ACL INJURY TREATMENT
WHAT IS THE ANTERIOR CRUCIATE LIGAMENT (ACL)?
The anterior cruciate ligament, commonly known as the ACL, is one of the most commonly injured ligaments in the knee. Running diagonally through the middle of the joint, the ACL works together with three other ligaments to connect the femur (thigh bone) to the tibia (the larger of the two lower leg bones). A tearing of this ligament causes the knee to become unstable and the joint to slide forward. ACL injuries occur most often in athletes as a result of direct contact or an awkward fall. About half of all ACL injuries are also accompanied by damage to the meniscus, cartilage, bone or other ligaments in the knee.
CAUSES OF AN ACL INJURY
The ACL ligament most frequently tears as a result of a sudden turn or change of direction that causes the knee to twist or hyperextend. Such an injury most often occurs in sports that involve abrupt stops and changes in direction, such as tennis, football, soccer and basketball. It may also occur as a result of an automobile or skiing accident. Many ACL ligament tears also result from commonplace accidents like falling off a ladder or missing a step on a staircase.
RISK FACTORS FOR AN ACL INJURY
Women are more likely to experience an ACL tear than men, even when they are engaging in the same activities. This is because women have a strength imbalance in their thighs, with the quadriceps, the muscles at the front of the thigh, being more powerful than the hamstrings, the muscles at the back.
SYMPTOMS OF AN ACL INJURY
Signs of an ACL injury are difficult to ignore. These signs include:
- Popping sound as the ligament tears
- Immediate pain, swelling and instability
- Increasing swelling and pain following the injury
- Limited range of motion of the knee
- Tenderness at the site
- Inability to walk
Patients who are suspected of having ACL injuries should obtain medical attention immediately to avoid further joint damage.
DIAGNOSIS OF AN ACL INJURY
A physical examination for an ACL injury includes evaluation of swelling and tenderness, especially in comparison to the unaffected knee. It also involves moving the knee into different positions to assess possible ACL damage. For a definitive diagnosis of an ACL tear, imaging tests, including X-rays, ultrasound, MRI and CT scans, are administered so that the internal structure of the knee can be visualized.
TREATMENT FOR AN ACL INJURY
Patients who suffer ACL injuries must use crutches and possibly knee braces during the early stages of recovery. Depending on the severity of the injury, surgery may or may not be necessary. While not all ACL injuries require surgery, leaving the ligament torn or damaged puts the patient at risk for recurring episodes of knee instability. It may also increase the likelihood of developing tissue damage or arthritis over time. For athletes who want to return to high-risk sports, surgical reconstruction is always necessary.
Ligament tears cannot be repaired by simple reattachment. Normally grafting of part of another ligament, usually taken from the patient’s knee or hamstring muscle, will be used in the procedure. At times, the graft may be taken from a deceased donor. Physical rehabilitation is always necessary to restore strength, function and stability to the knee, whether or not the patient undergoes surgery.
KNEE ARTHRITIS
Arthritis is a condition that causes pain, stiffness and swelling in the joints. Osteoarthritis is the most common form of arthritis and it commonly affects the knees.
CAUSES OF KNEE ARTHRITIS
Arthritis of the knee may develop as the cartilage protecting the bones of the knee joint wears down over time. Over the years, as stress is put on the joints, cartilage wears thin and sometimes even erodes completely, resulting in stiffness and pain. Arthritis of the knee occurs more frequently in older individuals, however it sometimes develops in athletes from overuse of the knee joint or after an injury.
SYMPTOMS OF KNEE ARTHRITIS
Symptoms of arthritis of the knee may include pain, swelling and stiffness within the joint. Some individuals also experience a feeling of weakness in the knee that results in the knee locking or buckling. These symptoms tend to worsen after increased physical activity and as the condition progresses. Over time, as arthritis of the knee progresses, the knee joint becomes increasingly stiff and inflamed, difficult to move, and very painful, even when at rest.
