Meniscal Tears in the Knee

 

In the knee the meniscus is the load-bearing cartilage ring. They are akin to tires on your car. There are two in each knee, one on the medial side of the joint (inside aspect of the knee) and one on the lateral side of the knee (outside aspect of the knee). They are C-shaped and very rubbery. These meniscal cushions are very important to the knee for distribution of weight forces through the joint, to reduce the stress on the articular cartilage (cartilage on the end of the bones). Injury to the meniscus has been shown to predispose to early arthritis in the joint.

 

Injury to the meniscus usually occurs with sudden twisting and shearing forces. Sometimes unusual axial load forces can also injure the meniscus. Sometimes the meniscus is more prone to injury in rare circumstances where it is abnormally large, which is a well known anatomical variant called a discoid meniscus. As we get older sometimes the meniscus will tear just from normal activities, if the tissue has become degenerative, like a "blow-out" of a tire on your car which has had too many miles put on it.

 

The signs of a torn meniscus include knee pain, swelling, catching and popping. The pain can come and go, or be more activity specific. "Giving way" can occur as a result of pain induced as meniscal fragments catch in the joint. The meniscus can frankly get stuck in the joint at times creating a "locked knee". Some meniscal tears may create very little problems for the knee, and the patient may choose to live with it that way. In other cases, the meniscal tear will drastically impact daily activities and sporting endeavors, and may require surgery.

 

The cartilage rings of the knee do not show up on plain x-rays. Nevertheless, initial work-up for a potential knee meniscal injury includes a history, physical exam, and plain x-rays. An MRI may become necessary. On MRI the meniscus is well-visualized, as well as all the other important ligamentous structures. Often, meniscus tears occur at the same time as ligament tears, and this is why an MRI is helpful. Once a meniscus tear is identified, treatment is initiated, and in most cases will include surgery.

 

Since the meniscus is critical to the longevity of the knee, preservation or repair of the meniscus is the optimal solution. Unfortunately, many tears do not lend themselves to repair, and, hence, a portion of the meniscus has to be trimmed out. The determination of repair ability is often made at the time of surgery. Surgery involves arthroscopy, which is a minimally invasive diagnostic and therapeutic procedure done through two small incisions about the front of the knee. The surgery usually takes less than an hour to perform, but does usually require a general anesthetic. Since the surgery is done as an outpatient, early rehabilitation can be expected. If the meniscus is repaired, then restrictions will be necessary for several months, but if no repair is performed, full recovery may be expected within the month.

 

Not all knee pain suggests a torn meniscus. Therefore, concerning knee pain should be discussed with a Sports specialist, who can initiate the evaluation of the problem, and plan effective treatment.

 

 

Foot Problems: An ounce of prevention goes a long way

 

Eighty percent of foot problems that present to my office are preventable. The prevention can be so easy that it should embarrass most people.

 

Our feet were designed for muddy, grassy grounds. If you look at foot designs of many animals, you will see that animals designed to be on rocky, hard terrains have hooves, not soft fleshy feet like ours. This simple fact of biology should help people to understand what leads to many of our most common foot ailments.

 

The fact is that most of us like going barefooted most of the time. We do this outside and in our own houses. Unfortunately, outside involves a lot of concrete and pavement, and inside involves a lot of hardwood floors, linoleum, and ceramic tile. Also, there are hard obstacles such as chairs, tables, rocks, just about everywhere.

 

The most common diagnoses for which I see foot patients in my office include: heel pain, forefoot pain, falling arches, tendonitis, toe fractures, and foot fractures. Incredibly, all of these can be easily prevented. Shockingly, 80% of people will have forefoot pain or heel pain at some point in there life. Also, these diagnoses usually lead to significant disruption in the patient's life, including substantial time off work and out of sports.

 

So why has this become so common? Because our environments have evolved quicker than our feet have evolved. We have created our own problems. But we have also tried to help with the problem. The help comes in the form of shoe wear. That's right, shoes are not just a fashion statement. In fact, a great deal of science and research goes into our shoe wear. Each year that I have been in practice, the technology in shoe wear has improved. Think about it, the good shoe provides a good fit with arch support and heel padding, naturally covering the toes for protection.

 

If my patients wore these kind of protective, supportive shoes at all times, then heel pain syndromes and forefoot syndromes would be virtually eliminated. As well, toe fractures would never happen. Arches would be supported from the bottom up, resisting the tendency to fall with age.

