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common injuries - knee

Anterior Cruciate Ligament (ACL) Tear

Description
The Anterior Cruciate Ligament (ACL) is a strong ligament inside the knee that connects the thighbone (femur) to the shinbone (tibia). It may become torn, resulting in instability of the knee.
Ligaments(hide)

Ligaments are the strong tissues that connect a bone to another bone. Ligaments are very important in joint stability, by holding the bones in a joint together.

Excessive tension on a ligament will cause injury, also known as a sprain: A grade 1 sprain is a stretch injury to the ligament, without damage to its structure. These injuries typically heal rather quickly, with little long-term problems. A grade 2 sprain involves microscopic damage to the ligament, but the ligament remains structurally intact. These painful injuries will usually heal well, but often the joint needs to be supported while the ligament heals, up to 6 or 8 weeks. A grade 3 sprain involves actual disruption of the ligament, and may render a joint unstable. Depending on the location of the injury, the ligament may or may not heal on its own, and surgery to repair the ligament may be necessary for these injuries.

Common Causes
Falls that cause the knee to twist or pivot. Rapid deceleration or pivoting in sports. Common in skiing, basketball, and soccer.
Symptoms
At the time of injury, many patients recall a 'pop' in their knee. Swelling usually develops. The knee may feel unstable, with patients not being able to 'trust' the knee, or complain of the knee 'giving way'. Pain is unpredictable.
Physical Findings
Swelling in the knee, especially at the time of injury. Instability of the knee can be demonstrated on physical exam.
Workup
History and physical examination are the main aids to diagnosis. X-rays are usually necessary to rule out a fracture or other injury. Your doctor may obtain an MR scan as well.
Non-Operative Treatment
Initial treatment includes rest, ice, and elevation. A torn ACL will not heal on its own. Some patients, however, can reduce their symptoms with physical therapy, bracing, and activity modification.
Surgical Treatment
The ACL may be successfully repaired with an arthroscopic ACL reconstruction, using one of several surgical techniques.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments

Left untreated, ACL tears do not heal on their own. Persistent knee instability may predispose the knee to early wear, leading to arthritis. Patients with a damaged ACL are at much higher risk for causing additional injury to their knees, including meniscus tears and cartilage injuries.

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Meniscus Tear

Description
The meniscus is a ring shaped piece of tissue that acts as a cushion, or gasket between the thighbone (femur) and the shinbone (tibia). It functions as a shock absorber, distributing stress across the knee joint. It also acts to aid in smooth hinge-like knee motion. There are two menisci in the knee joint; one in the inside of the knee (medial meniscus) and one in the outside of the knee (lateral meniscus). Either of these structures may become ripped, or torn.
Common Causes
Pivoting or twisting, squatting or kneeling activities. Often there is some trauma to the knee, but many meniscus tears are 'degenerative' or simply occur as part of the aging process.
Symptoms
Pain in the knee, especially with squatting or kneeling, getting up out of a chair, getting in and out of a car, etc. The pain may be sharp, in the back of the knee. Patients may report clicking, or a sense of catching inside of the knee. Frank locking of the knee is highly suspicious of a certain type of meniscus tear. There may be intermittent swelling.
Physical Findings
Tenderness along the joint line of the knee, either medially or laterally. A sense of clicking with the knee flexed and rotated is suspicious for a meniscus tear.
Workup
Often the diagnosis is made solely on history and physical examination. MR scans are fairly accurate in detecting these injuries, if the diagnosis is uncertain.
MR scans(hide)

MR scans (MRI, Magnetic Resonance Imaging) are a valuable way to visualize the soft tissues in the body, such as tendons, ligaments, muscles, and other organs. The MR scan uses a magnetic field, not radiation. Basically, you lie still on a flat table, with the MR tube over the body part, in a magnetic field. A computer is able to analyze the data (how fast hydrogen atoms change their spin direction!) and provide exquisitely detailed pictures of slices of your body. It is painless and safe, but people with significant claustrophobia may require some sedation. It is not cheap: about a thousand dollars per scan. It is also not perfect, and one must be careful not to rely too heavily on the MR scan. It does a poor job with bones and cartilage.

