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THE KNEE JOINT By Othon Molia The knee is the biggest joint in the body, and prone to injury in most athletic sports. The reason is because it only moves forward and backward, flexion and extension, consequently if there is any side to side stress on it it will get hurt. I'm sure if you go to a football game, basketball game or even baseball someone hurts their knee. So whenever someone gets hit as in football, it's the knee, whenever you twist too fast, as in basketball, it's the knee and the same for most other intense fast cutting sports. There are many injuries to the knee that come from just running, I believe that if your hips are out of alignment, your knee suffers from improper mechanical functioning, you will eventually get some sort of pain in the knee. The jogging revolution has started many knee problems, I can't tell you how many patients come in with some sort of knee problem. There are over twenty potential knee injuries. If a patient comes in and can point right to the problem, it's not too difficult to figure out what it is. As long as you can do a resistance test and find the tendon, muscle or ligament. Torn cartilage is another tricky problem as is bursitis or chondromalacia. The knee is made up of the Femur, the tibia, the fibula, and the patella or knee cap. This floating bone is woven into the rectus femoris tendon(Quadriceps Muscle) it's a tendon that functions like a ligament and attaches at the tibia. The other major muscle groups are the hamstrings (see below for a better description. The knee is also held together with lots of ligaments. The major ligaments are the medial collateral (inside)l and the lateral collateral ligaments (outside). Then a common football or skiing injury is the anterior cruciate ligament: This ligament is in the center of your knee, it hold the knee joint together with the posterior cruciate. They cross in the middle. The other ligaments in the knee less injured are the medial coronary ligament, the lateral coronary ligament, they hold the cartilage in place that follows and then we have the meniscus cartilage that acts as the shock absorber in the joint as well as keeping the bones from rubbing on themselves. Warring away of any of these material, can cause arthritis of the knee sometimes called chondromalacia. Fortunately,with state-of-the-art surgery now athletes, after a properly done cruciate repair or reconstruction, can return to sports within the year. It use to end most athletes career. The anterior cruciate ligament is the most commonly injured ligament in the knee. The ligaments have a relatively poor vascular supply and is virtually impossible to heal a complete tear. Injuries of the ligament produce bleeding into the knee; the reason why you get a swollen knee after a rupture. Just like a muscle tear the swelling represents blood in the joint. Once torn, the knee usually becomes unstable and can cause other injuries to the cartilage. The patients who remain in sports have a 75% chance of further damage to one or more of the important cartilage structures within the joint and the potential for arthritis. To prevent and protect against ligament injury and early return to athletics after ligament surgery is achieved by strengthening the muscles around the knee. These muscles that act as shock absorbers and joint stabilizers need to be strengthened. Specifically, hamstring strength protects the tibia from the anterior translocation that can rupture the cruciate. Often we see that the Quadriceps are twice as strong as the Hamstring group. So it's important to focus on the hamstrings to stabilize the knee joint. If the hamstrings are weak, the knee goes into hypertension, thus creating the situation for injury. When the skier "catches an edge," or in the cutting sports if you take a sharp turn, the stability is often dependent on the quadriceps and hamstring power for balance. When you are on one ski while attempting to reign in the wayward leg is a potential problem. If the quadriceps muscles are weak, the leg wobbles under the unexpected load, twists as the skier or athlete falls, and "pop you tear the cruciate". Of course contact injuries to the knee as in football where someone hits your knee and it bends backwards will often tear the cruciate. The knee also has many bursars, these fluid sacks also get injured, especially the one under the knee cap. This kind of pain my feel like dull ache, and of course often knee injuries can actually cause damage to several tissues as well as structures of the knee. Careful examination is necessary. Pain in the front of the knee Patellar tendinitis, is one of the most common over-use syndromes dealing with the knee joint. Many runners get this in fact they often call it "runners knee". Like the Achilles tendinitis it's a problem because the pain comes and goes. It seems to hurt when running, and intense walking. It can hurt to climb stairs, it only hurts all the time when it's in the acute phase. Then it seems to get better if you rest it for a few days. Then of course they run again and then it hurts again. It can hurt all around the patella. Although it is