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Part of the body

KNEE

This articulation is the most complex joint of the human body. Its proper functioning is a complex phenomenon and is the result of flawless coordination of all of its parts below.  Knee joint anatomy:

  • femur
  • tibia
  • patella
  • inner / outer meniscus – contact bodies influencing the correct function (meniscilateralis et medialis)
  • cartilages – cover the joint surfaces
  • internal and external lateral ligaments (ligamentum colaterale mediale et laterrale)
  • cruciate ligaments, front and back (ligamentum cruciatum anterior et posterior)

Pain in the area of the knee joint

The inside of the knee contains a synovial tissue that produces fluid reducing joint friction and contributing to cartilage nutrition. The menisci are imaginary pads of a fibrous nature, which are on the sides of the contact joint surface of the tibia, where the femoral condyles abut. Simply put, menisci really work like such pads, they line the articulation surfaces and prevent increased pressure and contact between the joint surfaces.

The joint stability is ensured by:

  • Static stabilizers – ligaments and menisci
  • Dynamic stabilizers – composed of joint muscles (especially quadriceps muscle and hamstrings).

As a result of frequent injuries to soft knee joints structures and significant load, signs of degenerative affection (osteoarthritis) are often found on the knee joint.

The main causes of knee pain can be divided into two main categories:

  • Injury of soft knee structures (especially of traumatic origin)
    • Injury of menisci
    • Injury of cruciate ligaments
    • Injury of lateral ligaments
    • Cartilage injury
    • Pain in patella
  • Arthritis of the knee joint (especially of degenerative origin)

 

Injury of menisci

What is it?

Menisci constitute soft structure to form a contact surface between femur/tibia.  Menisci compensate for the unequal curvature of the contact surfaces of the joint (so called incongruence), whereby they reduce the joint load and act as a sort of a “bumper” in the movement of the knee. They also have a stabilization function. They have a half-moon shape, they extend towards the circumference of the articulated surfaces and they are fixed into the articular capsule. Injury or tearing of the meniscus often occurs when the knee is rotated in combination with another movement.

  • The inner meniscus (meniscus medialis) is larger, having a half-moon shape and its tips are attached to the surface in front of and behind the intercondylar eminence. It does not cover the entire area of the inner condyle and leaves a deep oval flat surface in its center. Injuries to the internal meniscus occur more frequently (in 85%) due to a reduced mobility.
  • The outer meniscus (meniscus lateralis) is almost circular. Its front tip is attached close to the front cruciate ligament. It covers almost the entire area of the outer condyle of the tibia. The outer meniscus is highly mobile and injuries of the same are rare (15%).

Symptoms

As a result of the accident, a sharp pain occurs, often a rupture, a skirmish or skipping is heard, the knee can buckle. Your knee may remain locked – it cannot be fully stretched. This condition is followed by swelling and an effusion in the knee joint.

Diagnosis

Correct diagnosis requires an outpatient orthopaedic examination. It is important to describe the injury mechanism properly and to perform a complementary examination. The menisci are not visible on an X-ray image, but in some cases the x-ray imaging is beneficial. Ultrasound examination of menisci is also beneficial, but not entirely reliable. The most accurate examination method is the nuclear magnetic resonance, but it is also not absolutely foolproof.

Treatment options

When a meniscus rupture is detected, arthroscopy is indicated by default in which the injured part of the meniscus is removed. During this surgical intervention, the essential part is removed, the meniscal function will not be significantly affected after only a partial removal. By removing the entire meniscus, its “bumper” function is impaired and in the future there may be a faster development of cartilage wear and knee arthritis. Arthroscopic examination determines the extent of the affection and eliminates other injuries to the knee joint structures.

 

If the meniscus is damaged in a well perfused area, arthroscopy allows for it reconstruction. After arthroscopy, the operated limb is relieved, cooled and subjected to positioning. After the stitches are removed (10th day after surgery), controlled outpatient rehabilitation and physical therapy is started, the knee is exercised, including the thigh system. A month after the surgery the patients are able to walk normally, sports activities are allowed 6 weeks after surgery.

Injury of knee cruciate ligaments (LCA)

What is it?

