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Injuries, Symptoms & Treatments
Knee
Kick your knee pain for good.
Knee pain is a common complaint that affects people of all ages. Knee pain may be the result of an injury, such as a ruptured ligament or torn cartilage. Medical conditions — including arthritis, gout and infections — also can cause knee pain.
Knee pain can have different causes. Being overweight puts you at greater risk for knee problems. Overusing your knee can trigger knee problems that cause pain. If you have a history of arthritis, it could also cause knee pain.
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Diseases/Conditions of the knee
Common Knee Injuries
Meniscus Tears
ACL Injuries
Ligament Injuries
Fractures of the Knee
Osgood Schlatter Disease
Patellar Tendon Tear
Arthritis of the Knee
Shin Splints
Patellofemoral Pain Syndrome
Common Knee Injuries
Common Knee Injuries
Your knee is a complex joint with many components, making it vulnerable to a variety of injuries. Some of the most common knee injuries include fractures, dislocations, sprains, and ligament tears.
Many knee injuries can be successfully treated with simple measures, such as bracing and rehabilitation exercises. Other injuries may require surgery to correct.
Anatomy
The knee is the largest joint in the body, and one of the most easily injured. It is made up of four main things: bones, cartilage, ligaments, and tendons.
- Bones. Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella).
- Articular cartilage. The ends of the femur and tibia, and the back of the patella are covered with articular cartilage. This slippery substance helps your knee bones glide smoothly across each other as you bend or straighten your leg.
- Meniscus. Two wedge-shaped pieces of meniscal cartilage act as "shock absorbers" between your femur and tibia. Different from articular cartilage, the meniscus is tough and rubbery to help cushion and stabilize the joint. When people talk about torn cartilage in the knee, they are usually referring to torn meniscus.
- Ligaments. Bones are connected to other bones by ligaments. The four main ligaments in your knee act like strong ropes to hold the bones together and keep your knee stable.
- Collateral ligaments. These are found on the sides of your knee. The medial collateral ligament is on the inside of your knee, and the lateral collateral ligament is on the outside. They control the sideways motion of your knee and brace it against unusual movement.
- Cruciate ligaments. These are found inside your knee joint. They cross each other to form an "X" with the anterior cruciate ligament in front and the posterior cruciate ligament in back. The cruciate ligaments control the back and forth motion of your knee.
- Tendons. Muscles are connected to bones by tendons. The quadriceps tendon connects the muscles in the front of your thigh to your patella. Stretching from your patella to your shinbone is the patellar tendon.
Common Knee Injuries
Your knee is made up of many important structures, any of which can be injured. The most common knee injuries include fractures around the knee, dislocation, and sprains and tears of soft tissues, like ligaments. In many cases, injuries involve more than one structure in the knee.
Pain and swelling are the most common signs of knee injury. In addition, your knee may catch or lock up. Many knee injuries cause instability — the feeling that your knee is giving way.
Fractures
The most common bone broken around the knee is the patella. The ends of the femur and tibia where they meet to form the knee joint can also be fractured. Many fractures around the knee are caused by high energy trauma, such as falls from significant heights and motor vehicle collisions.
Dislocation
A dislocation occurs when the bones of the knee are out of place, either completely or partially. For example, the femur and tibia can be forced out of alignment, and the patella can also slip out of place. Dislocations can be caused by an abnormality in the structure of a person's knee. In people who have normal knee structure, dislocations are most often caused by high energy trauma, such as falls, motor vehicle crashes, and sports-related contact.
Anterior Cruciate Ligament (ACL) Injuries
The anterior cruciate ligament is often injured during sports activities. Athletes who participate in high demand sports like soccer, football, and basketball are more likely to injure their anterior cruciate ligaments. Changing direction rapidly or landing from a jump incorrectly can tear the ACL. About half of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments.
Posterior Cruciate Ligament (PCL) Injuries
The posterior cruciate ligament is often injured from a blow to the front of the knee while the knee is bent. This often occurs in motor vehicle crashes and sports-related contact. Posterior cruciate ligament tears tend to be partial tears with the potential to heal on their own.
Collateral Ligament Injuries
Injuries to the collateral ligaments are usually caused by a force that pushes the knee sideways. These are often contact injuries. Injuries to the MCL are usually caused by a direct blow to the outside of the knee, and are often sports-related. Blows to the inside of the knee that push the knee outwards may injure the lateral collateral ligament. Lateral collateral ligament tears occur less frequently than other knee injuries.
Meniscal Tears
Sudden meniscal tears often happen during sports. Tears in the meniscus can occur when twisting, cutting, pivoting, or being tackled. Meniscal tears may also occur as a result of arthritis or aging. Just an awkward twist when getting up from a chair may be enough to cause a tear, if the menisci have weakened with age.
Tendon Tears
The quadriceps and patellar tendons can be stretched and torn. Although anyone can injure these tendons, tears are more common among middle-aged people who play running or jumping sports. Falls, direct force to the front of the knee, and landing awkwardly from a jump are common causes of knee tendon injuries.
Content by the American Academy of Orthopaedic Surgeons
Meniscus Tears
Meniscus Tears
Meniscus tears are among the most common knee injuries. Athletes, particularly those who play contact sports, are at risk for meniscus tears. However, anyone at any age can tear the meniscus. When people talk about "torn cartilage" in the knee, they are usually referring to a torn meniscus.
Anatomy
Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella).
Two wedge-shaped pieces of fibrocartilage act as "shock absorbers" between your thighbone and shinbone. These are the menisci. The menisci help to transmit weight from one bone to another and play an important role in knee stability.
Description
The meniscus can tear from acute trauma or as the result of degenerative changes that happen over time. Tears are noted by how they look, as well as where the tear occurs in the meniscus. Common tears include bucket handle, flap, and radial.
Sports-related meniscus injuries often occur along with other knee injuries, such as anterior cruciate ligament (ACL) tears.
Cause
Acute meniscus tears often happen during sports. These can occur through either a contact or non-contact injury—for example, a pivoting or cutting injury.
As people age, they are more likely to have degenerative meniscus tears. Aged, worn tissue is more prone to tears. An awkward twist when getting up from a chair may be enough to cause a tear in an aging meniscus.
Symptoms
You might feel a "pop" when you tear the meniscus. Most people can still walk on their injured knee and many athletes are able to keep playing with a tear. Over 2 to 3 days, however, the knee will gradually become more stiff and swollen.
The most common symptoms of a meniscus tear are:
- Pain
- Stiffness and swelling
- Catching or locking of your knee
- The sensation of your knee "giving way"
- Inability to move your knee through its full range of motion
Content by the American Academy of Orthopaedic Surgeons
ACL Injuries
Anterior Cruciate Ligament (ACL) Injuries
One of the most common knee injuries is an anterior cruciate ligament sprain or tear.
Athletes who participate in high demand sports like soccer, football, and basketball are more likely to injure their anterior cruciate ligaments.
If you have injured your anterior cruciate ligament, you may require surgery to regain full function of your knee. This will depend on several factors, such as the severity of your injury and your activity level.
Anatomy
Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella). Your kneecap sits in front of the joint to provide some protection.
Bones are connected to other bones by ligaments. There are four primary ligaments in your knee. They act like strong ropes to hold the bones together and keep your knee stable.
Collateral Ligaments
These are found on the sides of your knee. The medial collateral ligament is on the inside and the lateral collateral ligament is on the outside. They control the sideways motion of your knee and brace it against unusual movement.
Cruciate Ligaments
These are found inside your knee joint. They cross each other to form an "X" with the anterior cruciate ligament in front and the posterior cruciate ligament in back. The cruciate ligaments control the back and forth motion of your knee.
The anterior cruciate ligament runs diagonally in the middle of the knee. It prevents the tibia from sliding out in front of the femur, as well as provides rotational stability to the knee.
Description
About half of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments.
Injured ligaments are considered "sprains" and are graded on a severity scale:
- Grade 1 Sprains. The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly stretched, but is still able to help keep the knee joint stable.
- Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose. This is often referred to as a partial tear of the ligament.
- Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable.
Partial tears of the anterior cruciate ligament are rare; most ACL injuries are complete or near complete tears.
Cause
The anterior cruciate ligament can be injured in several ways:
- Changing direction rapidly
- Stopping suddenly
- Slowing down while running
- Landing from a jump incorrectly
- Direct contact or collision, such as a football tackle
Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports. It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other suggested causes include differences in pelvis and lower extremity (leg) alignment, increased looseness in ligaments, and the effects of estrogen on ligament properties.