actually a tear or a strain of the patellar tendon it can be tested by doing the test. (see ppp) Causes for injury The most common cause for injury in this tendon is not warming up and stretching the quads properly. Another reason in my opinion is poor alignment of the hips and so the knee takes unusual stress when running. See picture of gate and knee stress when running. Often it is because the muscles are too tight and pull to heavy on the tendon. Also check the running shoes and the foot, flat feet, poor arch support or orthodics may be needed in the long term correction of this problem. The muscles of the knee The quads are actually four major muscles the Rectus Femoris, Vastus Lateralis, Vastus Medialis and the Vastus Intermedus. On the front of the leg also attaching on the knee are the Facial Lata, The Sartorius, and the Adductor groups. On the posterior side of the knee as we said are the Hamstrings, this muscle group is actually the Biceps Femoris, the Vastus Lateralis, Semitendinosis, Semimembranosis, the Gracilis, the Popliteus, the Plantaris, below the knee in the rear are also the calf muscles or the Gastrocnemus, the Soleus, the Plantaris, and the Peroneus. See the specific muscles for more detail on testing and action of these muscles. Testing of the Rectus Femoris for Patellar Tendinitis Because this muscle is so strong, and the pain may be defused it's best to test the muscle after it has been worked. If it's exhausted it will be easier to test for the problem. With the patient supine bend the knee at the hip and hold the knee at a 90% angle. Press hard on the tibia while stabilizing the knee with the other hand. If the tendon is injured this will set off the pain, and you will be able to locate it by palpation. Often you may not get a very specific pain site, so you may need to have them run up and down some stairs, or do some deep knee bends (careful with this as this may hurt too much). This can often get confused with chondromalacia or bursitis of the knee, however these are usually felt deeper in the knee joint. Treatment RICE is the recommended treatment for this condition, of course rest, stop running. Using an ice bag, with gentle movement is very helpful. It's a variation of RICE I call it MICE (Movement, Ice, Compression and Elevation) the movement will allow the body to heal without creating too much scar tissue. After two to three weeks of rest you may start activities easy, if it's not better after four weeks you should see a doctor. Of course DTF is very effective for this injury, it can hurt so you have to go easy. Also during the acute phase you could friction with the ice cube. If it's an old injury that has acted up due to unusual activity, such as training for a marathon in your forties, sometimes a well placed injection of some corticosteroid is beneficial. Of course with this must come rest, sometimes one or two injections is all it takes to turn it around. The other key is if it's a poor stable foot that causes this, Orthodics may be necessary. The Cruciate Ligament Injury This ligament is a broad, thick cord the size of a person's index finger. It has long collagen strands woven in a fashion that permits forces of up to 500 pounds to be exerted on it before it rips. This is a serious injury and is very common in football or skiing. Of course when hit from the front the knee bends backwards. It can also be a long term overuse type of injury, where it slowly comes on then is set off by an unusual event. Pain deep in the knee joint is a common complaint. It's hard to locate the pain because it's so deep in the joint. Some of the symptoms are the person cannot walk down hill, as they feel that their knee joint is going to give out. Walking stairs is also difficult as the joint is less stable. The ligament is crucial for guiding the tibia in a normal path along the end of the femur and maintains the joint stability. It can also be torn in a quick motion such as a fall, or running in a fast sprint. This is more unusual, but it does happen. The Test These tests should only be done if the pain is mild, as you may have just strained the ligament. If the pain is severe and you can hardly bend your knee see a doctor. The test for this injury is called the drawer test. The patient lies supine on the table and bends the knee at the hip, resting the foot on the table. The therapist then pushes at the tibia, and forces the tibia posterior. Any play in this joint during this push indicates a weak or partially torn cruciate ligament. It will hurt at times yet other times you don't get the pain that may be felt during walking. This pain can be a dull ache, and not sharp like other ligament injuries. If it hurts in the back part of the knee it could be a Posterior Cruciate injury. Keeping the knee in the same position grasp behind the knee, sitting on their foot to stabilize, then pull forward and check for motion or pain. Treatment Treatment for this injury is MICE (Ice will always help) but because the tissue is so deep in the knee there is really no massage that can be done. Other than working on all the peripheral muscles in the leg. Prevention of this injury is better and less painful, for