Non-Operative Treatment
Rest, anti-inflammatory medication, and physical therapy may improve symptoms to a very tolerable level.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
An operative arthroscopy, with either trimming of the torn piece of meniscus, or an arthroscopic meniscus repair.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments
These are common injuries, especially with sports and in an increasingly active middle age population. Not all patients require an arthroscopy, but if surgery is required, the success rate is high.

For more detailed information: Click here!

What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Collateral Ligament Sprain

Description
The knee has strong ligaments on both the inside of the knee (medial collateral ligament) and the outside of the knee (lateral collateral ligament). These ligaments attach to both the thighbone (femur) and to the shinbone (tibia). These two collateral ligaments provide stability to the knee, especially in resisting medial and lateral forces. If there is sufficient force, however, either of these collateral ligaments may become injured.
Ligaments(hide)

Ligaments are the strong tissues that connect a bone to another bone. Ligaments are very important in joint stability, by holding the bones in a joint together.

Excessive tension on a ligament will cause injury, also known as a sprain: A grade 1 sprain is a stretch injury to the ligament, without damage to its structure. These injuries typically heal rather quickly, with little long-term problems. A grade 2 sprain involves microscopic damage to the ligament, but the ligament remains structurally intact. These painful injuries will usually heal well, but often the joint needs to be supported while the ligament heals, up to 6 or 8 weeks. A grade 3 sprain involves actual disruption of the ligament, and may render a joint unstable. Depending on the location of the injury, the ligament may or may not heal on its own, and surgery to repair the ligament may be necessary for these injuries.

Common Causes
Struck in the side of the knee or leg during a football tackle. Rapid pivoting, in soccer or basketball.
Symptoms
Pain in the knee, either in the inside (most common) or outside of the knee. There may be feelings of instability in the knee with weight bearing or walking. There may be swelling or bruising present.
Physical Findings
Tenderness along the injured collateral ligament. Pain with stress testing of the ligament.
Workup
In addition to history and physical examination, x-rays are usually obtained to make sure there is no fracture. MR scans are usually not necessary in an isolated collateral ligament injury.
Non-Operative Treatment
Functional knee bracing until the ligament is healed. This may take months in some cases.
Surgical Treatment
Ligament repair.
Comments

Surgery is almost never required collateral ligament injuries of the knee, and non-operative treatment usually gives good results.

For more detailed information: Click here!

Cartilage Injury / Chondral Defect of the Knee

Description
Cartilage is the extremely smooth, shiny white material that coats the ends of the bones in almost all of the joints in our body (like the end of a chicken bone, with the soft tissues removed). Unfortunately, cartilage has a poor ability to repair itself when injured. Injuries to the smooth cartilage surface of the knee joint increase rubbing and friction in the knee, and predispose the knee to further cartilage wear and erosion.
Common Causes
Usually a history of trauma, such as a fall or direct blow to the knee. May occur with twisting injuries.
Symptoms
Pain in the knee, often described as aching. Swelling or symptoms of catching in the knee are not uncommon.
Physical Findings
The exam may be fairly unremarkable. There is usually tenderness over the damaged area, and swelling is a common finding.
Workup
This is a difficult injury to diagnose. Exam, x-rays, and possibly an MR scan may be required to rule out other injuries. Cartilage injuries usually do not show on either x-ray or MR scan reliably.
MR scans(hide)

MR scans (MRI, Magnetic Resonance Imaging) are a valuable way to visualize the soft tissues in the body, such as tendons, ligaments, muscles, and other organs. The MR scan uses a magnetic field, not radiation. Basically, you lie still on a flat table, with the MR tube over the body part, in a magnetic field. A computer is able to analyze the data (how fast hydrogen atoms change their spin direction!) and provide exquisitely detailed pictures of slices of your body. It is painless and safe, but people with significant claustrophobia may require some sedation. It is not cheap: about a thousand dollars per scan. It is also not perfect, and one must be careful not to rely too heavily on the MR scan. It does a poor job with bones and cartilage.