Symptoms
When you injure your anterior cruciate ligament, you might hear a "popping" noise and you may feel your knee give out from under you. Other typical symptoms include:
- Pain with swelling. Within 24 hours, your knee will swell. If ignored, the swelling and pain may resolve on its own. However, if you attempt to return to sports, your knee will probably be unstable and you risk causing further damage to the cushioning cartilage (meniscus) of your knee.
- Loss of full range of motion
- Tenderness along the joint line
- Discomfort while walking
Content by the American Academy of Orthopaedic Surgeons
Ligament Injuries
Combined Knee Ligament Injuries
The knee is the largest joint in your body and one of the most complex. It is also vital to movement.
Your knee ligaments connect your thighbone to your lower leg bones. Knee ligament sprains or tears are a common sports injury.
In the past, injuring more than one knee ligament would put an end to future sports activities. Today, many athletes are able to return to high level sports following multiple ligament injuries.
Anatomy
Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella). Your kneecap sits in front of the joint to provide some protection.
Bones are connected to other bones by ligaments. There are four primary ligaments in your knee. They act like strong ropes to hold the bones together and keep your knee stable.
Collateral Ligaments
These are found on the sides of your knee. The medial collateral ligament is on the inside and the lateral collateral ligament is on the outside. They control the sideways motion of your knee and brace it against unusual movement.
Cruciate Ligaments
These are found inside your knee joint. They cross each other to form an "X" with the anterior cruciate ligament in front and the posterior cruciate ligament in back. The cruciate ligaments control the back and forth motion of your knee.
Description
Because the knee joint relies just on these ligaments and surrounding muscles for stability, it is easily injured. Any direct contact to the knee or hard muscle contraction — such as changing direction rapidly while running — can injure a knee ligament.
Injured ligaments are considered "sprains" and are graded on a severity scale.
- Grade 1 Sprains. The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly stretched, but is still able to help keep the knee joint stable.
- Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose. This is often referred to as a partial tear of the ligament.
- Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable.
It is possible to injure two or more ligaments at the same time. These multiple injuries can have serious complications. They can disrupt blood supply to the leg. They can also affect the nerves that supply the muscles of the limb. In severe cases, multiple ligament injuries may lead to amputation.
The MCL is injured more often than the LCL. Due to the more complex anatomy of the outside of the knee, if you injure your LCL, you usually injure other structures in the joint, as well.
Content by the American Academy of Orthopaedic Surgeons
Fractures of the Knee
Distal Femur (Thighbone) Fractures of the Knee
A fracture is a broken bone. Fractures of the thighbone that occur just above the knee joint are called distal femur fractures. The distal femur is where the bone flares out like an upside-down funnel.
The distal femur is the area of the leg just above the knee joint.
Distal femur fractures most often occur either in older people whose bones are weak, or in younger people who have high energy injuries, such as from a car crash. In both the elderly and the young, the breaks may extend into the knee joint and may shatter the bone into many pieces.
Anatomy
The knee is the largest weightbearing joint in your body. The distal femur makes up the top part of your knee joint. The upper part of the shinbone (tibia) supports the bottom part of your knee joint.
The ends of the femur are covered in a smooth, slippery substance called articular cartilage. This cartilage protects and cushions the bone when you bend and straighten your knee.
Description
Distal femur fractures vary. The bone can break straight across (transverse fracture) or into many pieces (comminuted fracture). Sometimes these fractures extend into the knee joint and separate the surface of the bone into a few (or many) parts. These types of fractures are called intra-articular. Because they damage the cartilage surface of the bone, intra-articular fractures can be more difficult to treat.
Distal femur fractures can be closed — meaning the skin is intact — or can be open. An open fracture is when a bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone. Open fractures often involve much more damage to the surrounding muscles, tendons, and ligaments. They have a higher risk for complications and take a longer time to heal.
When the distal femur breaks, both the hamstrings and quadriceps muscles tend to contract and shorten. When this happens the bone fragments change position and become difficult to line up with a cast.
In this x-ray of the knee taken from the side, the muscles at the front and back of the thigh have shortened and pulled the broken pieces of bone out of alignment.
Cause
Fractures of the distal femur most commonly occur in two patient types: younger people (under age 50) and the elderly.
Distal femur fractures in younger patients are usually caused by high energy injuries, such as falls from significant heights or motor vehicle collisions. Because of the forceful nature of these fractures, many patients also have other injuries, often of the head, chest, abdomen, pelvis, spine, and other limbs.
Elderly people with distal femur fractures typically have poor bone quality. As we age, our bones get thinner. Bones can become very weak and fragile. A lower-force event, such as a fall from standing, can cause a distal femur fracture in an older person who has weak bones. Although these patients do not often have other injuries, they may have concerning medical problems, such as conditions of the heart, lungs, and kidneys, and diabetes.
Symptoms
The most common symptoms of distal femur fracture include:
- Pain with weightbearing
- Swelling and bruising
- Tenderness to touch
- Deformity — the knee may look "out of place" and the leg may appear shorter and crooked
- In most cases, these symptoms occur around the knee, but you may also have symptoms in the thigh area.
Content by the American Academy of Orthopaedic Surgeons
Osgood Schlatter Disease
Osgood-Schlatter Disease (Knee Pain)
Osgood-Schlatter disease is a common cause of knee pain in growing adolescents. It is an inflammation of the area just below the knee where the tendon from the kneecap (patellar tendon) attaches to the shinbone (tibia).
Osgood-Schlatter disease most often occurs during growth spurts, when bones, muscles, tendons, and other structures are changing rapidly. Because physical activity puts additional stress on bones and muscles, children who participate in athletics — especially running and jumping sports — are at an increased risk for this condition. However, less active adolescents may also experience this problem.
In most cases of Osgood-Schlatter disease, simple measures like rest, ice, over-the-counter medication, and stretching and strengthening exercises will relieve pain and allow a return to daily activities.
Description
The bones of children and adolescents possess a special area where the bone is growing called the growth plate. Growth plates are areas of cartilage located near the ends of bones. When a child is fully grown, the growth plates harden into solid bone.
Some growth plates serve as attachment sites for tendons, the strong tissues that connect muscles to bones. A bony bump called the tibial tubercle covers the growth plate at the end of the tibia. The group of muscles in the front of the thigh (called the quadriceps) attaches to the tibial tubercle.
When a child is active, the quadriceps muscles pull on the patellar tendon which, in turn, pulls on the tibial tubercle. In some children, this repetitive traction on the tubercle leads to inflammation of the growth plate. The prominence, or bump, of the tibial tubercle may become very pronounced.
Symptoms
Painful symptoms are often brought on by running, jumping, and other sports-related activities. In some cases, both knees have symptoms, although one knee may be worse than the other.
- Knee pain and tenderness at the tibial tubercle
- Swelling at the tibial tubercle
- Tight muscles in the front or back of the thigh
Content by the American Academy of Orthopaedic Surgeons
Patellar Tendon Tear
Patellar Tendon Tear
Tendons are strong cords of fibrous tissue that attach muscles to bones. The patellar tendon works with the muscles in the front of your thigh to straighten your leg.
Small tendon tears can make it difficult to walk and participate in other daily activities. A large tear of the patellar tendon is a disabling injury. It usually requires surgery and physical therapy afterward to regain full knee function.
Anatomy
The tendons of the knee. Muscles are connected to bones by tendons.
The patellar tendon attaches the bottom of the kneecap (patella) to the top of the shinbone (tibia). When a structure connects one bone to another, it is actually a ligament, so the patellar tendon is sometimes called the patellar ligament.
The patella is attached to the quadriceps muscles by the quadriceps tendon. Working together, the quadriceps muscles, quadriceps tendon, and patellar tendon enable you to straighten your knee.
Description
Patellar tendon tears can be either partial or complete.
Partial tears. Many tears do not completely disrupt the tendon. This is similar to a rope stretched so far that some of the fibers are frayed, but the rope is still in one piece.
Complete tears. When the patellar tendon is completely torn, the tendon is separated from the kneecap. Without this attachment, you cannot straighten your knee.
The patellar tendon often tears at the place where it attaches to the kneecap, and a piece of bone can break off along with the tendon. When a tear is caused by a medical condition — like tendinitis — the tear usually occurs in the middle of the tendon.
Cause
Injury
It takes a very strong force to tear the patellar tendon.
Falls
Direct impact to the front of the knee from a fall or other blow is a common cause of tears. Deep lacerations are often associated with this type of injury.
