Knee injuries and conditions

Specializing in the treatment of knees

The Shelbourne Knee Center "specializes in the treatment of knees." Years of experience and research have shown that treatment options should be individualized for each patient depending on the many variables surrounding the knee injury or condition and the patient's lifestyle. Please use this page for information only and visit Publications for articles published on these subjects and more.

This page contains descriptions, symptoms and treatment for various knee injuries and is not intended to diagnose or recommend specific treatments.

Injuries
Ligament injuries
ACL tears
Meniscus inuries
Tibial spine avulsion
Conditions
Osteoarthritis
Deconditioned knee
Patellofemoral disorders
Tendonitis
Arthrofibrosis
Knee anatomy
Interactive Knee

Knee ligament injuries

There are 4 main ligaments that provide stability to the knee: knee ligaments

Anterior Cruciate Ligament (ACL) Keeps the tibia (shin bone) from moving forward on the femur (thigh bone)
Posterior Cruciate Ligament (PCL) Keeps the tibia (shin bone) from moving backward on the femur (thigh bone)
Medial Collateral Ligament (MCL) Prevents the knee from buckling inward
Lateral Collateral Ligament (LCL) Prevents the knee from buckling outward

Injuries to the knee can cause these ligaments to tear. A torn ligament may cause your knee to feel loose or unstable. Sometimes knee injuries will cause more than one of these ligaments to be injured at the same time.

Symptoms of a Knee Ligament Injury

Pain in the knee joint following the injury
Swelling (may not always be present)
Feelings of instability

Treatment of Knee Ligament Injuries

Knee ligament injuries may or may not need surgery. This depends on which ligament is torn. MCL and PCL tears usually heal without surgery. ACL tears should be treated with surgery in active patients who want to return to recreational or competitive athletic sports.

People who have a torn ACL can participate in some sports that don’t involve a lot of cutting or changes of direction. The decision of how to treat your injury will be discussed with you at your appointment.

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Anterior cruciate ligament (ACL) tear:

Overview

Anterior Cruciate Ligament (ACL) is located in the center of the knee joint. The ACL, along with the posterior cruciate ligament (PCL), provides stability to knee.

ACL tears typically occur:

In non-contact sports or situations
With an unexpected change of direction while the foot is planted
When landing awkwardly
An ACL tear is a major injury. Patients describe falling to the ground and knowing immediately that they had done something bad to their knee.

Common symptoms of an ACL tear

Significant swelling soon after the injury
Hear/feel a “pop” during the injury
Feeling like the knee “comes apart” during the injury
Walking on your toes immediately after the injury
Unable to continue with the sport or activity you were doing at the time of the injury
Feelings of instability or fear that the knee will give way following the acute injury

Treatment of an ACL Tear

A normal ACL provides stability to the knee joint during activities such as cutting, pivoting, and jumping. A patient who wants to return to their previous level of activity in sports that require these types of movements, should have the torn ACL surgically reconstructed. For patients with lower activity levels, ACL surgery may not be needed. We will review these options with you during your appointment.

ACL Reconstruction

ACL reconstruction replaces your torn ACL and restores stability to your knee. Click here for detailed description of our ACL reconstruction technique.

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Meniscus injuries

Overview

The menisci are two cartilage discs that sit between the tibia (shin bone) and the femur (thigh bone). The word menisci is the plural term for meniscus. The two menisci are the medial meniscus and the lateral meniscus. The medial meniscus is on the inner side of the knee while the lateral meniscus is on the outer side of the knee.

The menisci serve two important roles. First, they help make the tibia and the femur fit together better. Second, the menisci act as cushions to distribute the impact of weight bearing across the joint surface.

A normal meniscus in a young, healthy person is very firm with smooth edges. Damage to the meniscus in younger people is rare and is normally caused by a traumatic injury.

The menisci slowly degenerate as people age. Over time this can cause small tears to develop within the meniscus that can get caught during bending and straightening movements of the knee. This is a very common problem in people over the age of 40. Patients commonly complain of locking or catching in the knee when there is a meniscus tear. Often times, the knee also becomes swollen and stiff. The pain can start with or without a specific injury.

Common Symptoms of a Meniscus Tear

Pain that is in one spot in the knee
Swelling
Pain when bending the knee
Decreased range of motion
Clicking/Catching sensation in the knee
Locking sensation in the knee

Treatment of Meniscus Tears

The symptoms from a meniscus tear occasionally go away with time and rehabilitation. In these cases surgery may not be necessary.In some situations a knee arthroscopy is required to remove the torn piece.

A meniscus tear can be compared to having a pebble in your shoe. If the pebble doesn’t prevent you from doing normal activities and is not too uncomfortable, it doesn’t necessarily need to be removed.

If surgery is indicated, a knee arthroscopy will be scheduled. This is an outpatient surgery, but is done under a general anesthesia. Following surgery, rehabilitation focuses on preventing and eliminating swelling, restoring full range of motion, normal gait (walking), and full strength.

