The Knee

The knee is one of the most important and powerful joints in the human body. The knee is a basic hinge joint that is used for ambulation, activity, and stabilization of the trunk and lower extremity. Unfortunately, due to the location and importance of the joint it can be easily prone to injury.

If you’re experiencing knee pain, call one of our offices or book an appointment online to get started.

Knee Anatomy

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The knee joint is a hinge joint made of three bones called the femur, tibia, and fibula. They combine to allow flexion and extension of the lower extremity. The medial and lateral meniscus are cartilage bumpers that sit between the tibia and femur and are important for cushioning the knee.

There are four important ligaments surrounding the knee including the medial and lateral collateral ligaments (MCL and LCL) that sit on the outside of the knee and the anterior and posterior cruciate ligaments (ACL and PCL) inside the knee. These ligaments provide stability in various directions around the knee.

A healthy functioning knee not only benefits from the above bones, meniscuses, and tendons being in good condition, but also benefits from the support of the patellofemoral compartment. The kneecap, also known as the patella, is attached to the quadricep tendon and patellar tendon. The hamstring tendons also attach to the posterior aspect of the knee. Together these tendons aid in the flexion and extension of the knee and are important for walking and other daily activities.

What causes
knee pain?

What causes knee pain?

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There are many causes of knee pain. Some common causes are damage to the cartilage of the knee leading to arthritis, tears of the meniscus, tears of one of the cruciate or collateral ligaments, patellar dislocations, fractures, or inflammation of one of the tendons. Pain from these injuries can be experienced in various locations in the knee joint, but is commonly noticeable while weight-bearing or during activity.

Common Conditions

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Patellofemoral syndrome and patellar tendonitis are both overuse injuries. They are more commonly known as “Jumper’s Knee” or “Runner’s Knee.” These injuries typically occur in younger athletes and are due to repetitive and forceful activity that causes inflammation in the anterior part of the knee near the patella and the patellar tendon. They most commonly present as anterior knee pain that’s worse with running, jumping, or ascending or descending stairs. Diagnosis requires a physical exam. Treatment for these injuries involves rest, antiinflammatories, and physical therapy.

Patellar instability is a disorder that causes the kneecap to track incorrectly. This maltracking can be due to ligamentous laxity or other anatomical factors. Some individuals may not notice any symptoms, but for some people this malalignment can lead to anterior knee pain or an acute dislocation. Patellar instability without a dislocation is typically diagnosed on physical exam and with an X-ray. Physical therapy to work on patellar stabilization exercises is the most important treatment.

Patellar instability can predispose one to a patellar dislocation. Patellar dislocations can occur from a direct blow to the knee or from a noncontact twisting injury. These are traumatic injuries that can cause significant pain, inability to flex the knee, and swelling. Some of these will spontaneously reduce, while some require a visit to an emergency room or orthopedic for proper reduction. Diagnosis also usually involves an X-ray. Following a dislocation, a lateral patella stabilization brace and rest are used to stabilize the knee. Physical therapy is then used to help regain range of motion and strength.

A patellar fracture is a rare fracture that most commonly occurs with a direct impact to the anterior portion of the knee or a significant contracture of the quadriceps muscle. Symptoms include decreased range of motion and immediate pain and swelling to the anterior portion of the knee. Diagnosis is done with an X-ray and occasionally a CT for more information. Depending on fracture pattern, treatment may involve knee immobilization in extension with weight bearing as tolerated, or surgical fixation of fracture. Proper treatment is needed to maintain healthy flexion of the knee.

Meniscus injuries are common injuries in young patients participating in sports or in older patients as a degenerative condition. The lateral and medial meniscus are cartilage bumpers in the knee that aid in cushioning and stability. A meniscus tear can occur suddenly from an acute injury or be noticeable over time with repetitive use or degeneration. Symptoms typically involve joint line tenderness on either the medial or lateral sides of the knee and possibly swelling. For diagnosis a physical exam and an MRI are needed to evaluate the injury and extent of the tear.

Initial treatment typically involves rest, antiinflammatories, and physical therapy. In those that are not improving, surgical options such as a meniscectomy or meniscus repair can be done. A bucket handle tear is a rare meniscus tear that causes significantly decreased range of motion of the knee, and is most commonly fixed with prompt surgical treatment.

The medial collateral ligament (MCL) is the ligament that sits on the inside, or medial side of the knee. This ligament can get easily damaged in sporting injuries that cause the knee to be stressed inwards. Symptoms usually involve immediate pain on the medial side of the knee after injury, occasionally hearing a “pop”, swelling, and difficulty weightbearing. Diagnosis is made by physical exam and, in some cases, an MRI to further evaluate the extent of tear.

This is a unique ligament in the knee, as it often will heal without surgery. Tears of this ligament are graded from a small strain, partial, or a full tear of the ligament. Initial treatment for most MCL injuries involves a knee brace, rest, NSAIDs and physical therapy. Surgery may be recommended in full tears that are causing instability of the knee or in patients with multiple ligament injuries at once.