Non-Operative Treatment
Rest, ice, anti-inflammatory medication and the mainstays of non-operative care.
Surgical Treatment
Arthroscopy of the knee, with one of a variety of surgical procedures, including smoothing out the defect, trying to stimulate scar tissue to grow into the defect, or a cartilage repair procedure.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments

This is a potentially devastating injury to the knee. Until recently, there was no way to actually repair injured cartilage. New methods, including growing new cartilage in the defect are very exciting.

For more detailed information: See video or photos of before and after Cartilage Repair.

Arthritis of the Knee

Description
The ends of the bones in the knee joint are normally covered with a layer of smooth cartilage. If the cartilage wears out, bone will rub on bone, resulting in a stiff and painful arthritic knee.
Common Causes
Most degenerative knee arthritis is genetic, with a family predisposition. It is probably not activity related, and in fact activity may be helpful in reducing the risk of arthritis. 'Post-traumatic;' arthritis develops a long time after a significant knee injury, or as a consequence of a chronic knee injury or instability.
Symptoms
Pain when walking, worsened with increased activity and relieved with rest. Difficulty tying your shoes, or putting on socks. Difficulty with stairs. Swelling in the knee joint.
Physical Findings
Tenderness, and swelling in the knee. Loss of motion or deformity may be present.
Workup
History, examination, and x-rays are generally diagnostic.
Non-Operative Treatment
Activity modification, weight loss, physical therapy, and anti-inflammatory medication may be helpful. Corticosteroid injections may bring temporary relief, but should be performed sparingly. Injections of hyaluronic acid may reduce symptoms for a period of time in some patients. Some patients report relief with chondroitin sulfate or glucosamine pills, but scientific studies are inconclusive.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Corticosteroids ("cortisone")(hide)

Key words: cortisone, corticosteroid, Medrol

Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.

Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.

This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.

Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.

Surgical Treatment
An arthroscopy, with debridement, will remove debris and cartilage fragments from the knee, and can provide relief. Ultimately, a total knee replacement may be necessary.
Comments

Total knee replacement surgery has a high success rate, and great patient satisfaction. Biggest problem is durability of the prosthesis, which wears out or loosens with time. The success rate for a redo, or revision knee replacement is not nearly so high. Therefore, this surgery should be delayed as much as possible, especially in the younger patient.

For more detailed information: Click here!

Patellar Tendonitis

Description
The patellar tendon runs from the kneecap (patella) to the front of the shinbone (tibia). When the thigh muscles (quadriceps) contract, the knee extends, or straightens, by way of the patellar tendon. Overuse may lead to inflammation of the tendon.
Tendons(hide)

Tendons are the strong whitish tissues that attach muscles to bones. All muscles cross a joint, and when the muscle contracts, the joint moves. If the muscle is overloaded beyond its normal strength, the tendon may begin to tear, causing a strain. These may range from a mild strain, which heals quickly, to a complete tendon rupture. Since the normal elasticity of the muscle causes the torn tendon to pull away from the bone, the tendon end does not remain near its normal attachment. This means that most complete tendon ruptures will not heal normally, and thus many complete tendon ruptures require surgical repair.

Common Causes
Frequent kneeling, squatting, or climbing. Jumping (frequently seen in basketball players).
Symptoms
Pain in the front of the knee, just below the kneecap. The pain is worsened by kneeling or squatting.
Physical Findings
Tenderness along the patellar tendon, usually near the attachment of the kneecap. Swelling, or thickening of the tendon may be present.
Workup
Diagnosis is made by history and physical examination. X-rays are frequently obtained to make sure there is no other injury.
X-rays(hide)

X-rays are the most common study used in Orthopaedic Surgery. Different tissues in the body, especially bone, will block the x-rays from passing through the body onto a sheet of film. Thus x-rays are an excellent way to visualize the bones in the body. This is useful for diagnosing fractures, dislocation, arthritis, tumors, growth injuries, and many other conditions. While X-rays are a form of radiation, they are generally extremely safe to the body in doses and quantities typically obtained by your doctor.

