or cast. Again, in children as in adults, if the defect is displaced or loose, or if an MRI shows fluid under it, surgery may be necessary.
Treatment options
If the bone and cartilage aren’t completely detached from the bone, nonsurgical treatment may be appropriate. The younger you are, the more likely it will be successful. It may require up to six weeks of immobilization and using crutches so you don’t put any weight on the injured leg. It could take three months to heal so a brace can also be helpful. After casting you should avoid any activities that cause pain. Remember, after long periods of immobilization, a good physical therapy program to build the muscles around the knee is always important.
If conservative treatment is unsuccessful, the fragment is unstable or in an older patient, surgery is the best choice to restore the smooth surface. There are several options for surgery, depending on the state of the fragments. First, if the cartilage hasn’t broken loose, it can be drilled to stimulate a new blood supply, and it can be fixed in place using pins or screws that are sunk into the cartilage to hold it in place while it heals. If biodegradable pins are used, they do not need to be taken out. Some- times the damaged fragment may not fit perfectly back into place. The bone around the defect may have also changed, and the surgeon will therefore need to re-contour it, rebuild it or graft it. If the fragments are completely loose, fragmented or missing altogether, the surgeon might clear the cavity to reach fresh, healthy bone and attach a bone graft into position with screws or pins. If it is loose and can be replace the piece should be put back and fixed in place.
When there is complete bone loss, the bone may have to be replaced. It will usually be with a local autograft, an allograft (from a donor) or a scaffold material. An autograft (from your own body) works well, but there is concern about loss of cartilage at the donor site. The doctor will try to pick a non-weight bearing donor site that won’t cause any pain or further problems. Finally, fragments from smaller shallow defects that cannot be mended are cleaned, and the bone is drilled in order to stimulate new growth of cartilage. This is called the “micro fracture technique”. This has an advantage of not requiring a graft and has overall good clinical outcomes. The only down side is that the cartilage
that forms after micro fracture is fibrocartilage (scar cartilage), not true Hyaline cartilage (joint surface cartilage), and it has different properties than the natural joint surface.
When the option is to harvest bone that’s covered with undamaged articular cartilage from a non-weight bearing part of the body. Plugs of bone (like hair plugs) are moved to a new location. Lastly, cartilage cells can be harvested and grown in a laboratory to make healthy cartilage, which is then implanted. If the cartilage defect is very large and is severely damaged, it may need to be re- placed. Allograft cartilage that is fresh frozen may be needed. There are also other procedures being developed, for example, a “biological knee replacement”. In these procedures, the body’s articular cartilage and bone is harvested, mashed into a paste and put onto the part of body without cartilage to grow a new cartilage piece. This last option is very experimental and not generally available now. These last few options are for larger defects and the first option (bone plug grafting), along with micro fracture, are considered most frequently.
It must be noted that even if it’s treated, joint damage from an OCD lesion can lead to future joint problems (e.g., degenerative arthritis or osteoarthritis). However, with corrective surgery and once the bone heals completely, most people can return to normal activities.
Osteonecrosis
Osteonecrosis (also known as Avascular Necrosis, or AVN) means “bone death”. It is very similar to Osteochondritis Dissecans except that the cause is most often vascular in nature, instead of repetitive trauma; it involves the bone more than the cartilage surface at first. Like in OCD, it is most commonly located in the medial femoral condyle. It could occur on the outside of the leg (lateral femoral condyle) or near the upper end of the tibia as well. Osteonecrosis starts when a piece of bone loses its blood supply and starts to die. In time and untreated, loss of joint space or support for the cartilage occurs as the body reabsorbs the dead bone. It could end up involving the cartilage, as in a case of OCD. If the area collapses, it will resemble severe arthritis and be treated similarly. Women are three times more likely to get osteonecrosis, or AVN, than men are. Women over sixty are especially susceptible. AVN is most often the cause of OCD type lesions in adults and is extremely rare in children.
Doctors are at times unsure of how osteonecrosis develops in a given patient, although it’s associated with obesity, sickle cell anemia, lupus, kidney transplants and steroid therapy. It could be from coagulation problems, a genetic disorder called Gaucher’s Disease or an injury. Many people get it for an unexplainable reason. In those cases it is called SPONK (Spontaneous OsteoNecrosis of the Knee).
When you have osteonecrosis, you may experience pain and swelling. It will get worse after activity. When the bone segment involved is dying, the joint surface over it may start to collapse, causing a lot of pain. In early stages, the diagnosis can be made by a bone scan or an MRI. In later
stages, diagnoses can be easily made by an X-ray, particularly a standing knee film.