 

Despite the fact that all of these conditions would be drastically reduced by the simple use of shoe wear at all times, people continue to go barefooted. In fact, many families have rules about no shoe wear in the house. Yet most toe fractures occur in the house to unprotected feet.

 

Having someone miss 4 - 6 weeks of sports or work because of a completely preventable toe fracture always makes me cringe. But once the toe is fractured, the swelling usually prevents normal shoe wear for a month. Hence, work and sports are out.

 

In conclusion, preventive medicine can be really simple; so simple that it defies us. Breaking patients of bad habits can be difficult, and thus many doctors do not even try. But I am going to take a stand. Let's stamp out barefootedness. Unless you are planning on growing hooves, get use to wearing a pair of comfortable, supportive shoes at all times. Your feet will reward you for it, with many years of pain free activities of your choice.

 

 

Anterior Cruciate Ligament Reconstruction

 

 

The main stabilizing ligament of the knee is the anterior cruciate ligament (ACL). It is centrally located in the knee joint, and is attached on the back side of the thigh bone (femur) and spans toward the front of the shin bone (tibia). Hence, it prevents the shin bone from shifting forward in relation to the thigh, especially when the knee is bent. It also prevents some external rotation of the shin bone, since it attaches from outside of the thigh bone toward the inside of the shin. When this ligament is torn or deficient, the knee will periodically feel as if it is actually dislocating or shifting abnormally. This occurs frequently with quick stops and starts, or changes in direction. Pain and swelling can become common, due to the damage to other cartilage structures within the knee during the shifting. Many athletes will find that they are completely unable to perform with this injury, while others may have less frequent shifting episodes.

 

The current recommended treatment in young active people is surgical reconstruction. Without reconstruction, the knee is predisposed to shifting episodes, which leads to early arthritic problems. If activities are severely restricted, then reconstruction can be avoided. On the other hand, if the patient wants to continue a healthy, active lifestyle, then reconstruction is strongly encouraged. In fact, the younger the patient, the more strongly we encourage the need for surgery and reconstruction, as post-traumatic arthritis has been seen to develop very rapidly in even teenage patients.

 

The initial step after knee injury is to get to a Sports Medicine specialist for evaluation. In most cases, the integrity of the ligament can be determined by a combination of review of the mechanism of the injury and physical exam. X-rays and an MRI often complete the picture, and can help planning for surgery.

 

Surgical reconstruction is a major step. Even though it is an arthroscopic surgery, it is still a major surgery. There currently are many options for reconstruction, each with its own risks and benefits. The procedure and technique choices should be discussed thoroughly with the surgeon. Although the internet is a good source for information on the procedure, it is also a good source for misinformation. One common misunderstanding of the procedure is that the ligament can be primarily repaired. In fact, the ligament is usually destroyed in the injury and has to be replaced. What should be clarified with the surgeon is the choice of the graft replacement. Once that is determined, then an understanding of the graft fixation is needed. On average, considering the common graft choices and fixation techniques, the surgical success rate is greater than 90% at restoring stability to the knee.

 

A commonly overlooked element of the success of the surgery is the rehabilitation in the post-operative period. It has been considered that 80% of the success of the surgery is determined by the post-operative therapy, and strict compliance with the restrictions set by the surgeon. It should be expected that a period of 4 to 6 months without sports will be required after surgery, and elite level athletes have been found to need more in the neighborhood of 1 to 2 years to reach their pre-injury elite level.

 

 

Conditioning in Athletics

 

 

The best advice an Orthopedic Surgeon or Sports Specialist can give a young athlete would be how to prevent injury in the first place. Unfortunately, we only end up in the specialist's office after an injury. Therefore, the information does not always get out to those who need it most.

 

Preventing all injuries would be impossible, since most truly occur as a result of an accident or fluke. But many injuries can be reduced in frequency, and Sports medicine research has proven this. Prevention does not cost a lot of money or involve elaborate bracing, taping or equipment. For the most part, the best mode of injury prevention is conditioning. Physical fitness is not just to help improve sports performance, but is also for injury prevention and longevity. Those that keep themselves more physically fit traditionally have a longer, sustained lifespan within their sport. Reducing the number of serious injuries is how this is achieved.