Non-Operative Treatment
Rest, avoidance of aggravating activities, anti-inflammatory medication and physical therapy are the mainstays of non-operative care.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
Debridement of the damaged tissue. Rarely indicated.
Comments
Non-operative care is generally successful.

Chondromalacia Patella / Patellofemoral pain / Anterior Knee Pain

Description
The kneecap, or patella, rides along a trough or groove at the end of the thighbone (femur), much like a bobsled down a track. The patella is attached to the strong thigh muscles on one end, and is attached via the patellar tendon to the front of the shinbone (tibia) on the other end. Thus, when the thigh muscles contract, they pull on the patella, and the leg straightens. The undersurface of the patella has a thick layer of smooth cartilage, and rides nearly friction free. Damage to the cartilage undersurface of the patella is termed Chondromalacia Patella.
Tendons(hide)

Tendons are the strong whitish tissues that attach muscles to bones. All muscles cross a joint, and when the muscle contracts, the joint moves. If the muscle is overloaded beyond its normal strength, the tendon may begin to tear, causing a strain. These may range from a mild strain, which heals quickly, to a complete tendon rupture. Since the normal elasticity of the muscle causes the torn tendon to pull away from the bone, the tendon end does not remain near its normal attachment. This means that most complete tendon ruptures will not heal normally, and thus many complete tendon ruptures require surgical repair.

Common Causes
May be due to direct trauma, such as a fall on a flexed knee. Abnormal cartilage wear may develop due to chronic maltracking or subluxation of the patella (see patellar instability). Weight gain, or other increased load on the knee can cause symptoms. Also frequently seen in adolescent girls.
Symptoms
Pain in the front of the knee. Worsened with going up and down stairs, climbing, squatting or kneeling, and prolonged standing.
Physical Findings
Tenderness in the front of the knee, with a positive patellar compression test. Findings are often unimpressive.
Workup
Diagnosis is made by history and physical examination. X-rays are useful to rule out other injury.
Non-Operative Treatment
Anti-inflammatory medication, rest, physical therapy and possible patellar stabilizer knee bracing are the mainstays of treatment for this condition.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
Generally not indicated.
Comments

Most cases resolve with appropriate treatment.

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Patellar Instability / Patellar Subluxation

Description
The patella, or kneecap, rides along a trough or groove at the end of the thighbone (femur), much like a bobsled down a track. The patella is attached to the strong thigh muscles on one end, and is attached via the patellar tendon to the front of the shinbone (tibia) on the other end. Thus, when the thigh muscles contract, they pull on the patella, and the leg straightens. The patella is supposed to ride in the center of its track. With abnormal patellar tracking, the kneecap can start to ride out of its groove, and can even dislocate.
Common Causes
Twisting injury to the knee, a direct blow to the kneecap. Certain people have a predisposition to this problem, based on their own knee alignment.
Symptoms
Pain in the front of the knee, increased with exercise or activity. A patellar dislocation results in an obvious deformity of the front of the knee, with an inability to move the knee.
Physical Findings
Abnormal patellar tracking on physical examination. Tenderness with compression of the patella, or with attempts to shift the patella to the side.
Workup
History examination, and x-rays. Special x-rays can detail how the patella tracks down the end of the thighbone.
X-rays(hide)

X-rays are the most common study used in Orthopaedic Surgery. Different tissues in the body, especially bone, will block the x-rays from passing through the body onto a sheet of film. Thus x-rays are an excellent way to visualize the bones in the body. This is useful for diagnosing fractures, dislocation, arthritis, tumors, growth injuries, and many other conditions. While X-rays are a form of radiation, they are generally extremely safe to the body in doses and quantities typically obtained by your doctor.

Non-Operative Treatment
Physical therapy, with attention directed on strengthening specific muscle groups. Anti-inflammatory medication is helpful to reduce discomfort. Patellar stabilizing knee braces are effective.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
Patellar realignment procedures. These range from an arthroscopic lateral release, to open realignment of the insertion of the patellar tendon on the tibia.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments
The majority of cases can be successfully treated with therapy and exercise. Symptoms may be exacerbated during growth spurts in adolescents.