Jumping
The patellar tendon may tear when the knee is bent and the foot planted, like when landing from a jump or jumping up.
Tendon Weakness
A weakened patellar tendon is more likely to tear. Several things can lead to tendon weakness.
Patellar tendinitis. Inflammation of the patellar tendon, called patellar tendinitis, weakens the tendon. It may also cause small tears.
Patellar tendinitis is most common in people who participate in activities that require running or jumping. Although it is more common in runners, it is often referred to as "jumper's knee."
Corticosteroid injections to treat patellar tendinitis have been linked to increased tendon weakness and increased likelihood of tendon rupture. Therefore, doctors typically avoid giving these injections in or around the patellar tendon.
Chronic disease.
Weakened tendons can also be caused by diseases that disrupt blood supply, including:
- Chronic kidney failure
- High cholesterol
- Inflammatory diseases (rheumatoid arthritis, systemic lupus erythmatosus)
- Diabetes mellitus
- Infection
- Metabolic disease
Steroid use.
Using medications like corticosteroids and anabolic steroids has been linked to increased muscle and tendon weakness.
Surgery
Previous surgery around the tendon, such as a total knee replacement or anterior cruciate ligament reconstruction, might put you at greater risk for a tear.
Symptoms
When a patellar tendon tears, you often experience a tearing or popping sensation. Pain and swelling typically follow, and you may not be able to straighten your knee. Additional symptoms include:
- An indentation at the bottom of your kneecap where the patellar tendon tore
- Bruising
- Tenderness
- Cramping
Your kneecap moving up into the thigh because it is no longer anchored to your shinbone
Difficulty walking due to the knee buckling or giving way
Content by the American Academy of Orthopaedic Surgeons
Arthritis of the Knee
Arthritis of the Knee
Arthritis is inflammation of one or more of your joints. Pain, swelling, and stiffness are the primary symptoms of arthritis. Any joint in the body may be affected by the disease, but it is particularly common in the knee.
Knee arthritis can make it hard to do many everyday activities, such as walking or climbing stairs. It is a major cause of lost work time and a serious disability for many people.
The most common types of arthritis are osteoarthritis and rheumatoid arthritis, but there are more than 100 different forms. While arthritis is mainly an adult disease, some forms affect children.
Although there is no cure for arthritis, there are many treatment options available to help manage pain and keep people staying active.
Anatomy
The knee is the largest and strongest joint in your body. It is made up of the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap). The ends of the three bones that form the knee joint are covered with articular cartilage, a smooth, slippery substance that protects and cushions the bones as you bend and straighten your knee.
Two wedge-shaped pieces of cartilage called meniscus act as "shock absorbers" between your thighbone and shinbone. They are tough and rubbery to help cushion the joint and keep it stable.
The knee joint is surrounded by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage and reduces friction.
Normal knee anatomy. The knee is made up of bones, cartilage, ligaments, and tendons.
Description
The major types of arthritis that affect the knee are osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis.
Osteoarthritis
Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative,"wear-and-tear" type of arthritis that occurs most often in people 50 years of age and older, although it may occur in younger people, too.
In osteoarthritis, the cartilage in the knee joint gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone, and produce painful bone spurs.
Osteoarthritis usually develops slowly and the pain it causes worsens over time.
Rheumatoid Arthritis
Rheumatoid arthritis is a chronic disease that attacks multiple joints throughout the body, including the knee joint. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.
In rheumatoid arthritis, the synovial membrane that covers the knee joint begins to swell, This results in knee pain and stiffness.
Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. The immune system damages normal tissue (such as cartilage and ligaments) and softens the bone.
Posttraumatic Arthritis
Posttraumatic arthritis is form of arthritis that develops after an injury to the knee. For example, a broken bone may damage the joint surface and lead to arthritis years after the injury. Meniscal tears and ligament injuries can cause instability and additional wear on the knee joint which, over time, can result in arthritis.
Symptoms
A knee joint affected by arthritis may be painful and inflamed. Generally, the pain develops gradually over time, although sudden onset is also possible. There are other symptoms, as well:
- The joint may become stiff and swollen, making it difficult to bend and straighten the knee.
- Pain and swelling may be worse in the morning, or after sitting or resting.
- Vigorous activity may cause pain to flare up.
- Loose fragments of cartilage and other tissue can interfere with the smooth motion of joints. The knee may "lock" or "stick" during movement. It may creak, click, snap or make a grinding noise (crepitus).
- Pain may cause a feeling of weakness or buckling in the knee.
- Many people with arthritis note increased joint pain with changes in the weather.
Content by the American Academy of Orthopaedic Surgeons
Shin Splints
Shin Splints
Shin splints are a common exercise-related problem. The term "shin splints" refers to pain along the inner edge of the shinbone (tibia).
Shin splints typically develop after physical activity. They are often associated with running. Any vigorous sports activity can bring on shin splints, especially if you are just starting a fitness program.
Simple measures can relieve the pain of shin splints. Rest, ice, and stretching often help. Taking care not to overdo your exercise routine will help prevent shin splints from coming back.
Description
Shin splints (medial tibial stress syndrome) is an inflammation of the muscles, tendons, and bone tissue around your tibia. Pain typically occurs along the inner border of the tibia, where muscles attach to the bone.
Cause
In general, shin splints develop when the muscle and bone tissue (periosteum) in the leg become overworked by repetitive activity.
Shin splints often occur after sudden changes in physical activity. These can be changes in frequency, such as increasing the number of days you exercise each week. Changes in duration and intensity, such as running longer distances or on hills, can also cause shin splints.
Other factors that contribute to shin splints include:
- Having flat feet or abnormally rigid arches
- Exercising with improper or worn-out footwear
- Runners are at highest risk for developing shin splints. Dancers and military recruits are two other groups frequently diagnosed with the condition.
- Flat feet can increase stress on lower leg muscles during exercise.
Symptoms
The most common symptom of shin splints is pain along the border of the tibia. Mild swelling in the area may also occur.
Shin splint pain may:
- Be sharp and razor-like or dull and throbbing
- Occur both during and after exercise
- Be aggravated by touching the sore spot
Content by the American Academy of Orthopaedic Surgeons
Patellofemoral Pain Syndrome
Patellofemoral Pain Syndrome
Patellofemoral pain syndrome (PFPS) is a broad term used to describe pain in the front of the knee and around the patella, or kneecap. It is sometimes called "runner's knee" or "jumper's knee" because it is common in people who participate in sports—particularly females and young adults—but PFPS can occur in nonathletes, as well. The pain and stiffness caused by PFPS can make it difficult to climb stairs, kneel down, and perform other everyday activities.
Many things may contribute to the development of PFPS. Problems with the alignment of the kneecap and overuse from vigorous athletics or training are often significant factors.
Symptoms are often relieved with conservative treatment, such as changes in activity levels or a therapeutic exercise program.
Anatomy
Your knee is the largest joint in your body and one of the most complex. It is made up of the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap).
Ligaments and tendons connect the femur to the bones of the lower leg. The four main ligaments in the knee attach to the bones and act like strong ropes to hold the bones together.
Muscles are connected to bones by tendons. The quadriceps tendon connects the muscles in the front of the thigh to the patella. Segments of the quadriceps tendon—called the patellar retinacula—attach to the tibia and help to stabilize the patella. Stretching from your patella to your tibia is the patellar tendon.
Several structures in the knee joint make movement easier. For example, the patella rests in a groove on the top of the femur called the trochlea. When you bend or straighten your knee, the patella moves back and forth inside this trochlear groove.
A slippery substance called articular cartilage covers the ends of the femur, trochlear groove, and the underside of the patella. Articular cartilage helps your bones glide smoothly against each other as you move your leg.
Also aiding in movement is the synovium—a thin lining of tissue that covers the surface of the joint. The synovium produces a small amount of fluid that lubricates the cartilage. In addition, just below the kneecap is a small pad of fat that cushions the kneecap and acts as a shock absorber.
Description
Patellofemoral pain syndrome occurs when nerves sense pain in the soft tissues and bone around the kneecap. These soft tissues include the tendons, the fat pad beneath the patella, and the synovial tissue that lines the knee joint.
In some cases of patellofemoral pain, a condition called chondromalacia patella is present. Chondromalacia patella is the softening and breakdown of the articular cartilage on the underside of the kneecap. There are no nerves in articular cartilage—so damage to the cartilage itself cannot directly cause pain. It can, however, lead to inflammation of the synovium and pain in the underlying bone.