A bone scan is a special study that takes advantage of the element Technetium’s propensity to find and stick to bone proportional to the amount of blood flowing through it. A radioactive version of Technetium dye (Technetium 99) is injected into the blood stream. The dye is a very weak radioactive chemical so that the radiation exposure is minimized. Then pictures are taken of the bones with a special camera. This camera, like a Geiger counter, picks up very small amounts of radiation. Areas of bone that are undergoing rapid changes, such as a healing fracture, pick up more dye; bone with no blood supply shows no uptake. Because osteonecrosis is ‘cold’ (meaning there is no blood flow), a bone scan is the best way to see the lesions in the earliest stages.
Left untreated, osteonecrosis can cause severe osteoarthritis and a complete collapse of the bone. Sometimes it can heal on its own, but conservative treatment is necessary as well as modification of activities. Try RICE (rest, ice, compression and elevation) to help with the pain and swelling. Calcitonin is a nasal spray that slows down bone reabsorption and has been thought to be helpful. Complete unloading of the knee is helpful in SPONK, so using crutches, knee immobilizer and/or an unloader brace may be recommended.
Arthroscopic surgery in mild or early disease with debridement of the loose fragments can clean out the knee and make the bone smooth. The doctor may drill the dead bone in order to reduce pressure on the bone surface or stimulate new blood flow. Bone grafts could also help support the knee while the defect heals. In the end stages of the disease, the joint surface has collapsed and can require a knee replacement. In cases where patients may be too young for a knee replacement, an osteotomy, a wedge-shaped cut in the bone that alters the loading on the involved side of the knee by moving the weight from one side of the knee to the other, may help compensate for degeneration near the osteonecrosis lesion.
Knee
Locking, Buckling and Giving Way
Standing still, I turned to get something off a shelf behind me, and bam, my knee just went.” “Every time I get up from a squatting position, my knee won’t straighten.” “Going down stairs, my knee gives out. I just don’t trust it.” Frequently, statements like these are the first clue that a patient has an unstable knee. So why does this happen, and what should be done?
The knee is the joint connecting the femur (the thighbone) to the tibia (the shinbone). In the knee joint, the end of the thighbone is rounded, and the top of the shin is relatively flat. The two bones are very much like a rolling pin sitting on a narrow table. Given even a small push, the rolling pin will fall off. That’s why the knee’s cartilage and ligaments are so important. They hold the two together and still allow the knee to bend and straighten smoothly. Without the ligaments and the cartilage, we wouldn’t be able to run, jump, twist, turn, squat or pivot; and it’s when they are injured or not working properly that we have problems.
The examples above are stories of locking (the knee gets stuck in one position and won’t move), buckling (the knee is made unstable by a twist or a turn) and giving way (the force of a routine activity causes the knee to stop supporting the body’s weight).
Locking can be caused by a piece of torn cartilage (the meniscus) stuck between the bones. Until it’s pushed back into place, the knee remains locked and often difficult to straighten. This can be both painful and disabling.
If an examination is positive for signs of injury to the cartilage, a tear may be the reason for the problem. A Magnetic Resonance Image (MRI) or a diagnostic arthroscopy (looking into the knee with a fiber optic telescope) can show the cartilage tear so that the problem can be treated properly.
Giving way can be caused by a cartilage tear or a ligament problem. This is where the physician’s examination of the knee is key. Telling the difference can be difficult. This is especially true if the knee is swollen or painful, both common findings in a recent injury. Fortunately, there are specific clinical tests, parts of a good routine knee exam, to help us find the cause. Sometimes, special instruments like the KT-1000 (a very sensitive knee testing device that allows us to measure small movements between the femur and the tibia) can help us decide if one of the major ligaments, like the ACL (anterior cruciate ligament) or PCL (posterior cruciate ligament), is damaged.
Buckling can be caused by cartilage problems, ligament injuries or kneecap problems. The kneecap is part of the quads mechanism. This muscle and tendon unit allows us to kick, jump and squat. It also prevents us from falling when going downhill or down stairs. The body can sense when the kneecap is going to hurt and frequently causes the quads mechanism to release or give (hence the term give-way) to protect itself, and you, from pain.
Once your doctor makes the diagnosis, the treatment for these problems varies. They can in-
clude simple exercises, physical therapy, bracing and arthroscopy (fiber optic, outpatient surgery). The early correction of these mechanical problems can lead to a speedy recovery greatly reducing the risk of recurrence, future injury, long term problems and early degenerative arthritis.