HOW IS KNEE ARTHRITIS DIAGNOSED?
To diagnose arthritis of the knee, a doctor will review all symptoms and perform a physical examination. X-rays and other imaging tests are often used to assess the amount of damage to the joint.
KNEE ARTHRITIS TREATMENT
Treatment for arthritis of the knee initially focuses on relieving pain and addressing symptoms and is commonly treated with a combination of methods. Avoiding certain physical activities that place stress on the knee may be helpful. Medication may also be used to treat pain and may include:
- Anti-inflammatory medication such as aspirin, ibuprofen or acetaminophen
- Prescription pain relievers
- Corticosteroid injections
AVASCULAR NECROSIS
WHAT IS AVASCULAR NECROSIS?
Avascular necrosis, also known as osteonecrosis, is a disorder in which the bone does not receive enough blood, resulting in small breaks that can eventually cause it to collapse.
CAUSES OF AVASCULAR NECROSIS
Insufficient blood flow to a bone may occur as a result of a fracture or dislocation, excessive alcohol use, extended use of corticosteroids, or certain diseases that impede blood flow, such as sickle cell anemia, diabetes, lupus, Gaucher disease and HIV. Medications taken for osteoporosis or bone cancer, called bisphosphonates and radiation therapy also increase the risk of a patient developing avascular necrosis. The condition can occur in numerous joints, but it most commonly affects the hip.
WHAT ARE THE SYMPTOMS OF AVASCULAR NECROSIS?
In the early stages of avascular necrosis, patients may be asymptomatic. As the disease progresses, patients typically experience pain and a diminished range of motion in the affected area. In addition to occurring in the hip, this disorder can affect the knee or shoulder, feet, ankles, spine, jaw or wrists.
The pain from avascular necrosis may begin as mild discomfort, experienced only when joint is weight-bearing. Over time, however, the pain will become more severe and the patient may experience pain even when at rest. The pain associated with avascular necrosis of the hip may radiate into the thigh, buttock or groin. It is not unusual for some patients to experience bilateral pain from the condition, such as in both hips or both knees.
HOW IS AVASCULAR NECROSIS DIAGNOSED?
In order to diagnose avascular necrosis, a thorough review of the patient’s medical history and a full physical examination of the patient are necessary. Because joint pain can be caused by a variety of conditions, imaging tests are normally administered as well, such as X-rays, MRI, CT or bone scans.
AVASCULAR NECROSIS TREATMENT OPTIONS
There are several treatments available for avascular necrosis. Some are designed to reduce inflammation and relieve pain and some are recommended as a means of improving the patient’s condition or preventing further bone deterioration. Rest, at times including the use of crutches, is usually the first treatment prescribed, followed by one or more of the others listed below.
MEDICATIONS
Patients with avascular necrosis may be advised to take:
- Over-the-counter anti-inflammatories
- Medications normally prescribed for osteoporosis
- Cholesterol-lowering drugs
- Anti-coagulants (blood thinners)
The last two on this list may be of help in keeping blockages that interfere with blood circulation from occurring and so assist the bones in receiving proper nourishment.
PHYSICAL REHABILITATION
Physical therapy may be useful during the early stages of avascular necrosis. Such rehabilitation efforts may include exercises to maintain range of motion and electrical stimulation of the affected area.
SURGICAL PROCEDURES
Most patients don’t have symptoms of avascular necrosis until the condition is well-advanced, at which point surgery may be necessary. Procedures performed to help patients with avascular necrosis include:
- Core decompression
- Bone transplant
- Joint replacement
Of these three surgical procedures, joint replacement is the most complex operation, usually requiring the lengthiest rehabilitation. It is also the procedure most likely to provide a permanent solution to the problem.
While patients with mild, early stage avascular necrosis may be helped by noninvasive treatments, for most patients the disorder requires surgical intervention.
