ORTHOPAEDIC PROBLEMS OF THE KNEE

Site of pain Patella Common differentials Prepatellar bursitis Jumpers knee Osteochondritis dissecans Chondromalacia patellae Suprapatellar bursitis Patellar tendonitis Osgood Schlatters syndrome Infrapatellar bursitis Lateral collateral ligament tendinopathy Lateral meniscus tear Popliteal tendinopathy Pes anserinus bursitis Iliotibial band bursitis Medial collateral ligament tendinopathy Medial meniscus tear Bakers cyst/gastrocnemius bursa Hamstring/gastroc-soleus injury Popliteal tendinopathy Osteoarthritis

Suprapatellar area Infrapatellar area

Lateral knee

Medial knee Posterior knee

Pain anywhere (age/wear dependent)

BURSITIS: bursae are little sacs filled with synovial fluid that are located where friction occurs (e.g. where tendons move over bony edges). Their role is to facilitate movement and reduce friction. Several knee bursae communicate with the articular cavity, so when they are swollen and inflamed it may indicate a joint pathology. Causes of bursitis: 1. Direct trauma, friction or compression 2. Inflammatory joint disease 3. Joint derangement meniscal tear, O/A etc. 4. Infection in or around the joint. Bakers Cyst usually occurs secondary to another knee problem or instability and consequent irritation from popliteus or the gastrocnemius, the cysts are in fact swellings of a bursa that is posterior to the knee. It usually communicates with the joint cavity through a small opening in the posterior capsule. These are usually in the gastrocnemius or popliteal bursae, or can communicate with the semi-membranosus bursa. MENISCUS TEARS: Meniscal tears most commonly occur as a result of a loading and twisting movement, but may also occur in older people (degenerative tears) as the collagen in the meniscus starts to break down. Classic signs and symptoms are swelling, pain and locking of the joint. Meniscal tears are classified as stable or unstable; a tear is unstable when part or all of the tear can be displaced into the joint space.

OSTEOCHONDRITIS DISSECANS: avascular necrosis of subchondral bone and overlying articular cartilage; can lead to fragmentation/fracture. It can be preceded by months to years of vague knee ache. s: signs of meniscal damage, chronic knee pain, oedema and joint line tenderness. Males > females, 2:1 between 12 20 yoa; two forms, juvenile (<15 yoa) and traumatic (16 20 yoa). Causes are poorly understood but may include repetitive trauma or ischaemia leading to poor healing following trauma. Often successfully treated by casting in children and by surgery in skeletally mature patients. OSGOOD-SCHLATTERS SYNDROME: traction apophysitis of the tibial tubercle. Occurs in M > F, 3:1. Common age of onset M = 10 15 yoa, F = 8 13 yoa (in line with ossification dates). s: pain and tenderness over tibial tuberosity, pain on ARMT of quads, history of pain going up/downhill/stairs, insidious onset. TTT: rest, ice, reduce quads tone, axx joints above and below, consider lumbar spine and weight-bearing re; gait mechanics/standing posture stressing anterior leg. Usually self-limiting with age. CHONDROMALACIA PATELLA: patellofemoral joint disorder involving softening, erosion, fragmentation and scarring of the articular/posterior surface of the patella. Occurs in all age groups but particularly in adolescents and the elderly.
Causes: 1. Trauma e.g. following dislocation or compressive strike to patella. 2. Repetitive stress more common in active/sporting young and middle-aged. 3. Biomechanical increased Q-angle leads to patella abutting the lat. femoral condyle, leading to earlier-than-usual degeneration; patella sitting high or low; knee hypermobility; muscle imbalance. 4. Ageing progresses to O/A of knee 5. Idiopathic in children

s: gradually increasing anterior knee ache; sometimes grinding/popping sensation; aggravated by going up/downstairs, after repetitive activities and sitting with the knees flexed. VMO atrophy is common in chronic conditions. Findings: patellar tenderness, crepitus and pain on ARMT quads. OSTEOARTHRITIS (little review): this occurs when the stress on the articular cartilage exceeds its capacity for orderly regeneration. It is a non-inflammatory disorder of synovial joints and is often asymptomatic. F > M, 2:1. Secondary OA identifiable causes, e.g. trauma, infection, inflammatory arthropathy, metabolic (e.g. Pagets disease), iatrogenic, crystal arthropathy, obesity, recurrent dislocation, hypermobility.
The 5 stages: i. Breakdown of articular surface (fibrillation), causing ii. Synovial irritation iii. Remodelling -> subchondral sclerosis, osteophytic growth iv. Eburnation of bone and cyst formation subchondral bone is exposed and microfracture occurs. v. Disorganisation joint becomes stiffer, more deformed.

s: aching or burning pain, worse after activity and end of day - relieved by rest; stiffness, weakness; swelling, reduced ROM, hxx of gradually increasing asymmetrical joint pain over years, tenderness over joint line. COMMON ORTHOPAEDIC INTERVENTIONS KNEE REPLACEMENT: knee arthroplasty can be a total knee replacement or a partial knee replacement. Half knee means a shorter stay in hospital and shorter recovery period. Most knee replacements are performed on people aged 65+. Knee replacements are considered where the pain is severe enough to interfere with quality of life or sleep, everyday tasks are impossible and work and social activities are limited by the knee pain. For TKR, patients usually stay in hospital for 6 10 days (less for PKR) and it can take 3 6 weeks to be walking without a frame or crutches. Swelling remains for 3 months and it can take about 2 years to recover fully (e.g. muscle redevelopment). LIGAMENT REPAIR: most commonly a repair of the ACL. This can be either a repair of the tendon or a graft from a hamstring, quadriceps or patellar tendon via arthroscopy. In a graft, a hole is drilled into the bone to pass the tendon through, and it is secured in place with screws or staples that are not removed. Usually overnight stay in hospital. Recovery: 2 weeks on crutches, weeks 2 6 = physio exx, 6 wks 6 months = gradual return to activities + safe sports, 6 months+ = sports that can involve twisting, jumping, turning.