“Water on the Knee”
Many times, patients will show up in my office with seemingly unexplainable swelling of the knee. When asked, there was no history of a fall or a twist. There was no trauma and no history of sports participation. In short, there is no mechanical reason (e.g., a ligament tear, unstable kneecap, torn cartilage, trauma or fracture) for the swelling. In these cases, we must look elsewhere for the cause of the problem.
To better understand the other sources of knee swelling, we must understand what makes the knee, or any joint, move so smoothly. The knee is well lubricated by a constant production of small amounts of fluid made by the lining of the joint. The lining is called the synovium, and the fluid is therefore called synovial fluid. The fluid is what enables the smooth motion of the joint. Conditions of the knee that irritate the lining cause it to make more fluid. If there is enough extra liquid in the knee, it will swell, hence the expression “water on the knee”. So what causes the lining to be irritated and make fluid, and, more importantly, what can we do about it?
Why does my knee make fluid and swell?
Most commonly, the knee makes fluid after an injury in an attempt to “solve” the “problem”. Like in any injury, if the knee is arthritic for any reason, it tries to fix the lack of smooth motion by making fluid. Therefore, the first cause of “water on the knee” can be just simple wear and tear (in the absence of trauma, a torn ligament or a cartilage tear). Removal of some of the fluid can help decrease the symptoms of water on the knee and yield important clues to its cause. In simple wear and tear, the fluid is clear yellow and a little like a very light syrup in consistency. In other conditions, it may appear cloudy, bloody or opaque. It may contain a high number of white blood cells, altered sugar and protein content, flecks of cartilage, crystals or bacteria. Sometimes, when the diagnosis is not clear, sending a sample of the fluid to the lab for testing is very helpful in finding the cause of the problem.
The lining itself can also be a direct cause of swelling. For example, if the knee accumulates crystals as it does in Gout, the crystals will cause the lining to become inflamed and make fluid, like sand in your gearbox. In Gout, there is a significant inflammatory response, and the synovium and white blood cells try in vain to digest the crystals. Unfortunately, they cannot, and in the process the white cells release destructive enzymes that slowly destroy the joint itself. In Rheumatoid arthritis, the swelling is caused by the body’s own immune reaction to cartilage, and the knee makes fluid. The lining in rheumatoid arthritis, as in other inflammatory arthritic conditions, can grow and worsen the situation. There are a whole host of diseases like this, and they can all be painful, cause swelling and ultimately the destruction of any joint that they involve. These include Psoriatic arthritis, that can be.
associated with even the smallest patches of psoriasis, Rider’s syndrome, Ankylosing Spondylitis and
Psuedogout (calcium pyrophosphate crystals instead of calcium urate) to name a few.
Infection is another cause of swelling. After a viral infection, there are syndromes associated with transient swelling of a joint, a viral synovitis. These are often self-limited. There are arthritic conditions associated with infection, like Lyme disease. This is the second phase of a three-part infection that starts with a local rash near the bite of a very small deer tick. In time, the spirochete infection can move to a joint and is associated with a relatively painless swelling. It may resolve without treatment, but that doesn’t mean the infection is cured. Untreated, it will return in its third phase, which involves the central nervous system. In this form, it can include seizures, heart rhythm abnormalities, coma and even death. Needless-to-say, it is important to recognize potential Lyme cases and treat them in one of the first two stages. Bacterial infections can occur after puncturing the joint with a small object. This can be a piece of dirt after a fall on the ground, a nail, a needle or a splinter. These can be urgent problems, and are associated with fevers, painful motion, significant swelling and redness.
Bleeding into the joint can also be another cause of knee swelling. In special situations, bleeding can happen with a minor trauma. People prone to this are on blood thinners, have bleeding disorders like hemophilia or sickle cell disease, have low platelet counts or poor platelet function. Sometimes chronic use of non-steroidal anti- inflammatory drugs (NSAIDs) in high doses or cancer chemotherapy can inhibit platelet function as well. Recurrent bleeding into a joint without one of these problems can be the only sign of another disease of the knee lining, PVNS (Pigmented Vilo-Nodular Synovitis, with MRI findings similar to the nodules seen in the example of psoriatic arthritis already shown, except for the additional finding of hemosiderin deposits, iron containing, deposits in the nodules).
PVNS is a thickening of the lining of the joint. It can occur in any joint but most commonly appears in the knee. It is seen equally in men and women and most frequently between young adult- hood and age forty. It is most often seen in one of three forms. The first is a single nodule of abnormal lining that has hemosiderin (the remains of hemoglobin from blood cells). The second involves a larger area of the lining. The third is considered a locally malignant form that can extend past the joint and into the local tissue. It is very rare (1/2,000,000 of the population) but can be destructive if not treated early and aggressively.