the athletes that do the sports where this injury is common (football, skiing, rugby, track, basketball, or baseball) building up the knee joint is imperative. Not only building up the muscles but you can also build up the ligaments, they just take much longer. (see building the base) I have also heard of injections in this area at the acute state are able to increase the healing if just partially torn. They even use proliferants that help create scar tissue to help support this injury. Note however that these very specialized treatments need to be done by a doctor that specializes in sports medicine as the location is very difficult to reach. Specific exercises can diminish the incidence of cruciate ligament injury. Most often if it is torn badly surgery is needed. Now a days our surgical approaches can promptly correct this injury with an early return to sports. This injury is serious and usually requires surgical repair or reconstruction. Injuries to the Medial Collateral or Lateral Collateral Ligament This is a very common ligament sprain on the medial part of the knee. It can come and go and gets irritated with activity in it's mild form. If it is more severe it can knock you down and swell up and hurt a lot. After a few weeks the pain is more concentrated in the points in the drawing (88) The pain may come and go and can be confusing. If it came on suddenly once again I blame mis-alignment of the pelvis, especially if there is knock knees. Too much tendon in the facial lata as well. Sometimes old injuries that formed improper scar tissue that holds the ligament tight will create further injuries. Then you let it heal, and the cycle starts all over again. The test for the Medial Collateral is to have the patient supine and extend the leg. The therapist puts pressure on the lateral side of the knee, trying to open the two bones. This causes the ligament to stretch causing the pain. The test for the Lateral Collateral Ligament is the opposite, your hand is placed on the medial part of the knee joint and the pressure is lateral, overstreatching the ligaments will hurt laterally. This injury is less frequent and for some reason it heals faster, than the medial. MICE is great, the movement with the ice bag keeps scar tissue from forming between the ligament and the bones. DTF done every other day for at least four weeks will help heal and preven improperly formed scar tissue. If the scar tissue is old and chronic, DTF will be painful but will help make a subtler tissue. Manipulations to increase ROM may be necessary to pull the old scar tissue off the bone. These treatments must be done by professionals trained in sports medicine or sports massage. Some clinics use diathermy and ultrasound to aid in healing, my experience shows this to be less effective, than DTF. Sometimes injections can stop the inflammation and pain. This will allow the body to increase healing. The corticosteroid will reduce inflammation and the proliferant will help tighten loose and overstreatched ligaments. If the tear is bad enough sometimes they put a cast on the leg, now a days this is not often done as severe scar tissue can form, and freeze up the knee joint. Surgery is the other treatment if the ligament is completely torn. This should be done as soon as possible, with DTF, deep massage and manipulations used in the rehab period. Pain in the Tensor Facia Lata, Outside of the knee This again is a very common injury for runners,especially distance runners or athletes that do a lot of fast cutting, such as football, rugby, basketball and soccer. With a tear or a strain on this tendon, the pain is felt just above and to the outside of the knee, at the insertion of the facia lata. It's actually all facia down at this point as the muscle is short and up at the hip. It's an overuse type of injury. Once again the pain comes on at heavy activity and gets better at night. It doesn't get swollen very often, so you go train again and it hurts again each time taking less time for the pain to return. Test To test this tendon, have the patient supine, holding the leg up in the Facial Lata test. Exert pressure medially on the lateral part of the tibia, if this hurts in the spot suspected, palpate for the lesion. Treatment RICE of course with some movement, flexing and extending the knee with the ice bag. As well as DTF massage. DTF is very effective for this injury. In fact, prevention of this injury by deep massage and friction on the tendons may help most runners. I have always found this facia is very tight in most people. Once again prevention is less painful. A well placed injection may also help, if the injury is more severe. However, taking the athlete out of training is imperative. I use to have them swim, with a floater between their legs to keep cardiovascular fitness during the recovery. Easy bike workouts can be done within three to four weeks, so that scar tissue doesn't build up the knee joint. Running should only be resumed after there is no pain in doing that activity. Hamstring Injury or pain on the inside of the knee These are common sprinter injuries, as well as fast cutting sports. If you feel pain on the back of the