Cause
Overuse
In many cases, PFPS is caused by vigorous physical activities that put repeated stress on the knee —such as jogging, squatting, and climbing stairs. It can also be caused by a sudden change in physical activity. This change can be in the frequency of activity—such as increasing the number of days you exercise each week. It can also be in the duration or intensity of activity—such as running longer distances.
Other factors that may contribute to patellofemoral pain include:
- Use of improper sports training techniques or equipment
- Changes in footwear or playing surface
- Patellar Malalignment
Patellofemoral pain syndrome can also be caused by abnormal tracking of the kneecap in the trochlear groove. In this condition, the patella is pushed out to one side of the groove when the knee is bent. This abnormality may cause increased pressure between the back of the patella and the trochlea, irritating soft tissues.
Factors that contribute to poor tracking of the kneecap include:
- Problems with the alignment of the legs between the hips and the ankles. Problems in alignment may result in a kneecap that shifts too far toward the outside or inside of the leg, or one that rides too high in the trochlear groove—a condition called patella alta.
- Muscular imbalances or weaknesses, especially in the quadriceps muscles at the front of the thigh. When the knee bends and straightens, the quadriceps muscles and quadriceps tendon help to keep the kneecap within the trochlear groove. Weak or imbalanced quadriceps can cause poor tracking of the kneecap within the groove.
Symptoms
The most common symptom of PFPS is a dull, aching pain in the front of the knee. This pain—which usually begins gradually and is frequently activity-related—may be present in one or both knees. Other common symptoms include:
- Pain during exercise and activities that repeatedly bend the knee, such as climbing stairs, running, jumping, or squatting.
- Pain on the front of the knee after sitting for a long period of time with your knees bent, such as one does in a movie theater or when riding on an airplane.
- Pain related to a change in activity level or intensity, playing surface, or equipment.
- Popping or crackling sounds in your knee when climbing stairs or when standing up after prolonged sitting.
Content by the American Academy of Orthopaedic Surgeons
Meniscus Tear
This is a common injury of the knee. Your knee joint is cushioned by two c-shaped wedges of cartilage called the "menisci." Each individual cushion is called a "meniscus." This injury is a tear of one of these cushions.
Patellofemoral Pain Syndrome
This is a pain you feel in the front of your knee. It involves the patella. That's the bone we commonly call the "kneecap."
ACL Tear
This injury is a tearing of the ACL ligament in the knee joint. The ACL ligament is one of the bands of tissue that connects the femur to the tibia. An ACL tear can be painful. It can cause the knee to become unstable.
Shin Splints
This is pain you feel in the front of one or both of your lower legs. It can be a problem for runners, dancers, gymnasts and other active people.
Common Treatments of General Orthopedics
Knee Arthroscopy
Total Knee Replacement
Patellofemoral Replacement
Minimally Invasive Total Knee Replacement
Osteotomy of the Knee
Knee Arthroscopy
Knee Arthroscopy
Knee arthroscopy is a surgical procedure that allows doctors to view the knee joint without making a large incision (cut) through the skin and other soft tissues. Arthroscopy is used to diagnose and treat a wide range of knee problems.
During knee arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your knee joint. The camera displays pictures on a video monitor, and your surgeon uses these images to guide miniature surgical instruments.
Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions, rather than the larger incision needed for open surgery. This results in less pain for patients, less joint stiffness, and often shortens the time it takes to recover and return to favorite activities.
Anatomy
Your knee is the largest joint in your body and one of the most complex. The bones that make up the knee include the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap).
Other important structures that make up the knee joint include:
- Articular cartilage. The ends of the femur and tibia, and the back of the patella are covered with articular cartilage. This slippery substance helps your knee bones glide smoothly across each other as you bend or straighten your leg.
- Synovium. The knee joint is surrounded by a thin lining called synovium. This lining releases a fluid that lubricates the cartilage and reduces friction during movement.
- Meniscus. Two wedge-shaped pieces of meniscal cartilage act as "shock absorbers" between your femur and tibia. Different from articular cartilage, the meniscus is tough and rubbery to help cushion and stabilize the joint.
- Ligaments. Bones are connected to other bones by ligaments. The four main ligaments in your knee act like strong ropes to hold the bones together and keep your knee stable.
- The two collateral ligaments are found on either side of your knee.
- The two cruciate ligaments are found inside your knee joint. They cross each other to form an "X" with the anterior cruciate ligament in front and the posterior cruciate ligament in back.
When Knee Arthroscopy is Recommended
Your doctor may recommend knee arthroscopy if you have a painful condition that does not respond to nonsurgical treatment. Nonsurgical treatment includes rest, physical therapy, and medications or injections that can reduce inflammation.
Knee arthroscopy may relieve painful symptoms of many problems that damage the cartilage surfaces and other soft tissues surrounding the joint.
Common arthroscopic procedures for the knee include:
- Removal or repair of a torn meniscus
- Reconstruction of a torn anterior cruciate ligament
- Removal of inflamed synovial tissue
- Trimming of damaged articular cartilage
- Removal of loose fragments of bone or cartilage
- Treatment of patella (kneecap) problems
- Treatment of knee sepsis (infection)
Preparing for Surgery
Evaluations and Tests
Your orthopaedic surgeon may recommend that you see your primary doctor to assess your general health before your surgery. He or she will identify any problems that may interfere with the procedure. If you have certain health risks, a more extensive evaluation may be necessary before your surgery.
To help plan your procedure, your orthopaedic surgeon may order preoperative tests. These may include blood tests or an electrocardiogram (EKG).
Admissions Instructions
If you are generally healthy, your knee arthroscopy will most likely be performed as an outpatient. This means you will not need to stay overnight at the hospital.
Be sure to inform your orthopaedic surgeon of any medications or supplements that you take. You may need to stop taking some of these before surgery.
The hospital or surgery center will contact you ahead of time to provide specific details of your procedure. Make sure to follow the instructions on when to arrive and especially on when to stop eating or drinking prior to your procedure.
Anesthesia
Before your surgery, a member of the anesthesia team will talk with you. Knee arthroscopy can be performed under local, regional, or general anesthesia:
- Local anesthesia numbs just your knee
- Regional anesthesia numbs you below the waist
- General anesthesia puts you to sleep
- Your orthopaedic surgeon and your anesthesiologist will talk to you about which method is best
Surgical Procedure
Positioning
Once you are moved into the operating room, you will be given anesthesia. To help prevent surgical site infection, the skin on your knee will be cleaned. Your leg will be covered with surgical draping that exposes the prepared incision site.
At this point, a positioning device is sometimes placed on the leg to help stabilize the knee while the arthroscopic procedure takes place.
Procedure
To begin the procedure, the surgeon will make a few small incisions, called "portals," in your knee. A sterile solution will be used to fill the knee joint and rinse away any cloudy fluid. This helps your orthopaedic surgeon see the structures inside your knee clearly and in great detail.
Your surgeon will insert the arthroscope and surgical instruments through small incisions called "portals."
Your surgeon's first task is to properly diagnose your problem. He or she will insert the arthroscope and use the image projected on the screen to guide it. If surgical treatment is needed, your surgeon will insert tiny instruments through other small incisions.
Specialized instruments are used for tasks like shaving, cutting, grasping, and meniscal repair. In many cases, special devices are used to anchor stitches into bone.
Closure
Most knee arthroscopy procedures last less than an hour. The length of the surgery will depend upon the findings and the treatment necessary.
Your surgeon may close each incision with a stitch or steri-strips (small bandaids), and then cover your knee with a soft bandage.
Complications
The complication rate after arthroscopic surgery is very low. If complications occur, they are usually minor and are treated easily. Possible postoperative problems with knee arthroscopy include:
- Infection
- Blood clots
- Knee stiffness
- Accumulation of blood in the knee
Recovery
After surgery, you will be moved to the recovery room and should be able to go home within 1 or 2 hours. Be sure to have someone with you to drive you home and check on you that first evening.
While recovery from knee arthroscopy is faster than recovery from traditional open knee surgery, it is important to follow your doctor's instructions carefully after you return home.
Pain Management
After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.
Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.
Medications
In addition to medicines for pain relief, your doctor may also recommend medication such as aspirin to lessen the risk of blood clots.
Swelling
Keep your leg elevated as much as possible for the first few days after surgery. Apply ice as recommended by your doctor to relieve swelling and pain.