ILIOTIBIAL BAND SYNDROME
The iliotibial band is a band of tissue that runs along the outside of the leg from the hip to just below the knee, providing functionality and stability to the knee joint and surrounding area. Iliotibial band syndrome occurs when this band becomes so tight and inflamed that it rubs against the outer portion of the femur, causing irritation and instability to the knee joint. Also known as IT band syndrome, this condition often occurs in people who are physically active, such as runners or cyclists.
SYMPTOMS OF ILIOTIBIAL BAND SYNDROME
Frequent bending of the knee during physical activity may result in the symptoms of IT band syndrome, which may include:
- Pain on the outside of the knee
- Hip pain that comes and goes
- Swelling of the knee
Pain may worsen with movement and improve with rest.
DIAGNOSIS OF ILIOTIBIAL BAND SYNDROME
IT band syndrome is diagnosed after a physical examination and review of symptoms. An MRI scan may be performed to confirm a diagnosis of this condition, as MRI images may show a thickening of the band, which is often the cause of irritation.
TREATMENT OF ILIOTIBIAL BAND SYNDROME
IT band syndrome is often treated with conservative methods to reduce pain and swelling and may include:
- Applying ice to the affected area
- Anti-inflammatory medications
- Rest
Stretching exercises are also recommended and physical therapy can help individuals to strengthen muscles and develop methods for exercises to prevent further injury. Cortisone injections may be beneficial if pain does not subside, and in severe cases, surgery may be recommended.
TENDONITIS
Tendonitis is an inflammation of one of the tendons, the soft flexible cords of tissue that connect muscle to bone. Such inflammations can occur as a result of overuse or traumatic injury. Tendonitis can occur anywhere in the body, but most often occurs in joints such as the shoulder, knee, wrist, ankle and elbow.
CAUSES OF TENDONITIS
Although tendonitis may occur because of a sudden injury, it is much more frequently the result of repetitive stress. Commonly, the condition occurs when an individual makes repetitive motions almost daily because of occupational or athletic pursuits. Tendonitis more often occurs as individuals age and their tendons become less flexible.
People whose employment involves frequent overhead reaching, vibration, repetitive motions or forceful or awkward positions are also at greater risk. Involvement in certain sports also makes individuals more likely to suffer tendonitis. Participants in baseball, basketball, golf, bowling, swimming, tennis an running are particularly vulnerable. Various forms of tendonitis are sometimes known colloquially by the sports that commonly result in the injuries, such as tennis elbow or pitcher’s shoulder.
Taking prescribed antibiotics in the fluoroquinolone family, such as Cipro and Levaquin, also presents a serious risk of tendon injury for which the FDA now requires a “black box” warning.
SYMPTOMS OF TENDONITIS
Symptoms of tendonitis include aching pain, tenderness to the touch, and sometimes mild swelling of the area. These symptoms are typically exacerbated by movement.
DIAGNOSIS OF TENDONITIS
The broad term for these tendon conditions, which include chronic tendinosis as well as tendonitis, is tendinopathy. Particular tendon disorders are diagnosed through physical examination, X-rays and other imaging tests. Since untreated tendonitis can lead to tendinosis, a chronic and degenerative condition, tendonitis that lasts for more than a few days, should be diagnosed and treated promptly.
TREATMENT OF TENDONITIS
If tendonitis is severe and leads to the rupture of a tendon, surgical repair may be required. In most cases, however, tendonitis can be successfully treated with rest, medications to reduce pain and inflammation, and physical therapy.
Physical therapists, in addition to helping patients strengthen their muscles and stretch to increase flexibility, are often helpful in guiding patients to more efficient movement patterns so they can avoid stressing joints and tendons in the future. Exercises to assist contraction while simultaneously stretching the muscle (eccentric stretches) have been demonstrated to be especially effective in treating muscle-tendon inflammation.
