Comprehensive Care for Your Knees
Knees are among the most commonly injured joints in sports – especially those sports that involved pivoting or quick start and stop. We treat the following knee injuries and conditions:
ACL Injury - Complete Tear
The ACL is very important for rotational stability of the knee. When injured, most patients feel a sense of giving way or experience a pop. Usually the knee begins to swell within a few hours. When tears are complete, most patients will not be able to return to pivoting sports. Some will experience instability even with daily activities such as getting out of a car or stepping off of a curb.
Diagnosis is best made with a thorough examination and is usually supported with an MRI. The MRI also allows for evaluation of additional injuries to the articular cartilage and to the meniscus structures.
Surgical reconstruction is often recommended for those who wished to return to pivoting sports and for those who have not regained stability with physical therapy. There are several graft options for this procedure. The most common involves using a central strip of the patellar tendon. This has the advantage of having bone at each end of the graft which heals readily within the tunnels created during surgery. Use of a hamstring tendon graft is also common and has the advantage of being a little less invasive. Allograft or cadaver tissue has also been utilized especially in more mature patients, but there is now some evidence which raises concerns about loosening over time.
The timeframe to return to one’s activities is often one of the most pressing issues brought up by patients who have had this injury. Much like with surgical technique, there have been many improvements in the rehabilitation process and decisions regarding return to sports. These days, the criteria for returning to sports involves an assessment of strength symmetry and knee control rather than simply using the number of months from surgery.
ACL Injury - Partial Tear
Injuries to one portion of the ACL can also occur. Some of these will behave like complete tears while others may be more of a mild strain. Many of the milder injuries are amenable to nonsurgical treatment provided that there is excellent dynamic stability and strength. There are now some interesting, less invasive options for the more significant partial tears which include modern repair and augmentation techniques, synthetic scaffold materials and cell-based treatments.
ACL Injury - Combined or Multiple Ligament Tear
Tears of the ACL combined with other ligament tears are much more significant injuries. These can result from complete dislocations of the knee (which should not be confused with patellar dislocations). Treatment of these is most often surgical and typically has a longer recovery with less optimism for return to preinjury activities. However, again with modern techniques, results are more promising.
ACL Injury - Childhood or Adolescent Injury
When these injuries occur in patients who have significant growth remaining, special considerations and adjustments must be made. In the past, these kids were held out of organized sports until maturity. Unfortunately, many of these normally very active patients suffered additional injuries during less-organized “backyard” activities. Thus, surgical treatment may be preferable for many of these patients. The surgical procedures must protect the remaining growth by avoiding grafts that will “tether” the growth plates and in some cases completely avoid the growth plates.
The menisci are fibrocartilage structures that provide some cushioning and also help provide some stability to the knee. Some tears come from a single traumatic injury but most tears come from accumulated microscopic damage.
Flap Tears, Radial Tears, Horizontal Tears
These are the most common types of tears. They usually cause mechanical symptoms like sudden sharp pains, pain with twisting, or catching and even locking. Many patients will feel the knee become filled with fluid called an effusion. Most of these can be treated according to the symptoms present. But since these structures do not have much healing capacity, the symptoms tend to persist on an intermittent basis and arthroscopy is often needed. Generally, the recovery is relatively simple compared with other orthopedic surgical procedures. In most cases weight-bearing is as tolerated. If arthritis is present, this may significantly affect the results of arthroscopy.
Acute tears near the periphery of the meniscus may be amenable to suturing or repair. Tears in this area do have a blood supply and therefore have the potential to heal. These usually occur in younger patients and often in combination with ACL injuries. Recovery after repair is much longer than meniscus trimming (partial meniscectomy).
These tears occur near the meniscus attachment to the bone. Because these tears allow the meniscus to splay (spread out), they are highly associated with the development of arthritis. This is similar to many years ago when the meniscus would be completely removed. If a root tear occurs and arthritis is not present or is minimal, a root repair can be performed. This has a significant recovery process similar to other meniscal repairs.
The smooth cartilage on the end of the bone (articular cartilage) can break off leaving a “pothole” in the cartilage. Depending on the size of the defect, there are several options for treatment. While this tissue does not have much inherent healing potential, some defects can be treated without surgery as long as there are not mechanical symptoms such as catching, locking or swelling. Many of these may be amenable to techniques where the underlying bone is stimulated to fill in the lesion (microfracture or picking). Larger defects with symptoms may require more significant procedures such as the use of a bone and cartilage plug called an osteoarticular graft. There are also options to use membranes with cells in an effort to grow cartilage within the defect.
When cartilage breaks off it can create a loose body or chip in the knee. Most of these cause locking and swelling and usually need to be removed. Usually loose body removal is done through a scope procedure and at the defect is typically treated at the same time. The recovery of this depends primarily on the size of the defect treated.
Osteochondritis Dessicans (OCD)
Spontaneous defects of cartilage and bone can occur in late childhood through adolescence. In younger patients with this condition where there is still significant growth remaining, some will heal without surgery. In patients where growth is nearly complete or where there are loose fragments, the surgical options are similar to those for cartilage defects described above.
Patella (kneecap) Injuries/Disorders
Patellar dislocations occur when the patella comes out of its groove on the femur. Subluxation refers to when the patella partially comes out of the groove but comes right back. This happens mostly in adolescent years but can happen to most anyone with certain twisting injuries. One of the biggest problems is the potential for this happening repeatedly (recurrence) as well as damage to the cartilage and ligaments. Some of these can be treated with a rehab program if there are not loose bodies present. Recurring dislocations and subluxations can be treated with surgery. The most common procedure involves reconstructing the medial patellofemoral ligament (MPF L). But there are many factors that contribute to patella stability including hip and femur alignment, general looseness of the joints, muscular angles and strength and neuroprotective reflexes.
Patella Tracking Problems/Chondromalacia
How the patella glides within its groove cannot only lead to patellar instability but can also lead to pain and premature cartilage wear called chondromalacia. These issues are often looped together as anterior knee pain. Most of these conditions can be treated non-surgically but severe or persistent cases may be treated with surgery. These procedures can range from a relatively simple arthroscopic lateral release (which is simply a pressure relieving measure) to similar operations as those for patellar dislocations. The rehab for these conditions is usually extensive regardless of whether surgery is performed.
Patellar Tendon/Quadriceps Tendon Tears
The quadriceps tendon (deep tendon above the kneecap) or the patellar tendon (tendon below the kneecap) can rupture when one lands from a jump or stumble. These occur mostly in middle-aged males. Full-thickness tears usually require surgical repair. These large tendons have relatively poor blood supply and can have very slow recovery and return to sports. This can be improved with modern repair techniques and a full commitment to the rehab process.
Other Ligament Tears
Injury to the other three main ligaments of the knee are much less common and are often very serious. Posterior cruciate ligament (PCL) injuries can occur from a direct blow to the knee or upper shin area. They also occur as part of a knee dislocation. When isolated, PCL tears are mostly treated without surgery. Severe grade 3 or combined injuries can be treated with reconstruction. Similarly, injury to the medial collateral ligament (MCL) or to the lateral collateral ligament (LCL), when isolated, are mostly treated non-surgically. But again, severe injuries may require surgery. Historically, these have a long recovery but with modern surgical techniques and rehab, results are more promising.
Other Areas of Knee Treatment
- Knee Tendonitis
- Osteonecrosis (Avascular Necrosis)
Advances in Knee Care
- Ligament augmentation
- Cell based treatment
- Growth factors (PRP)