 

The sports that have the higher rates of serious injury involve quick stops and starts, changes in direction, jumping, and contact. Most coaches and athletes prepare for their sport by repetitively performing routines specific to their sport. Unfortunately, this may not be enough, and may exclude certain forms of conditioning that may be helpful to prevent injury. For instance, most running sports concentrate on running routines. The mistake is neglecting core strengthening, which requires more resistance and strength training. Core strengthening has been found to be pivotal in preventing significant knee injuries in running athletes.

 

Core strengthening involves exercises to target the back, abdominals, gluteals, and thighs. Improving the strength of these muscle groups improves stability at the knee and hip, and helps with landing from a jump. An adequate program would include resistance type training 4-5 days/week targeting these muscle groups. This type of training often should not be done on the field of play, but more appropriately in the gym, where use of universal weight equipment and other resistance machines can be optimized.

 

As one improves strength with resistance training, one must not forget flexibility. While endurance improves with sports specific cardio work, and strength improves with resistance training, flexibility must be addressed as well. Each of the major muscle groups worked will tighten from strength training, actually increasing the susceptibility to certain strain type injuries. Hence, before and after each exercise routine, some flexibility should be worked as well. Flexibility is improved by taking a muscle group to maximal stretch, and maintaining the stretch for 20-30 seconds. Stretching is more effective after work-outs when the muscles are warm.

 

The perfect program would include sports specific cardio, resistance strengthening of core muscles, and flexibility. Programs have been developed with the assistance of Sports Specialists, and are accessible via the internet. The "PEP program" is one of the more well recognized examples of this. These websites review and explain the "PEP program" in detail: http://aafla.org (under the Coaching Education) and www.aclprevent.com

 

 

Osgood-Schlatter’s Disease: It sure sounds bad.

 

 

Parents of athletic kids entering teenage years are sure to have heard of this. Because of its name and anatomical location, it strikes fear into some. Fortunately, it’s not as bad as the name may sound. The prognosis is good, so do not let the name scare you.

 

Osgood-Schlatter’s disease is always characterized by activity-related pain that occurs a few inches below the knee-cap, or patella, on the front of the knee. The child will have swelling in the area, and tenderness to touch. Sports requiring lots of running, jumping, kneeling, and squatting are particularly associated. Many children first signal the start of the problem by rubbing the top of their "shinbones" with their hands, or even ice cubes, at practice sessions. The three main factors that contribute to Osgood-Schlatter’s are:

 

1. Between 10 and 15 years old.

2. Involved in youth sports.

3. In a "growth spurt".

 

Osgood-Schlatter’s is defined by a characteristic soreness and swelling at the tibial tuberosity. It usually originates in those between the ages of 10 and 15 who are both physically active and in a "growth spurt".

 

A recent Finnish study found that 13% of the teenagers of that country had symptoms of Osgood-Schlatter’s disease.

 

The disease was named after two physicians who defined it independently in 1903, Dr. Robert Osgood and Dr. Carl Schlatter. The condition is caused by the powerful quadriceps muscle pulling on the attachment point of the patellar tendon during running activities such as soccer, basketball, track and other sports. The patellar tendon is a thick rope-like structure that connects the bottom of the kneecap (patella) to the top of the large shin bone (tibia). The powerful muscles on the front of the thigh, the quadriceps muscles, straighten the knee by pulling at the patellar tendon via the patella. Osgood-Schlatter’s disease is caused by inflammation (irritation) where the patellar tendon attaches to the tibia. The disease is caused by repetitive stress or tension on part of the growth area of the upper tibia (the apophysis). The disease may also be associated with an injury in which the tendon is stretched so much that it tears away from the tibia and takes a fragment of bone with it.

 

Sport or physical activity is not likely to cause any permanent damage, but may make the pain worse. Difficult decisions may have to be made about training schedules and sporting commitments. Each case is different, and your doctor will advise. An approach similar to the following may be advised.

 

• You do not usually need to stop sport. However, easing off strenuous or vigorous sport may be sensible for a while until the pain eases to a tolerable level. Let the pain be your guide. Play sport only to a bearable level of pain. Avoid heavy sport activities if the pain is bad. Consider a complete break from sport for a while if pain remains bad.

• An ice pack applied below the kneecap for about 5 minutes before and after exercise may prevent some inflammation and pain.

• Consider wearing knee pads during sports such as football, volleyball, and basketball to protect the tender area.

• Concentrate on flexibility and quadriceps stretching, especially during growth spurts.

• Anti-inflammatory medications, i.e. ibuprofen, are often very helpful.