Dressing Care
You will leave the hospital with a dressing covering your knee. Keep your incisions clean and dry. Your surgeon will tell you when you can shower or bathe, and when you should change the dressing.
Your surgeon will see you in the office a few days after surgery to check your progress, review the surgical findings, and begin your postoperative treatment program.
Bearing Weight
Most patients need crutches or other assistance after arthroscopic surgery. Your surgeon will tell you when it is safe to put weight on your foot and leg. If you have any questions about bearing weight, call your surgeon.
Rehabilitation Exercise
You should exercise your knee regularly for several weeks after surgery. This will restore motion and strengthen the muscles of your leg and knee.
Therapeutic exercise will play an important role in how well you recover. A formal physical therapy program may improve your final result.
Driving
Your doctor will discuss with you when you may drive. Typically, patients are able to drive from 1 to 3 weeks after the procedure.
Outcome
Many people return to full, unrestricted activities after arthroscopy. Your recovery will depend on the type of damage that was present in your knee.
Unless you have had a ligament reconstruction, you should be able to return to most physical activities after 6 to 8 weeks, or sometimes much sooner. Higher impact activities may need to be avoided for a longer time.
If your job involves heavy work, it may be longer before you can return to your job. Discuss when you can safely return to work with your doctor.
For some people, lifestyle changes are necessary to protect the joint. An example might be changing from high impact exercise (such as running) to lower impact activities (such as swimming or cycling). These are decisions you will make with the guidance of your surgeon.
Sometimes, the damage to your knee can be severe enough that it cannot be completely reversed with surgery.
Content by the American Academy of Orthopaedic Surgeons
Total Knee Replacement
Total Knee Replacement
If your knee is severely damaged by arthritis or injury, it may be hard for you to perform simple activities, such as walking or climbing stairs. You may even begin to feel pain while you are sitting or lying down.
If nonsurgical treatments like medications and using walking supports are no longer helpful, you may want to consider total knee replacement surgery. Joint replacement surgery is a safe and effective procedure to relieve pain, correct leg deformity, and help you resume normal activities.
Knee replacement surgery was first performed in 1968. Since then, improvements in surgical materials and techniques have greatly increased its effectiveness. Total knee replacements are one of the most successful procedures in all of medicine. According to the Agency for Healthcare Research and Quality, in 2017, more than 754,000 knee replacements were performed in the United States.
Whether you have just begun exploring treatment options or have already decided to have total knee replacement surgery, this article will help you understand more about this valuable procedure.
Anatomy
The knee is the largest joint in the body and having healthy knees is required to perform most everyday activities.
The knee is made up of the lower end of the thighbone (femur), the upper end of the shinbone (tibia), and the kneecap (patella). The ends of these three bones are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily within the joint.
The menisci are located between the femur and tibia. These C-shaped wedges act as "shock absorbers" that cushion the joint.
Large ligaments hold the femur and tibia together and provide stability. The long thigh muscles give the knee strength.
All remaining surfaces of the knee are covered by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage, reducing friction to nearly zero in a healthy knee.
Normally, all of these components work in harmony. But disease or injury can disrupt this harmony, resulting in pain, muscle weakness, and reduced function.
Cause
The most common cause of chronic knee pain and disability is arthritis. Although there are many types of arthritis, most knee pain is caused by just three types: osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.
Osteoarthritis. This is an age-related "wear and tear" type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones of the knee softens and wears away. The bones then rub against one another, causing knee pain and stiffness.
Rheumatoid arthritis. This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed "inflammatory arthritis."
Post-traumatic arthritis. This can follow a serious knee injury. Fractures of the bones surrounding the knee or tears of the knee ligaments may damage the articular cartilage over time, causing knee pain and limiting knee function.
Description
A knee replacement (also called knee arthroplasty) might be more accurately termed a knee "resurfacing" because only the surface of the bones are replaced.
There are four basic steps to a knee replacement procedure:
- Prepare the bone. The damaged cartilage surfaces at the ends of the femur and tibia are removed along with a small amount of underlying bone.
- Position the metal implants. The removed cartilage and bone is replaced with metal components that recreate the surface of the joint. These metal parts may be cemented or "press-fit" into the bone.
- Resurface the patella. The undersurface of the patella (kneecap) is cut and resurfaced with a plastic button. Some surgeons do not resurface the patella, depending upon the case.
- Insert a spacer. A medical-grade plastic spacer is inserted between the metal components to create a smooth gliding surface.
Is Total Knee Replacement for You?
The decision to have total knee replacement surgery should be a cooperative one between you, your family, your primary care doctor, and your orthopaedic surgeon. Your doctor may refer you to an orthopaedic surgeon for a thorough evaluation to determine if you might benefit from this surgery.
When Surgery Is Recommended
There are several reasons why your doctor may recommend knee replacement surgery. People who benefit from total knee replacement often have:
- Severe knee pain or stiffness that limits everyday activities, including walking, climbing stairs, and getting in and out of chairs. It may be hard to walk more than a few blocks without significant pain and it may be necessary to use a cane or walker
- Moderate or severe knee pain while resting, either day or night
- Chronic knee inflammation and swelling that does not improve with rest or medications
- Knee deformity — a bowing in or out of the knee
- Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries
Candidates for Surgery
There are no absolute age or weight restrictions for total knee replacement surgery.
Recommendations for surgery are based on a patient's pain and disability, not age. Most patients who undergo total knee replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total knee replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.
The Orthopaedic Evaluation
An evaluation with an orthopaedic surgeon consists of several components:
- Medical history. Your orthopaedic surgeon will gather information about your general health and ask you about the extent of your knee pain and your ability to function.
- Physical examination. This will assess knee motion, stability, strength, and overall leg alignment.
- X-rays. These images help to determine the extent of damage and deformity in your knee.
- Other tests. Occasionally blood tests or advanced imaging, such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your knee.
Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether total knee replacement is the best method to relieve your pain and improve your function. Other treatment options — including medications, injections, physical therapy, or other types of surgery — will also be considered and discussed.
In addition, your orthopaedic surgeon will explain the potential risks and complications of total knee replacement, including those related to the surgery itself and those that can occur over time after your surgery.
Deciding to Have Knee Replacement Surgery
Realistic Expectations
An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and cannot do.
Most people who have total knee replacement surgery experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living. But total knee replacement will not allow you to do more than you could before you developed arthritis.
With normal use and activity, every knee replacement implant begins to wear in its plastic spacer. Excessive activity or weight may speed up this normal wear and may cause the knee replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports for the rest of your life after surgery.
Realistic activities following total knee replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom dancing, and other low-impact sports.
With appropriate activity modification, knee replacements can last for many years.
Possible Complications of Surgery
The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit full recovery.
Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.
Infection. Infection may occur in the wound or deep around the prosthesis. It may happen within days or weeks of your surgery. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.
Blood clots. Blood clots in the leg veins are one of the most common complications of knee replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings, and medication to thin your blood.
Implant problems. Although implant designs and materials, as well as surgical techniques, continue to advance, implant surfaces may wear down and the components may loosen. Additionally, although an average of 115° of motion is generally anticipated after surgery, scarring of the knee can occasionally occur, and motion may be more limited, particularly in patients with limited motion before surgery.
Continued pain. A small number of patients continue to have pain after a knee replacement. This complication is rare, however, and most patients experience excellent pain relief following knee replacement.
Neurovascular injury. While rare, injury to the nerves or blood vessels around the knee can occur during surgery.
Preparing for Surgery
Medical Evaluation
If you decide to have total knee replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your doctor several weeks before the operation. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such as a cardiologist, before the surgery.
Tests
Several tests, such as blood and urine samples, and an electrocardiogram, may be needed to help your orthopaedic surgeon plan your surgery.
Medications
Tell your orthopaedic surgeon about the medications you are taking. He or she will tell you which medications you should stop taking and which you should continue to take before surgery.
Dental Evaluation
Although the incidence of infection after knee replacement is very low, an infection can occur if bacteria enter your bloodstream. To reduce the risk of infection, major dental procedures (such as tooth extractions and periodontal work) should be completed before your total knee replacement surgery.
Urinary Evaluations
People with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before undertaking knee replacement surgery.
Social Planning
Although you will be able to walk with a cane, crutches, or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing, and doing laundry.
If you live alone, a social worker or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at home. They also can help you arrange for a short stay in an extended care facility during your recovery if this option works best for you.