KNEE ARTHROSCOPY
Arthroscopy is a minimally invasive procedure that allows doctors to examine tissues inside the knee. During an arthroscopic procedure, a device known as an arthroscope is inserted into a small incision in the knee. Through this tube, a thin fiberoptic light, magnifying lens and tiny video camera are inserted, allowing the doctor to examine the joint in great detail. Arthroscopy may be a diagnostic procedure following a physical examination and imaging tests such as MRI or CT scans or X-rays. It may also be used as a method of treatment to repair small injuries in the knee.
KNEE ARTHROSCOPY AS TREATMENT
Relatively minor knee damage is frequently treated using arthroscopic techniques. Most knee damage results from sports injuries or osteoarthritis. During an arthroscopic procedure, the surgeon may be able to treat:
- Loose bone or cartilage
- Meniscal tears
- Torn ligaments
- Synovitis (swelling of the joint lining)
- Misalignment of the patella (knee cap)
- Inflamed tissue
In patients with osteoarthritis of the knee, arthroscopy is also used in the removal of dead tissue, a process known as debridement.
BENEFITS OF KNEE ARTHROSCOPY
Because it is minimally invasive, arthroscopy offers the patient many advantages over traditional, more invasive, surgery. These include:
- No cutting of muscles or tendons
- Smaller incisions
- Less bleeding during surgery
- Less scarring
- Shorter recovery time
- Shorter and more comfortable rehabilitation
CANDIDATES FOR KNEE ARTHROSCOPY
Knee arthroscopy is quickly becoming the ideal procedure for many conditions affecting the knee. Its minimally invasive advantages allow patients to receive fast and simple pain relief, increased range of motion and restored function, while avoiding or delaying the need for joint replacement surgery. Despite its many advantages, arthroscopy is not appropriate for every patient. Some patients, especially those with knee problems that are in difficult-to-see areas, may benefit more from conventional surgery.
THE KNEE ARTHROSCOPY PROCEDURE
Knee arthroscopy is performed on an outpatient basis under local or general anesthesia, depending on the type and severity of the condition, as well as the patient’s personal preference. During the procedure, the surgeon inserts the arthroscope into the knee through a tiny incision. This instrument is used to identify any damage or abnormalities within the knee, or to confirm the diagnosis of a previous imaging exam.
If damaged areas are detected, they can be repaired during the same procedure by inserting surgical instruments into additional small incisions.
RECOVERY FROM KNEE ARTHROSCOPY
After a knee arthroscopy , patients often experience swelling and pain for several days. These symptoms can be controlled by the usual home remedies: resting and elevating the leg, applying ice and taking over-the-counter painkillers. Patients are encouraged to get up and walk around as soon as possible after the procedure, although crutches or a cane may be needed for some period of time.
Most patients can usually return to work within a week, but will need to undergo physical therapy in order to restore full range of motion to the joint. Most patients can resume light physical activities after a few weeks, although full recovery from knee arthroscopy may take 12 weeks or longer.
RISKS OF KNEE ARTHROSCOPY
While knee arthroscopy is considered safe for most patients, there are certain risks associated with any surgical procedure. These risks include: infection, blood clots, accumulation of blood in the knee, nerve damage or adverse reactions to medications or anesthesia. In the great majority of cases, the knee arthroscopy goes smoothly.
TOTAL KNEE REPLACEMENT
WHAT IS A TOTAL KNEE REPLACEMENT?
WHAT CAUSES KNEE PAIN?
Chronic knee pain is often caused by arthritis. There are various types of arthritis, but three types have been associated with potentially debilitating knee pain. These include:
OSTEOARTHRITIS
This condition is related to the wear and tear on the joints over time. Related to age, osteoarthritis is typically diagnosed in adults over the age of 50 but can occur at a younger age. Pain occurs when the cartilage that pads the knee joint degrades. This results in pain and stiffness in the knee.