The anterior cruciate ligament (ACL) is a ligament that sits inside the knee and prevents anterior translation of the tibia relative to the femur. Injuries to the ACL are incredibly common and account for half of all knee injuries. This ligament is most commonly injured in young athletes with noncontact pivoting injuries. Symptoms include hearing a pop after twisting the knee incorrectly, immediate pain, swelling, decreased range of motion, and difficulty weightbearing. Symptoms can vary depending on the extent of the tear and whether there were additional injuries that occurred. Diagnosis is made with a physical exam and imaging, including an X-ray and MRI.

Treatment for ACL tears varies depending on the extent of the tear and the patient. In tears that are partial or just a strain, physical therapy and a knee brace are commonly used. For full ACL tears in active patients, surgical reconstruction is usually recommended to restore full motion and activity of the knee. ACL reconstructions are done using a variety of graft choices.

The posterior cruciate ligament (PCL) is a ligament that sits inside the knee and prevents posterior translation of the tibia relative to the femur. Injuries to the PCL are rare but can be the result of hyperflexion accidents or from more high energy mechanisms such as car accidents where the knee hits the dashboard. Symptoms involve swelling, pain in the posterior aspect of the knee, and, occasionally, instability. Diagnosis is commonly made with a combination of a physical exam from your surgeon followed by an X-ray or MRI to confirm the diagnosis.

Most isolated PCL injuries can be treated conservatively with physical therapy and protective weight bearing. For full tears that are causing instability or for multiligament injuries, surgical repair may be recommended.

Iliotibial band friction syndrome (IT Band Syndrome) is an overuse injury that causes inflammation of the IT Band. The IT Band is a structure on the lateral side of the hip and knee that is important in lower extremity movement. In athletes, friction between the IT Band and the bone can occur causing point tenderness on the outside of the hip or knee that worsens with activity. A physical exam is done to diagnose this condition. Initial treatment involves rest from the aggravating activity, anti-inflammatory medications, and physical therapy. Cortisone injections can be used in cases that are not improving.

Tibial plateau fractures are injuries to the proximal part of the tibia, the portion that aligns with the knee joint. They can be the result of falls or from more high energy mechanisms such as car accidents or contact sports injuries. Symptoms include immediate pain, swelling, and difficulty moving the knee. This is primarily diagnosed with an X-ray, but a CT or MRI can also be ordered if more information about the extent of the fracture is needed.

All of these injuries should be first evaluated by your provider. Treatment of tibial plateau fractures depends on the positioning and extent of the fracture. In nondisplaced stable fractures, typically a hinged knee brace used and patients undergo a period of non-weight bearing followed by physical therapy. In more complex fractures, surgical treatment may be recommended. Surgical treatment will often involve placing a combination of plates and screws at the site of the fracture in order to stabilize the bone and to allow for good future outcomes and function.

Osteoarthritis is the most common type of knee arthritis. It can affect the main knee joint or the patellofemoral joint in the knee. Osteoarthritis is usually caused by age along with wear and tear from activity and work. As such, it usually develops slowly over time and is most common in patients over 60 years of age. Progressive loss of cartilage leads to pain and joint stiffness.

There are other causes of arthritis. Some inflammatory conditions such as Rheumatoid arthritis and Psoriatic arthritis can also lead to loss of cartilage in the knee joint. Additionally, prior injury, such as ligamentous injury or fracture, can change the biomechanics of the knee or permanently injure the cartilage and lead to something called post-traumatic arthritis.

Symptoms usually begin very gradually with only a slight increase in pain with activity or walking or with subtle loss of motion in the knee. Sometimes, an unrelated injury in the knee can make underlying arthritis suddenly symptomatic. These symptoms tend to worsen over time, especially as people get older. More severe arthritis can be associated with significant pain with walking or daily activities, pain specifically with ascending or descending stairs, as well as catching or cracking noises known as crepitus.

Knee arthritis is diagnosed primarily on X-ray, as this best shows the extent to which the joint has worn out. Once diagnosed, treatment for arthritis depends on its severity. For more mild cases, preservation of range of motion and strengthening with physical therapy is very helpful. Multiple types of injections are available including cortisone injections, hyaluronic acid injections, or PRP. In severe cases, a knee replacement can be a very effective option for restoring full range of motion and eliminating pain.

Treatment

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At Pacific Crest Orthopedics, we customize a treatment plan to meet your individual needs. In the knee, some of the most common treatments include different types of injections, the use of anti-inflammatories, physical therapy, and the use of a knee brace. For some conditions, surgery is indicated as the best option. See more on our surgery treatments.

Ephraim Dickinson, MD at Pacific Crest Orthopedics has extensive experience treating your knee pain and providing therapies to prevent future problems and to keep you active and healthy. Don’t continue to suffer from knee pain or immobility. If you have questions about knee pain, call Pacific Crest Orthopedics in San Francisco or use the online booking tool to schedule an appointment today.

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