Home Planning
Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:
- Safety bars or a secure handrail in your shower or bath
- Secure handrails along your stairways
- A stable chair for your early recovery with a firm seat cushion (and a height of 18 to 20 inches), a firm back, two arms, and a footstool for intermittent leg elevation
- A toilet seat riser with arms, if you have a low toilet
- A stable shower bench or chair for bathing
- Removing all loose carpets and cords
- A temporary living space on the same floor because walking up or down stairs will be more difficult during your early recovery
Your Surgery
You will either be admitted to the hospital on the day of your surgery or you will go home the same day. The plan to either be admitted or to go home should be discussed with your surgeon prior to your operation.
Anesthesia
Upon arrival at the hospital or surgery center, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). The anesthesia team, with your input, will determine which type of anesthesia will be best for you.
Procedure
The surgical procedure usually takes from 1 to 2 hours. Your orthopaedic surgeon will remove the damaged cartilage and bone, and then position the new metal and plastic implants to restore the alignment and function of your knee.
After surgery, you will be moved to the recovery room, where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room or discharged to home.
Your Hospital Stay
If you are admitted to the hospital, you will most likely stay from one to three days.
Pain Management
After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.
Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose have become critical public health issues in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.
Blood Clot Prevention
Your orthopaedic surgeon may prescribe one or more measures to prevent blood clots and decrease leg swelling. These may include special support hose, inflatable leg coverings (compression boots), and blood thinners.
Foot and ankle movement is also encouraged immediately following surgery to increase blood flow in your leg muscles to help prevent leg swelling and blood clots.
Physical Therapy
Most patients can begin exercising their knee hours after surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement to allow walking and other normal daily activities soon after your surgery.
To restore movement in your knee and leg, your surgeon may use a knee support that slowly moves your knee while you are in bed. The device is called a continuous passive motion (CPM) exercise machine. Some surgeons believe that a CPM machine decreases leg swelling by elevating your leg and improves your blood circulation by moving the muscles of your leg, but there is no evidence that these machines improve outcomes.
Preventing Pneumonia
It is common for patients to have shallow breathing in the early postoperative period. This is usually due to the effects of anesthesia, pain medications, and increased time spent in bed. This shallow breathing can lead to a partial collapse of the lungs (termed "atelectasis"), which can make patients susceptible to pneumonia. To help prevent this, it is important to take frequent deep breaths. Your nurse may provide a simple breathing apparatus called a spirometer to encourage you to take deep breaths.
Your Recovery at Home
The success of your surgery will depend largely on how well you follow your orthopaedic surgeon's instructions at home during the first few weeks after surgery.
Wound Care
You will have stitches or staples running along your wound or a suture beneath your skin on the front of your knee. The stitches or staples will be removed several weeks after surgery. A suture beneath your skin will not require removal.
Avoid soaking the wound in water until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.
Diet
Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to help your wound heal and to restore muscle strength.
Activity
Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal activities of daily living within 3 to 6 weeks following surgery. Some pain with activity and at night is common for several weeks after surgery.
Your activity program should include:
- A graduated walking program to slowly increase your mobility, initially in your home and later outside
- Resuming other normal household activities, such as sitting, standing, and climbing stairs
- Specific exercises several times a day to restore movement and strengthen your knee. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy center the first few weeks after surgery.
You will most likely be able to resume driving when your knee bends enough that you can enter and sit comfortably in your car, and when your muscle control provides adequate reaction time for braking and acceleration. Most people resume driving approximately 4 to 6 weeks after surgery.
Avoiding Problems After Surgery
Recognizing the Signs of a Blood Clot
Follow your orthopaedic surgeon's instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.
Warning signs of blood clots. The warning signs of possible blood clots in your leg include:
- Increasing pain in your calf
- Tenderness or redness above or below your knee
- New or increasing swelling in your calf, ankle, and foot
Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:
- Sudden shortness of breath
- Sudden onset of chest pain
- Localized chest pain with coughing
Preventing Infection
A common cause of infection following total knee replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your knee replacement and cause an infection.
After knee replacement, patients with certain risk factors may need to take antibiotics prior to dental work, including dental cleanings, or before any surgical procedure that could allow bacteria to enter the bloodstream. Your orthopaedic surgeon will discuss with you whether taking preventive antibiotics before dental procedures is needed in your situation.
Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible knee replacement infection:
- Persistent fever (higher than 100°F orally)
- Chills
- Increasing redness, tenderness, or swelling of the knee wound
- Drainage from the knee wound
- Increasing knee pain with both activity and rest
Avoiding Falls
A fall during the first few weeks after surgery can damage your new knee and may result in a need for further surgery. Stairs are a particular hazard until your knee is strong and mobile. You should use a cane, crutches, a walker, handrails, or have someone to help you until you have improved your balance, flexibility, and strength.
Your surgeon and physical therapist will help you decide what assistive aides will be required following surgery and when those aides can safely be discontinued.
Outcomes
How Your New Knee Is Different
Improvement of knee motion is a goal of total knee replacement, but restoration of full motion is uncommon. The motion of your knee replacement after surgery can be predicted by the range of motion you have in your knee before surgery. Most patients can expect to be able to almost fully straighten the replaced knee and to bend the knee sufficiently to climb stairs and get in and out of a car. Kneeling is sometimes uncomfortable, but it is not harmful.
Most people feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending activities.
Most people also feel or hear some clicking of the metal and plastic with knee bending or walking. This is a normal. These differences often diminish with time and most patients find them to be tolerable when compared with the pain and limited function they experienced prior to surgery.
Your new knee may activate metal detectors required for security in airports and some buildings. Tell the security agent about your knee replacement if the alarm is activated.
Protecting Your Knee Replacement
After surgery, make sure you also do the following:
- Participate in regular light exercise programs to maintain proper strength and mobility of your new knee.
- Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.
- Make sure your dentist knows that you have a knee replacement. Talk with your orthopaedic surgeon about whether you need to take antibiotics prior to dental procedures.
- See your orthopaedic surgeon periodically for a routine follow-up examination and x-rays. Your surgeon will talk with you about the frequency and timing of these visits.
Extending the Life of Your Knee Implant
Currently, more than 90% of modern total knee replacements are still functioning well 15 years after the surgery. Following your orthopaedic surgeon's instructions after surgery and taking care to protect your knee replacement and your general health are important ways you can contribute to the final success of your surgery.
Content by the American Academy of Orthopaedic Surgeons
Patellofemoral Replacement
Patellofemoral Replacement
During knee replacement surgery, damaged bone and cartilage is resurfaced with metal and plastic components. Patellofemoral replacement is a type of "partial" knee replacement in which only a portion of the knee is resurfaced. The procedure is an alternative to total knee replacement for patients whose damaged bone and cartilage is limited to the underside of the patella (kneecap) and the channel-like groove in the femur (thighbone) that the patella rests in.
Because patellofemoral replacement is done through a smaller incision, there is less damage to soft tissues in the knee. In many cases, this allows patellofemoral replacement patients to recover faster and return to normal activities more quickly than total knee replacement patients.
There are a number of treatments for knee osteoarthritis. Your doctor will talk with you about the options that will best relieve your individual osteoarthritis symptoms.
Anatomy
Your knee is divided into three major compartments:
Medial compartment—the inside part of the knee
Lateral compartment—the outside part of the knee
Patellofemoral compartment—the front of the knee between the patella (kneecap) and femur (thighbone)
Within the patellofemoral compartment, the patella lies in a groove on the top of the femur called the trochlea. When you bend or straighten your knee, the patella moves back and forth inside this trochlear groove.
A slippery substance called articular cartilage covers the ends of the femur, trochlear groove, and the underside of the patella. Articular cartilage helps your bones glide smoothly against each other as you move your leg.
Description
In knee osteoarthritis, the cartilage protecting the bones of the knee slowly wears away. As the cartilage wears away, it becomes frayed and the underlying bone may become exposed. Moving the bones along this rough surface is painful. This can occur throughout the knee joint or just in a single area of the knee.
Advanced osteoarthritis that is limited to the patellofemoral compartment may be treated with patellofemoral replacement. During this procedure, the underside of the kneecap and the trochlear groove are resurfaced with metal and plastic implants. The healthy cartilage and bone, as well as all of the ligaments in the rest of the knee, are preserved.
Advantages of Patellofemoral Replacement
- Potential advantages of patellofemoral replacement over total knee replacement include:
- Less blood loss
- Quicker recovery
- Smaller surgical incision / less surgical trauma
- Decreased complications
- Increased knee function and activity
In addition, because the bone, cartilage, and ligaments in the healthy parts of the knee are kept, many patients report that a patellofemoral replacement feels more natural than a total knee replacement.