How do we treat non-traumatic knee swelling?
Many of the arthritic conditions are treated medically. In mild cases, the inflammations are often controlled with non-steroidal anti-inflammatory drugs (NSAIDs) like Motrin, Advil or Aleve. Swelling from mild to moderate degenerative arthritis due to wear and tear of the knee can also be treated with NSAIDs, glucosamine/chondroitin supplements, injections of cortisone and synthetic lubricant
Cortisone
Injections
If a steroid injection has been recommended for your condition, there are several things you should know about the use of these injections. There are many myths about their use, and the rumors are so common that many of my patients have an unwarranted fear of them. In the majority of cases, the proper use of these injects is both safe and effective for many conditions.
For the most part, a steroid injection is a safe, reliable method for resolving the inflammation, reducing the swelling and decreasing the pain of an affected area. Cortisone is a powerful anti-inflammatory drug similar to natural substances produced by your own body. When injected into the affected area, the irritation and inflammation can be reduced dramatically. This can pro- mote both short and, more importantly, long term healing. A misconception is that the injection is
simply for temporary pain relief. Our goal is actually long-term relief and, combined with the other recommendations, to hopefully cure the condition.
A steroid preparation, as used in our office, is mixed with a short, and sometimes long-acting, local Novocain-type anesthetic (Marcaine). We also add bicarbonate to reduce the acidity of the injection. This takes the sting out and helps the Lidocaine work faster. The injection, therefore, may bring immediate relief to your symptoms and last at least 6-8 hours after it is administered. The cortisone itself takes 7-10 days to achieve its full effect. Therefore, it may take time before your symptoms start to respond. There also may be a few days when your symptoms may worsen before they improve. For that reason, we recommend ice and an NSAID along with the injection and for several days after it.
There is a great difference between injecting Cortisone and taking Cortisone by mouth as a pill. Local injections of Cortisone, in general, have limited side effects on the body, mostly staying locally in the area injected. Still, diabetics may see a transient rise in their blood sugar; therefore, if you have diabetes, monitor your blood sugars and if there is a change, please let us or your diabetes doctor know. Less commonly, some patients can see an increase in appetite, heart rate, flushing of the face or an increase in energy level.
Side effects are rare. One third of patients get discomfort the night of the injection that usually will subside by the next day. Some people can get thinning of the skin or a change of pigmentation; these side effects occur in less than 5% of our patients. You should limit the number of cortisone injections to a given area of the body. In general, I do not recommend more than three injections to the same area in one year. If a third injection is being contemplated, your doctor
should be considering some other treatment and making further investigations (like more X-rays or an MRI). Infections are extremely rare after an injection, but even though the area will be prepared sterilely, they can still occur. If there is any concern for an infection (spreading redness, heat or
fever), you should contact your doctor’s office.
The
Cortisone
injection is but one component of your overall treatment, which may
include non-steroidal anti-inflammatory
drugs
(NSAIDS) and physical therapy.
After
your injection, you may resume normal light activities, but you
should avoid heavy activity for at least 7-10 days after the
injection.
Ice can help diminish discomfort from the injection or the underlying inflammation. Use it 15-20 minutes on, 15-20 minutes off and then on again with some type of thin cloth between the ice and your skin. Caution: Ice left on too long may cause frostbite.
Again, if there is any increased redness, swelling or pain at the injection site, or if you have a fever or chills or other concerns, please call your doctor’s office.
injection (Hyaluronan, the same substance that normally lubricates the joint, in a concentrated injection). In cases where weight is an issue, a weight loss program is very important. Most of these patients cannot control their weight on their own. When there is a mechanical deformity of the knee (bowed legs, a valgus knee, or knocked kneed, a varus knee), orthotics, braces and, in some selected patients, corrective surgery is helpful.
In more severe cases, when there is a synovial disease or a systemic inflammatory condition, like active Rheumatoid Arthritis, Psoriatic Arthritis or Ankylosing Spondylitis, oral and injected cortisone, immune system modulating drugs (like Methotrexate, Embrel, Anakinra, Remicade and Humira) and/or Disease Modifying Anti-Rheumatic Drugs (DMARDs, like Azulfidine, Plaquenil and Arava), along with a rheumatologist’s expertise to manage these treatments, are needed.
Acute Gout attacks are treated with anti-inflammatories, aspiration and/or injection of cortisone. Long term Gout is treated primarily by lowering uric acid levels in the blood. This is usually done with a medication called Allopurinol and a diet restriction of red wine and protein. Infections that are treated with antibiotics and acute septic arthritis may require emergent drainage as well as intravenous antibiotics.