The cruciate ligaments (front and rear) provide passive anterio-posterior knee joint stability. This stability is actively supported by the thigh muscles – flexors and extensors. The anterior cruciate ligament (LCA) is the major knee joint stabilizer and its damage causes a disruption to the knee stability. Its injury occur much more frequently. Chronic instability may lead to development of degenerative changes.

Symptoms

The injury of the anterior cruciate ligament occurs with the forced abduction and rotation of the crus, most often in contact sports, or when skiing. Patients often report an audible crack in the knee joint, dislocation of the knee, swelling and oedema.

Diagnosis

Diagnosis of the cruciate ligament injuries is determined by assessment of the injury mechanism, clinical orthopaedic examination, complementary imaging methods and possibly arthroscopy of the knee joint.

This is always complemented by an X-ray image in the anterior and posterior projection to exclude a fracture in the knee joint. In the event of an ambiguous clinical finding, it is advisable to subject the patient to an MRI examination with all soft tissues of the knee. Because even the MRI is not fully foolproof, a cracked anterior cruciate ligament is occasionally diagnosed only during an arthroscopy.

Treatment options

  • Post injury – when the knee is swollen and exudated, we perform blood puncture from the knee, we attach a short-term orthosis, we recommend to relieve load with crutches for the period of the knee swelling, intensive ice cooling, initiation of anti-oedematic physical treatment. An enzyme therapy is appropriate for resuscitation and acceleration of recovery.
  • Post swelling – the patient is sent for rehabilitation and physical therapy, it is necessary to strengthen the muscular apparatus. When deciding on further therapeutic procedure using conservative or surgical method, the patient enjoys an individual approach.
  • Surgical solution – the goal of surgical therapy is to restore knee stability, to prevent secondary damage to other structures in the knee joint. Acute LCA reconstructions are not recommended because of an increased risk of adhesions and arthritis, so the plastic surgery of the anterior cruciate ligament is only opted for after rehabilitation, i.e. at least 2 months after injury.

There are three basic techniques used for the plastic surgery of the anterior cruciate ligament:

  • a plasty formed of the central part of the patellar ligament,
  • a plasty created of hamstring tendons,
  • a plasty of the anterior cruciate ligament from the graft of an external donor.

The suitable type of LCA plasty is recommended by your orthopaedist. No immobilization is required after the surgery. During the first postoperative days, the patient positions the limb, exercises the movement in the ankle joint, isometrically retracts the femoral muscles, raises the stretched limb, and ice-cools the knee vigorously. It is also suitable to include dietary supplements and enzyme-containing preparations to reduce post-operative swelling and speed up recovery.

Standard course of recovery:

  • One day after the surgery, the patient starts to walk with the French crutches with a slight putting of the weight on the operated extremity;
  • On day 10 – 12 post surgery, the stitches are removed and the patient is sent for rehabilitation and physical therapy, after 14 days, the crutches are gradually put aside and the patient starts to fully load the operated limb;
  • Since the week 4, a bicycle without load is suitable;
  • Since the week 7, a stepper or elliptical trainer machine is suitable;
  • Starting from the week 9, strengthening of the thigh apparatus is in focus;
  • Starting from the week 12, running on even surface is recommended;

Since the 4th month post surgery, after the properly managed rehabilitation, it is possible to subject the patient to full sport load, but a special orthosis is required for this purpose.

Internal knee ligament injury (LCM)

What is it?

An LCM injury results from a violent abduction and external rotation or a directly acting force on the knee from outside. Such injuries occur especially in contact sports.

Symptoms

Pain on the inside of the knee, haematoma, lateral instability.

Diagnosis

It is important to carefully describe the mechanism of the knee injury in the course of the clinical examination. Complementary examinations include X-ray imaging performed to exclude injury to the knee skeleton, supplemented by ultrasonography or MRI. Lateral knee stability in extension and 30 degree flexion is examined too, and compared with the other side.

Treatment options

  • Conservative solution – if the internal joint space is only opened in the semiflexion (30 degrees of flexion), the conservative procedure is preferred with the application of gypsum splint or rigid orthosis for a period of 4-6 weeks.
  • Surgical solution – if the medial joint space is opened in the extension, it is preferable to employ a surgical method with revision and suture of the lateral ligament.

Additionally, medication supplementation, enzyme therapy and topical ointments are also suitable. Rehabilitation and physical therapy are an indispensable part of the treatment after removal of the orthosis.