One advantage of patellofemoral replacement over total knee replacement is that healthy parts of the knee are preserved, which helps to maintain more "natural" function of the knee.
Disadvantages of Patellofemoral Replacement
The primary disadvantage of patellofemoral replacement compared with total knee replacement is the potential need for more surgery. For example, a total knee replacement may be necessary in the future if arthritis develops in the parts of the knee that have not been replaced.
Candidates for Surgery
If your osteoarthritis has advanced and nonsurgical treatment options are no longer relieving your symptoms, your doctor may recommend knee replacement surgery.
Careful patient selection is crucial when considering patellofemoral replacement. In order to be a candidate for the procedure, your arthritis must be confined to only the patellofemoral compartment of your knee.
In addition, if you have any of the following characteristics, you may not be a good candidate for the procedure:
- Knee stiffness
- Ligament damage
- Poor patellar (kneecap) tracking
- Major deformity of the leg
- Inflammatory arthritis (such as rheumatoid arthritis)
- Crystalline arthritis (such as gout)
- Morbid obesity
Orthopaedic Evaluation
A thorough evaluation by an orthopaedic surgeon will determine if you are a good candidate for patellofemoral replacement.
Medical History
Your doctor will ask you several questions about your general health, your knee pain, and your ability to function.
Location of pain. It is important for your doctor to determine the exact location of your pain. Candidates for the procedure typically have pain only behind the kneecap. This pain usually occurs during activities that put pressure on the kneecap, such as:
- Going up and down stairs
- Sitting with the knee bent
- Rising from a chair
Physical Exam
Your doctor will perform a thorough physical examination in order to determine the source of your pain. During the exam, he or she will:
Inspect your knee to determine the overall alignment of the joint
Palpate (feel) around your knee to see if your pain can be reproduced
Test range of motion to determine if you have knee stiffness or problems in patellar tracking
Assess the quality of the ligaments around the joint and the overall stability of your knee
Imaging Studies
X-ray. This study provides images of dense structures, such as bone. Your doctor will order x-rays from several different angles to ensure that your arthritis is confined to the space between the kneecap and the femur, and to assess the overall alignment of your knee.
Magnetic resonance imaging (MRI) scan. This study creates better images of the soft tissues in your knee. Your doctor may order an MRI to better evaluate the cartilage in your knee.
Your Surgery
Because patients undergoing partial knee replacement typically recover faster than patients undergoing total knee replacement, the procedure can sometimes be performed on an outpatient basis. During your initial consultation, your doctor will determine if you are a candidate for outpatient surgery or whether you will require a brief stay in the hospital.
Before Surgery
When you arrive for surgery, your surgeon will see you and verify the surgical site by signing the correct knee.
In addition, a doctor from the anesthesia department will discuss anesthesia choices with you. You should also have discussed anesthesia choices with your surgeon during your preoperative visits. Anesthesia options include:
General anesthesia (you are put to sleep)
Spinal (you are awake but your body is numb from the waist down)
Surgical Procedure
Inspection of the joint. Your surgeon will make an incision at the front of your knee. He or she will explore the three compartments of your knee, verifying that the damaged cartilage is, in fact, located only between the patella and the femur and that your ligaments are intact.
If your surgeon finds damaged cartilage outside of the patellofemoral compartment, he or she may instead perform a total knee replacement. This contingency plan will have been discussed with you before your operation to make sure that you agree with this strategy.
Patellofemoral replacement. There are two parts to the procedure:
- Prepare the bone. Your surgeon will use special tools to remove damaged cartilage and a small amount of bone from the patellofemoral compartment of your knee.
- Position the implants. A thin metal component is used to resurface the trochlear groove at the end of the femur. A plastic "button" or cover is used to resurface the backside of the patella. These parts are typically held to the bone with cement.
- Patellofemoral replacement implants. The metal femoral implant (left) resurfaces the trochlear groove of the femur. The round plastic patellar implant (right) attaches to the underside of the kneecap.
After Surgery
After surgery, you will be taken to the recovery room where you will be closely monitored as you recover from the anesthesia. You will then be either taken to your hospital room or discharged (if your surgery is being performed on an outpatient basis).
Complications
As with any surgical procedure, there are risks associated with patellofemoral replacement. These risks are similar to those of total knee replacement. Your surgeon will discuss each of the risks with you and will take specific measures to help avoid potential complications.
The possible risks of patellofemoral replacement include:
- Infection
- Blood clots
- Persistent pain
- Patellar instability (dislocating kneecap)
- Injury to surrounding structures, including blood vessels or nerves
- Reaction to anesthesia
- The need for additional surgery
Recovery
Pain management. After surgery, you will feel some pain. Many types of medicines are available to help control pain, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Treating pain with medications can help you feel more comfortable, which will help your body heal and recover from surgery faster.
Opioids can provide excellent pain relief, however, they are a narcotic and can be addictive. It is important to use opioids only as directed by your doctor. You should stop taking these medications as soon as your pain starts to improve.
Weight bearing. You will begin putting weight on your knee immediately after surgery. You may need to use a walker, cane, or crutches for several days following your operation.
Rehabilitation exercise. A physical therapist will provide specific exercises to help restore strength to your quadriceps muscles and maintain range of motion in your knee. It is critical to perform these exercises as often as directed in order to achieve a good outcome.
Doctor visits. You will continue to see your orthopaedic surgeon for follow-up visits to evaluate your progress after surgery.
Content by the American Academy of Orthopaedic Surgeons
Minimally Invasive Total Knee Replacement
Minimally Invasive Total Knee Replacement
Total knee replacement (also called knee arthroplasty) is a common orthopaedic procedure that is used to replace the damaged or worn surfaces of the knee. Replacing these surfaces with an implant or "prosthesis" will relieve pain and increase mobility, allowing you to return to your normal, everyday activities.
The traditional approach to knee replacement uses a long vertical incision in the center of the knee to view and access the joint. Minimally invasive total knee replacement is a variation of this approach. The surgeon uses a shorter incision and a different, less-invasive technique to expose the joint—with the goal of reducing postoperative pain and speeding recovery.
Unlike traditional total knee replacement, the minimally invasive technique is not suitable for all patients. Your orthopaedic surgeon will discuss the different surgical options with you.
Description
During any knee replacement, the damaged cartilage and bone from the surface of the knee is removed, along with some soft tissues. The goal of knee replacement surgery is to provide the patient with a pain-free knee that allows for the return to daily activities and lasts for a long time.
Minimally invasive knee replacement differs from traditional knee replacement in that it uses an incision that is smaller and requires less cutting of the tendons and ligaments.
Traditional Knee Replacement
To perform a traditional knee replacement, the surgeon makes an 8- to 10-inch vertical incision over the front of the knee to expose the joint. The surgeon will then:
- Prepare the bone. The damaged cartilage surfaces at the ends of the femur and tibia are removed along with a small amount of underlying bone.
- Position the metal implants. The removed cartilage and bone is replaced with metal components that recreate the surface of the joint.
- Resurface the patella. The undersurface of the patella (kneecap) is cut and resurfaced with a plastic button. Some surgeons do not resurface the patella, depending on the case.
- Insert a spacer. A plastic spacer is inserted between the metal components to create a smooth gliding surface.
In a total knee replacement, the surface of the joint is resurfaced and replaced with metal components. A plastic spacer is placed between the components.
Minimally Invasive Knee Replacement
In minimally invasive knee replacement, the surgical procedure is similar, but there is less cutting of the tissue surrounding the knee. The artificial implants used are the same as those used for traditional knee replacement. However, specially designed surgical instruments are used to prepare the femur and tibia and to place the implants properly.
Minimally invasive knee replacement is performed through a shorter incision—typically 4 to 6 inches versus 8 to 10 inches for traditional knee replacement. A smaller incision allows for less tissue disturbance.
In addition to a shorter incision, the technique used to open the knee is less invasive. In general, techniques used in minimally invasive knee replacement are "quadriceps sparing," meaning they avoid trauma to the quadriceps tendon and muscles in the front of the thigh. Other minimally invasive techniques called "midvastus" and "subvastus" make small incisions in the muscle but are also less invasive than traditional knee replacement. Because the techniques used to expose the joint involve less disruption to the muscle, it may lead to less postoperative pain and reduced recovery time.