Blood clotting disorders, like Hemophilia or platelet abnormalities, are most often treated with clotting factors or platelet replacement by transfusion. PVNS is treated by arthroscopic removal of the diseased synovium. The malignant form requires a total synovectomy and radiation therapy to prevent recurrence.
When is surgery helpful?
Arthroscopic removal of the lining (a synovectomy) in some inflammatory conditions has
been helpful. When it is done, a biopsy of the lining may also help make the diagnosis, like in PVNS.
This procedure is often enough to cure this type of PVNS. Removing all the lining tissue (a total synovectomy) can be required in the treatment of chronic Lyme arthritis. A total synovectomy can also reduce recurrent swelling and pain when the synovitis of conditions such as rheumatoid or psoriatic arthritis is resistant to medical therapy. Knee replacement can be considered in the final stages of the arthritic condition, when the cartilage has worn away and quality of life is decreased because of loss of knee function. With modern knee replacement surgery, the surfaces are replaced with metal or ceramic prostheses and often a plastic liner with very high success rates. Like after hip replacement surgery, the patient’s satisfaction after knee replacement is amongst the highest of all surgical procedures.
Pre-patellar Bursitis (“Nursemaid’s Knee”)
There are many bursas in the body. They serve as sliding surfaces between body parts to help them move smoothly. They are more commonly located between a tendon and a nearby bone. There are still some between the skin and bone, near joints that have a good range of motion. When a bursa gets inflamed, it rubs against the bone and swells. There is a bursa between the skin over the kneecap and the kneecap itself. When this particular bursa swells, it looks like there is something wrong inside the knee. Often there is nothing wrong inside the knee joint. This is truly what is meant by “water on the knee.” The water is in a sack in front of the patella and not in the knee at all. Most of the time, this bursa swells from continued kneeling and repeated mild trauma to the front of the knee at work, or repetitive motion involving the front of the knee. It was most commonly known as nursemaid’s knee. This is because the nursemaid spent a lot of time kneeling (washing the floor), and the swelling was characteristic of constant trauma to the bursa. It is also seen in carpenters, plumbers, carpet layers and other laborers.
Treatment
Nursemaid’s knee is treated first with rest, ice and NSAIDs. If those treatments fail, your doc- tor may try an aspiration of the knee and an injection of cortisone. In chronic cases, removal of the bursa may be necessary. I have had cases where a bursa had become infected after being puncture by a foreign object (like a tack or needle) left on the floor. In one rare case, a few grains of sand were embedded in the bursa after a fall in the dirt. Years later, the painful swelling refused to clear. This was due to an infection that was so mild, but chronic, because the bacteria that caused it only lived on the grains of sand. It just hung onto the sand and could not spread elsewhere. This was completely cured only after the foreign bodies (grains of sand) were removed.
In patients with occupations that require kneeling, like carpet installers and tile masons, kneepads are necessary to avoid these issues and should be worn at all times. Even those who wear the pads may still have bursitis that is very hard to treat because they continue to traumatize the area daily.
ACL Tears
The Anterior Cruciate Ligament, or ACL, is located in the center of the knee joint. It is one of the four major knee ligaments that control the hinge-like movement of the knee. This ligament pre- vents the tibia (shinbone) from going too far forward in relation to the femur (thighbone) during activity. Some consider it the most important ligament in the knee because it helps maintain the stability of the joint during pivoting and cutting activities (fast changes in direction) in sports. In the knee, the ACL sits in front of the Posterior Cruciate Ligament (PCL), and they physically form a cross. This is why they are called “cruciate” ligaments, which comes from the Latin word meaning “cross-shaped”. A tear of the ACL is one of the most common injuries in the knee, and it is especially a problem for female athletes (1.4 million women have torn their ACL in the last ten years, see “Female Athletes”).
The ligaments in the knee give it a certain set range of motion. A tear, or sprain, occurs when the knee is forced past that range. Most ACL tears come from twisting injuries. They could also occur from the tibia being pushed too far forward or the leg being suddenly over-straightened. A tear is most likely to occur during sports such as basketball, football, skiing and soccer. In those cases, the leg may be twisted while the foot remains planted, hyper extended in a direct hit or quickly forced forward by the back of a ski hitting a mogul top. An injury can also happen while running. The runner could turn too suddenly, stop short or land incorrectly from a jump. After a tear, the tibia can shift forward more freely and the knee will buckle more easily.