POST-TRAUMATIC ARTHRITIS
This type of arthritis is a byproduct of an injury to the knee joint. Injury may have initially damaged a ligament or tendon or may have fractured a bone. These types of injuries can lead to damage to the articular cartilage, resulting in a limited range of motion and pain.
RHEUMATOID ARTHRITIS
This form of arthritis is inflammatory and related to the immune system. It is a chronic disease that causes the body’s immune system to attack and degrade the joint surfaces. Chronic inflammation results in pain, swelling, and damage to the cartilage.
WHAT CONDITIONS MAY CAUSE THE NEED FOR A TOTAL KNEE REPLACEMENT?
Osteoarthritis is the most common condition that leads to a need for total knee replacement. However, any form of arthritis can eventually result in the need for joint replacement.
WHAT ARE THE SIGNS OF NEEDING A KNEE REPLACEMENT?
If you are experiencing knee pain and stiffness that inhibits your daily activities, see an orthopedic specialist. Signs that knee replacement surgery may be needed include:
- Limitations in daily activities such as climbing stairs, walking and getting in and out of chairs indicating that the knee joint may need repair.
- Moderate to severe knee pain when at rest. Knee pain that wakes you up at night.
- Deformity of the leg, such as bowing of the knee.
- Chronic pain and swelling that does not improve with medication and rest.
- Conservative remedies like medication, rest, injections, and physical therapy are not improving comfort and range of motion.
HOW SUCCESSFUL IS A KNEE REPLACEMENT?
Studies suggest that more than 90% of knee replacement procedures are successful in the goal of reducing pain and improving mobility and quality of life.
HOW LONG WILL A KNEE REPLACEMENT LAST?
The new knee joint can last many years. Although every case is different, it is not unusual for artificial joints to last more than 25 years.
WILL I EVER NEED A SECOND KNEE REPLACEMENT?
If a joint breaks down or fails over time, it can be revised (or replaced with a new implant), although the majority of joint replacements performed are never revised. Normal daily activities will gradually degrade the joint. This process may be accelerated by excessive weight or the routine performance of high-impact activities. After a knee replacement, many doctors advise against jumping activities, running, and high-impact sports. Those who undergo knee replacement can expect to comfortably walk, swim, golf, dance, bike, hike, and enjoy low-impact sports. Many joint replacement patients maintain a very high level of activity.
HOW IS A TOTAL KNEE REPLACEMENT PERFORMED?
Knee replacement surgery is generally performed in a hospital operating room or an ambulatory surgery facility. During the procedure, diseased bone and cartilage are removed from the knee joint (where the femur and tibia meet). The surfaces that have been removed are replaced with a metal implant. A special plastic implant is normally placed at the backside of the kneecap and also in between the two metal parts of the artificial knee joint. The metal and plastic restore the smooth surface of the knee joint to support flexion and comfortable bending. Due to advances in joint replacement surgery, an increasing number of joint replacement procedures are now being done ambulatory, allowing patients to return home on the day of surgery.
HOW LONG IS RECOVERY AFTER KNEE REPLACEMENT SURGERY?
Patients who have their knee replaced in the hospital typically stay over one night or two. Recovery and rehabilitation are critical aspects of returning to an active lifestyle, so physical therapy usually begins the day following surgery. At discharge, patients are able to stand on their own with no assistance. They are able to use the bathroom, bathe, and dress and go on slightly longer walks. Patients also are able to climb and descend stairs by the time they are released from the hospital. With consistent work, many normal activities can resume in the 12 weeks after knee replacement.
WHAT IS THE IMPORTANCE OF PHYSICAL THERAPY AFTER KNEE REPLACEMENT?
Rehabilitation is one of the most important aspects of total knee replacement. Proper care is essential to restoring optimal comfort and range of motion. The purpose of physical therapy after total knee replacement is to regain strength and movement. Initially, patients may need a walker but most progress quickly to a cane and are able to abandon all assistive devices within a few short weeks.