knee, the hamstring tendon, or sometimes on the front below the knee joint, the hamstrings insertion. The hamstring group of are three muscles and they all originate at one tendon at the ischium tuberosity, or our sit bones. They then split up and some go on the outside of the knee and some on the inside of the knee. They then insert at the lateral and medial condyle of the tibia (see ooo). Part of the biceps femoris inserts on part of the head of the fibula as well. This is a common site for injury as well. (See peroneus test) Pain here is also due to over-use or pushing yourself beyond your capabilities. It often hurts worse later, because as the tendon cools pain returns. This is an injury do to lack of flexibility, many runners have very tight hamstrings. Sometimes it's lack of warm up and the tight muscle tears when pushed. Stretching is what you don't want to do to any tendon or muscle when injured. So often I have treated people that keep that injury going because they are told by someone to stretch it to make it better... ?????? As I said early on the other cause is muscles that are out of balance.?????Sentence makes no sense???? Usually, the Quadriceps are twice as strong as the Hamstrings, making this joint unstable, they then have to do more work and are prone to injury. The ratio should be about 60% quads and 40% hamstrings. I always work my hamstrings twice as what I work my quads. If you notice we use the quads much more, as in walking, moving to a standing position, walking up stairs. We use the hamstrings much less as they are designed to bend the knee raising our heel to our buttocks. To Test the Hamstrings Place the patient prone. Bend the leg at the knee in a 90% angle. Stabilize the leg at the hamstrings and pull down holding the ankle. You will note pain either medially or laterally. Palpate for the injury and follow standard treatment for a tendon or muscle injury. Treatment MICE, movement is important for this injury as you don't want improperly formed scar tissue. Extend and flex the knee with the ice bag on it two or three times a day, with five to ten sets of extensions minimally. DO NOT STRETCH, during the acute phase and don't run for four to five weeks. DTF massage is great for this, make sure the tendon is stretched just about 80% of it's full length and friction the sore spot. Using ice for the friction massage should be done for 48 hours. Then you can friction without ice every other day. Careful not to create more irritation as it will take longer to heal. If the athlete wants to workout, have them swim, and kick very gently. If that hurts have them use a floater between the legs, and not kick at all for two weeks. The best way to start back on training would be to use a bike until there is no pain with that activity, then and only then can they start running again, gently. If pain occurs during running, back to the bike. The area most common for this injury as at the insertion points of the tendons, in fact just rub any runner there and they will have some pain. Prevention of this injury can be done with lots of good stretching and DTF at the origin and insertion of the muscles. Deep massage will help if not done right on the injured tendon. It can reduce the pull on the rest of the leg, and hips. Working on the gluteus muscles will reduce tension on the knee joint as well as the whole leg area. Chondromalacia or Pain under the knee cap This is like siatica. Lots of people think that they have this condition when it's something else as it's not that common. The pain is a dull ache, like bursitis and when severe it can hurt the whole knee area. It usually happens in both knees as it's a condition where the lubrication of the knee is poor and the cartilage surrounding the patella gets worn down. The bones then start to rub together. It can actually create a grinding sound, or patients say my knees creek all the time when I walk. Just sitting can make your knees hurt, walking up or down stairs will also hurt, and forget about kneeling down, if you do the pain can get severe. Once again misalignment of the body is one of the causes, as sometimes a nutritional deficiency. If you have flat feet your more likely to pronate the foot. Turn in, see feet999. This puts more stress and straining on the knee joint, stress like this can cause it to ware down. Test The test for this condition is no fun, and can really hurt so be careful. The patient is sitting with the legs extended. Place your hand on the patella and push down on it and move it from side to side. If you hear a grinding sound, or it feels like there is gravel in the knee joint, you may have chondromalacia. It may also hurt without the sound if they have bursitis so check for that and for patellar tendinitis as well. Treatment There's not much you can do with massage, other than prevention, of the stress. Then again you can reduce the stress and pain in the other muscle groups that are in reaction to the pain. Ice may help temporarily but not for the long term. Anti-inflammatory drugs, can reduce some of the swelling but don't really effect a cure. Exercises don't really help, as does corticosteroid injections, they are all