 

Prevention of the problem has been low on the priority list for most healthcare providers. This may be because prevention techniques are unproven and controversial. Better pre-sport conditioning of the quadriceps may help prevent the problem entirely. Clearly, better flexibility and stretching throughout adolescence may be crucial.

 

Knee pain in kids can be concerning and confusing. My own personal experience with Osgood-Schlatter’s disease started when I was 11 or 12. I was passed from one pediatrician to the next with diagnoses of “water on the knee”, “torn ligaments”, and “strained tendons”. My treatments included restriction from physical education for half a year and knee sleeves. Nonetheless, the pain continued, and a noticeable bump below my knee started. By the age of 16, finally an orthopedic surgeon made the correct diagnosis, but by that time the pain had subsided. I now live with my Osgood-Schlatter’s bump that is non-painful, and have continued athletics until present.

 

If this story sounds familiar, or you’re just starting down this path, then I would recommend an early evaluation by a sports medicine physician or an orthopedic surgeon. Keep in mind, Osgood-Schlatter’s disease is not “torn ligaments” or “water on the knee”, nor is it the end of athletics for your young one, but many sources of information out there can be misleading and confusing. Entire websites have been dedicated to this diagnosis, some promoting herbal supplements, others requesting your money to provide the very information that was just discussed. Some sites out of Europe even discuss surgical options as the primary recommendation for this condition. Rest assured, surgery is not the recommended modality of treatment for this in the United States, nor is prolonged immobilization.

 

I hope the information provided here helps reduce some of the consternation created by the ominous name of the condition, Osgood-Schlatter’s disease. It is really not much of a disease at all, and it would have been nice if they did not have to combine two fairly odd sounding names for one condition. In essence, it is a self-limited adolescent condition that is fairly common in athletic kids, with no real permanent disabling sequelae except for a bump just below the knee. The pain from the condition usually subsides by 15 to 16 years old, and in only a very small percentage are there any residual symptoms associated with the visible bump.

 

 

Stress Fractures

 

 

Fracture in medical terms means the breaking or cracking of a bone. Typical fractures, or broken bones, occur from a violent force placed on the bone in an atypical, or unexpected, manner. Immediate pain and delayed swelling and bruising usually ensue. The episode that produces the fracture is always memorable and recognizable. Usually a trip to the emergency room or doctor is automatic.

 

Some fractures behave differently. "Stress fractures" by definition do not occur from a single defined event. They occur as a result of the repetitive trauma to the bone created by a recurrent activity. Often the recurrent activity is not separated by recuperative periods. Without periods for recuperation, the stress placed repetitively along the bone can create an inflammatory or injury reaction. This inflammatory reaction is usually heralded by pain and localized swelling. If the repetitive activity is not stopped at this point, then actual cracking of the bone can occur.

 

If the athlete presents to the doctor at the stage of inflammatory reaction, before actual cracking, then exam usually reveals localized tenderness and swelling. No definitive injury is usually identified. X-rays can be completely negative at this stage. Based on a history of repetitive stress and examination findings, the doctor usually has to presume that a stress fracture is eminent. If there is question, a bone scan or MRI can give further information. Treatment should be initiated to prevent potential true fracturing of the bone.

 

Treatment is actually very simple, although very frustrating for the athlete. The repetitive activity must be eliminated. The rule of thumb for stress fractures is that forced rest must be twice as long as the period of time it took to develop the stress reaction. Unfortunately, it can be near impossible to know exactly how long the stress had been developing. In addition to forced rest, non-steroidal anti-inflammatory medications, such as ibuprofen, help significantly with the pain secondary to the inflammatory nature of the problem. Usually, if caught early, no casting or bracing would be necessary. If caught late, after an actual crack in the bone is visible on x-ray, then casting and bracing will be required, just as any other fracture would require. In some cases, depending on the location of the fracture, surgery can be required.

 

Stress fractures heal, in most cases, at the same pace as most regular fractures, and in some cases quicker. Due to the inflammatory nature of the condition, pain can continue and is common even after the bone is well healed on x-ray, quite unlike typical fractures. Medications and rest should be continued until the inflammatory reaction resolves, otherwise recurrence of the stress fracture should be expected.

 

The take home message for the athlete is that recuperative time needs to be incorporated into your exercise regimen. At the first signs of persistent pain, more recuperation should be considered. If symptoms do not resolve quickly and completely, then prior to re-initiating the activity, medical attention should be sought.