DIAGNOSIS, SYMPTOMS, & TREATMENTS FOR MCL SPRAINS
WHAT IS THE MCL?
The collateral ligaments are located on the sides of the knees. The medial collateral ligament (MCL) is located in the knee, connecting the inner side of the thigh bone to the shin (tibia) bone. The MCL helps the knee to resist force and keeps it stable against unusual movement. The collateral ligaments also control the sideways motion of the knee. This ligament may become torn or damaged as a result of direct impact to the outside of the knee. An injury may cause the MCL to loosen, stretch and possibly tear, resulting in pain and inflammation.
WHAT ARE THE SYMPTOMS OF AN MCL SPRAIN?
Patients with an MCL sprain may experience the following symptoms on the inside of the knee:
- Pain
- Tenderness
- Swelling
After an MCL sprain, individuals may also experience, instability, or the feeling that the knee is going to give way.
TYPES OF MCL SPRAINS
An MCL sprain is diagnosed through a physical examination of the knee. Additional imaging tests may include an X-ray or MRI scan. The doctor determines the grade of the MCL sprain based on the extent of damage, which may range from a mild tear to a complete rupture. MCL sprains may be classified as:
- Grade 1 sprains occur when the ligament is mildly damaged
- Grade 2 sprains occur when the ligament has been stretched and loosened
- Grade 3 sprains occur when the ligament is completely torn
Grade 2 sprains are commonly referred to as a partial tear of the ligament.
HOW IS AN MCL SPRAIN TREATED?
Treatment for an MCL sprain varies based on the severity of the injury, but it can normally be treated with conservative methods that include:
- Rest
- Ice
- Compression
- Elevation
- Knee brace
A physical therapy program may help to strengthen and restore function to the knee. In severe cases, when the ligament has torn completely and not healed properly, surgery may be necessary for repair.
POSTERIOR CRUCIATE LIGAMENT
WHAT IS THE POSTERIOR CRUCIATE LIGAMENT?
The posterior cruciate ligament (PCL) is one of four ligaments that helps support the knee and protects the shin bone (tibia) from sliding too far backwards. The cruciate ligaments are located inside the knee joint and cross over each other, forming an “X”. The anterior cruciate ligament is in the front and the posterior cruciate ligament is located behind it in the back of the knee. These ligaments control the back and forth motion of the knee.
CAUSES OF A PCL INJURY
Injury to the PCL most commonly occurs when the knee is bent and an object strikes the shin, pushing it backwards. This is commonly referred to as a “dashboard injury” because it often happens during a car accident when the shin is forcefully pushed into the dashboard. A PCL tear may also be caused by a sports injury or a fall. In many cases, a posterior cruciate ligament tear occurs along with injuries to other parts of the knee, including other ligaments, cartilage and and bone.
SYMPTOMS OF A TORN PCL
Individuals with PCL tears may experience pain,swelling and limited range of motion within the knee. Some people may also experience a feeling that the knee has popped or given out, as it causes instability within the joint. In most cases, a PCL tear will make it difficult to walk.
HOW IS A PCL TEAR DIAGNOSED?
A PCL tear is diagnosed through a physical examination of the knee. Additional imaging tests may include an X-ray or an MRI scan which can show clearer images of a posterior cruciate ligament tear and help to determine if other knee ligaments or cartilage are also injured. A diagnostic arthroscopy may also be performed to view detailed images of the tear.
PCL TEAR TREATMENT OPTIONS
Treatment for a PCL tear varies based on the severity of the injury, but it is commonly treated with conservative methods that may include:
- Rest
- Ice
- Gentle compression
- Elevation
- Immobilization with a knee brace
A physical therapy program may help to strengthen and restore function to the knee. If there is significant swelling that interferes with the mobility of the knee, a joint aspiration procedure may be performed to drain any excess fluid from the joint. In severe cases, when the ligament has torn completely and not healed properly, surgery may be necessary to repair or rebuild the ligament.