temporary. Proliferant injections can help when the condition is not too severe, as it can stabilize the joint causing less stress. Nutritional supplements such as glucosamine, or high doses of bromaline, pineapple enzyme help. However, it's not medically proven. It's a mysterious problem. The best thing to do is avoid the activities that cause the pain. I have heard of some treatments in Europe where they inject a jelly type substance in the joint to help lubricate it better. It's called Dimethylpolysiloxane, not DMSO. (Benjamin) Injury to Meniscus Cartilage Turn cartilage is a common injury as well. It happens a lot in football and basketball, as well as some dancers and gymnasts. This can come from a sudden twist, as well as long term abuse. These tears can hurt deep in the knee so the pain can get confused with other injuries. What makes this easy to figure out is the patient will say stuff like, I was walking or running and my knee gave out or the knee actually locks up. As sometimes the cartilage piece gets in the way of the two bones, and you pinch it. This feels like someone stuck a knife in your knee. The knee feels very unstable. Like the Anterior Cruciate injury, but it locks or gives you a very sharp pain for no reason. The medial meniscus is more commonly injured, and you will feel the pain on the inside of the knee. Testing First of all if you suspect a cartilage tear send them to a doctor. There are several tests, all of which can tear the cartilage worse if you aren't careful. Usually with the symptoms mentioned above, you will more than likely not get this test. It involves the therapist holding your knee with one hand and your ankle with the other. Then you twist the knee medially and laterally, this will produce the sharp pain in the deep part of the knee joint. Most often you will require a Arthrogram. This is an x-ray with an injection of dye into the knee. The die allows you to see the tear. However we feel it's better to get an MRI, magnetic resonance imaging. This system works by a type of sonar with magnetic properties and creates images similar to x-rays, however it does show soft tissue injuries. This allows the doctor to really see the tear and injury to the cartilage. Sometimes injury to the Medial Coronary Ligament gets confused with a meniscus tear, or often both are present, Lateral Coronary Ligament The way to tell the difference is the test for these two ligaments is slightly different. The medial coronal ligament; You place the patient supine and bend the knee. Then you stabilize the knee joint with one hand and your place some torque on the foot pushing laterally. This puts stress on the medial coronary ligament, causing the pain medially. This injury responds well to DTF, and the following. To test the Lateral Coronary Ligament you place the bent leg in the same position and you push on the lateral side of the foot moving medial, this stresses the lateral side of this ligament. Following the treatment is similar, except that for DTF you can't reach all the parts of this ligament except for the anterior part, as the rest is deep in the knee cavity. Treatment Initially RICE can help heal this injury if it's minor. However if it locks up on you to the degree that it swells severely and causes pain for weeks, see a doctor. Massage does nothing for this condition, once it's happened. There are some manipulations of this knee joint that may help, place the meniscus back in place, but if it's torn it will just come out again. Injections of Corticosteroid, can help heal the area. However you must really rest after this injection. Then there are the proliferents, a mixture of lidocaine and dextrose. which create scar tissue. This can allow the injury some support and healing can begin. These are all for minor injuries. Once there is a severe tear, orthoscopic surgery is required and the doctors go in and trim off the piece of cartilage. Since cartilage has very little blood flow, they heal very slowly, and often it could be a long and painful recovery. Bursitis or water on the knee This condition can come from and injury, as well as gradually. This again can be due to misalignment of the knee joint. The swelling is the bodies mechanism to heal and immobilize an area to prevent further injury. It once again can hurt to bend the knee, as well as kneel down. The tests are kneeling and putting extreme pressure on the patella. The therapist may have the patient sit with the legs extended. Then place your thumb just distal to the patella and press down. This should hurt. If the patient has a hard time fully extending the knee and there is noticeable swelling, it could be very severe. Just as in the shoulder, manipulations or DTF massage will not help, if anything it makes it worse. Have them see a doctor, the best way to start the healing cycle is with an injection of corticosteroid, it reduces the inflammation better than anything else. It may take several injections, and you should see improvement right away. As prevention for the future look at the posture and do an extensive orthopedic and kinesiological examination to determine the cause.
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