The hospital stay after minimally invasive surgery is similar in length to the stay after traditional knee replacement surgery. This ranges from outpatient (same day) surgery to a hospital stay of 1 to 4 days. Physical rehabilitation is a critical component of recovery. Your surgeon or a physical therapist will provide you with specific exercises to help increase your range of motion and restore your strength.
Preparing for Joint Replacement Surgery
Candidates for Minimally Invasive Total Knee Replacement
Minimally invasive total knee replacement is not suitable for all patients. Your doctor will conduct a thorough evaluation and consider several factors before determining if the procedure is an option for you.
In general, candidates for minimal incision procedures are thinner, younger, healthier and more motivated to participate in the rehabilitation process, compared with patients who undergo the traditional surgery.
Minimally invasive surgeries may be less suitable for patients who are overweight or who have already undergone other knee surgeries.
In addition, patients who have a significant deformity of the knee, those who are very muscular, and those with health problems that may slow wound healing may be at a higher risk for problems from minimally invasive total knee replacement.
Conclusion
Minimally invasive knee replacement is an evolving area and more research is needed on the long-term function and durability.
The benefits of minimally invasive knee replacement have been reported to include less damage to soft tissues, leading to a quicker, less painful recovery and more rapid return to normal activities. Current evidence suggests that the long-term benefits of minimally invasive surgery do not differ from those of knee replacement performed with the traditional approach.
Like all surgery, minimally invasive surgery has a risk of complications. These complications include infection, wound healing problems, blood clots, nerve and artery injuries, and errors in positioning the prosthetic knee implants.
Like traditional knee replacement surgery, minimally invasive surgery should be performed by a well-trained, highly experienced orthopaedic surgeon. Your orthopaedic surgeon can talk to you about his or her experience with minimally invasive knee replacement surgery, and the possible risks and benefits of the techniques for your individual treatment.
Content by the American Academy of Orthopaedic Surgeons
Osteotomy of the Knee
Osteotomy of the Knee
Osteotomy literally means "cutting of the bone." In a knee osteotomy, either the tibia (shinbone) or femur (thighbone) is cut and then reshaped to relieve pressure on the knee joint.
Knee osteotomy is used when a patient has early-stage osteoarthritis that has damaged just one side of the knee joint. By shifting weight off of the damaged side of the joint, an osteotomy can relieve pain and significantly improve function in an arthritic knee.
Description
Osteoarthritis can develop when the bones of your knee and leg do not line up properly. This can put extra stress on either the inner (medial) or outer (lateral) side of your knee. Over time, this extra pressure can wear away the smooth articular cartilage that protects the bones, causing pain and stiffness in your knee.
Advantages and Disadvantages
- Knee osteotomy has three goals:
- To transfer weight from the arthritic part of the knee to a healthier area
- To correct poor knee alignment
- To prolong the life span of the knee joint
One advantage of the procedure is that, by preserving your own knee anatomy, a successful osteotomy may delay the need for a joint replacement for several years. Another advantage is that there are no restrictions on physical activities after an osteotomy—you will be able to participate in your favorite activities, even high-impact exercise.
Osteotomy does have disadvantages. For example, pain relief is not as predictable after osteotomy compared with a partial or total knee replacement. And recovery from osteotomy is typically longer and more difficult because you may not be able to bear weight on your operated knee right away.
In some cases, having had an osteotomy can make later knee replacement surgery more challenging.
Because results from total knee replacement and partial knee replacement have been so successful, knee osteotomy has become less common. Nevertheless, it remains an option for many patients.
Procedure
Most osteotomies for knee arthritis are done on the tibia (shinbone) to correct a bowlegged alignment that is putting too much stress on the inside of the knee.
During this procedure, a wedge of bone is removed from the outside of the tibia, under the healthy side of the knee. When the surgeon closes the wedge, it straightens the leg. This brings the bones on the healthy side of the knee closer together and creates more space between the bones on the damaged, arthritic side. As a result, the knee can carry weight more evenly, easing pressure on the painful side.
Tibial osteotomy was first performed in Europe in the late 1950s and brought to the United States in the 1960s. This procedure is sometimes called a "high tibial osteotomy."
Osteotomies of the thighbone (femur) are done using the same technique. They are usually done to correct a knock-kneed alignment.
Candidates for Knee Osteotomy
Knee osteotomy is most effective for thin, active patients who are less than 60 years old. Good candidates have pain on only one side of the knee, and no pain under the kneecap. Knee pain should be brought on mostly by activity, as well as by standing for a long period of time.
Candidates should be able to fully straighten the knee and bend it at least 90 degrees.
Patients with rheumatoid arthritis are not good candidates for osteotomy. Your orthopaedic surgeon will help you determine whether a knee osteotomy is suited for you.
Your Surgery
Before Surgery
You will likely be admitted to the hospital on the day of surgery.
Before your procedure, a doctor from the anesthesia department will evaluate you. He or she will review your medical history and discuss anesthesia choices with you. Anesthesia can be either general (you are put to sleep) or spinal (you are awake, but your body is numb from the waist down).
Your surgeon will also see you before surgery and sign your knee to verify the surgical site.
Surgical Procedure
A knee osteotomy operation typically lasts between 1 and 2 hours.
Your surgeon will make an incision at the front of your knee, starting below your kneecap. He or she will plan out the correct size of the wedge using guide wires. With an oscillating saw, your surgeon will cut along the guide wires, and then remove the wedge of bone. He or she will "close" or bring together the bones in order to fill the space created by removing the wedge. Your surgeon will insert a plate and screws to hold the bones in place until the osteotomy heals.
This is the most commonly used osteotomy procedure, and is called a closing wedge osteotomy.
In some cases, rather than "closing" the bones, the wedge of bone is "opened" and a bone graft is added to fill the space and help the osteotomy heal. This procedure is called an opening wedge osteotomy.
After the surgery, you will be taken to the recovery room where you will be closely monitored as you recover from the anesthesia. You will then be taken to your hospital room.
Complications
As with any surgical procedure, there are risks involved with osteotomy. Your surgeon will discuss each of the risks with you and will take specific measures to help avoid potential complications.
Although the risks are low, the most common complications include:
- Infection
- Blood clots
- Stiffness of the knee joint
- Injuries to vessels and nerves
- Failure of the osteotomy to heal
- In some cases, a second surgery may be required, particularly if the osteotomy does not heal.
Recovery
Hospital discharge. In most cases, patients go home 1 to 2 days after an osteotomy.
Pain management. After surgery, you will feel some pain, but your surgeon and nurses will make every effort to help you feel as comfortable as possible.
Many types of pain medication are available to help control pain, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDs) and local anesthetics. Treating pain with medications can help you feel more comfortable, which will help your body heal faster and recover from surgery faster.
Opioids can provide excellent pain relief, however, they are a narcotic and can be addictive. It is important to use opioids only as directed by your doctor. You should stop taking these medications as soon as your pain starts to improve.
Weight bearing. After the operation, you will most likely need to use crutches for several weeks. Your surgeon may also put your knee in a brace or cast for protection while the bone heals. Your surgeon will give you instructions about when weight bearing can begin.
Doctor visit. You will see your surgeon for a follow-up visit after surgery. X-rays will be taken so that he or she can check how well the osteotomy has healed. After the follow-up, your surgeon will tell you when it is safe to put weight on your leg, and when you can start rehabilitation.
Rehabilitation exercises. During rehabilitation, a physical therapist will give you exercises to help maintain range of motion in your knee and restore your strength.
You may be able to resume your full activities 3 to 6 months after surgery.
Outcome
For most patients, osteotomy is successful in relieving pain and delaying the progression of arthritis in the knee. It can allow a younger patient to lead a more active lifestyle for many years. Even though many patients will ultimately require a total knee replacement, an osteotomy can be an effective way to buy time until a replacement is required.
Content by the American Academy of Orthopaedic Surgeons
Knee Arthroscopy
If you have a joint problem, your surgeon may want to try arthroscopy. This lets your surgeon see inside your joint with a small, thin camera called an "arthroscope."
ACL Reconstruct.
This procedure repairs your knee after a tear of the anterior cruciate ligament (commonly called the "ACL"). This ligament is in the center of the knee. It helps anchor the femur to the tibia.
Total Knee Replacement
This procedure restores function to a severely damaged knee. Most commonly, it is used to repair a knee that has been damaged by arthritis.
Partial Meniscectomy
The meniscus is a cushion of cartilage. There are two in each knee. If one of these shock absorbers is worn out or hurt, you may need a partial meniscectomy to remove the damaged areas.
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