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Tibial Spine Avulsion

Ovewrview

A tibial spine avulsion is an injury to the area where the anterior cruciate ligament (ACL) attaches to the tibia (shin bone). Instead of tearing the ligament, the bony area where the ACL attaches gets pulled away from the rest of the bone.

The best way to explain this is to compare it to an uprooted tree.

Instead of the failure point occurring in the middle of the tree trunk, the tree’s root system gets pulled out of the ground.

With a tibial spine avulsion, the area of bone that is attached to the ACL gets pulled away from the rest of the bone. In our experience, this injury occurs in two age groups: preadolescent (age 9-14) and adult.

Common signs/symptoms

Stiffness including inability to straighten knee all the way out
Swelling
Pain in the joint
Difficulty walking

Treatment:

Our treatment approach to this problem is unique. We value the importance of restoring normal range of motion to the knee following this injury. We have found that attempting to re-attach the elevated piece of bone causes limitations in range of motion and function. Therefore, our surgical technique involves removing the elevated piece of bone. Our research shows that patients treated with this technique achieve excellent stability and range of motion.

The goal of treatment for a tibial spine avulsion injury is to regain full, symmetric range of motion and stability. The elevated piece of bone limits extension (straightening) motion. Sometimes this piece of bone can be put back into place by working on range of motion under the guidance of a medical professional. Other times, the piece of bone needs to be removed by doing an arthroscopy. Many times this is all that needs to be done to treat this problem. However, if patients have feelings of instability, an ACL reconstruction may be needed. The doctors at the Shelbourne Knee Center will discuss your options with you during your evaluation.

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Osteoarthritis

Overview

Healthy joints have a layer of cartilage lining the bone surfaces. Osteoarthritis occurs when this cartilage breaks down and the joint space becomes narrowed.

Osteoarthritis affects weight-bearing joints such as the hips, knees, and spine. The pain may worsen after repetitive use (walking or standing), or after periods of inactivity (sitting or sleeping).

Common symptoms:

Pain in thr joint
Stiffness or loss of motion
Swelling
“Creaking” in the joint

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Treatment of Osteoarthritis

Our knee rehabilitation program can often decrease or eliminate the pain caused by osteoarthritis. Many patients who think or have been told they need a knee replacement have been able to delay or avoid surgery with our rehabilitation program.

We have found that knee stiffness makes the pain of osteoarthritis worse, so our rehabilitation program focuses on reducing the stiffness of the knee. We begin by working to improve the knee extension (straightening) motion first. Once movement in this direction is maximized, we shift our focus toward improving knee flexion (bending). Finally, some gentle strengthening exercises may be used. Patients are also educated about the use of cold and compression to reduce pain and swelling.

If the rehabilitation program does not bring adequate relief, knee replacement surgery is an option. The improvements made during rehabilitation allow for a faster, easier recovery after surgery.

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Deconditioned Knee

Overview

Knees work at their best level when they have full range of motion (ROM) and strength. Another important concept that is often overlooked is symmetry.

The right and left knee should have the same range of motion (ROM) and strength when compared to one another.

Occasionally, an injury or pain in the knee joint will cause a person to favor one knee over a period of time. People with knee pain will habitually stand with their weight shifted

away from the knee that is bothering them. Patients also unknowingly make other compensations in an effort to protect that knee when walking, squatting, and climbing stairs. Over time, this can cause a significant decrease in the strength and range of motion in that leg. Consequently, decreased strength and range of motion (ROM) cause further pain. Increased pain causes the person to favor their knee more which perpetuates the cycle.

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Diagnosis

Our rehabilitation staff can perform an evaluation and series of strength tests to isolate the source of your problem. Range of motion is also evaluated at each visit. A significant side-to-side difference in strength or range of motion (ROM) causes a deconditioned knee.

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Treatment

An individualized rehabilitation program will be developed to help you regain full, symmetric range of motion and strength. Our therapists specialize in treating knee problems and will tailor your program to address your specific needs.

Strength and range of motion will be closely monitored to make sure that you are making progress.

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Patellofemoral Disorders

Overview

The patellofemoral joint is made up of two bones: the patella (the knee cap) and the femur (the thigh bone). When the knee bends and straightens, the patella glides along a groove on the femur called the trochlea. Some people have differences in the way the knee cap and this bone fit together.

These variations can lead to problems with the patellofemoral joint. For example, when the patella sits too high in this groove, the patella is prone to dislocations. Altered alignment may also cause the joint surfaces to wear down which can cause pain. Problems in the patellofemoral joint can be divided into several groups:

Chondromalacia Patellae
Patellar Malalignment
Patellar Subluxation/Dislocation

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Chondromalacia Patellae

The undersurface of the patella is lined with cartilage. This cartilage provides a smooth surface for the patella to glide during knee movement. Chondromalacia is when this cartilage breaks down. The pain may be along the sides of the patella or it may feel like it is deep inside the knee.

Treatment of Chondromalacia Patellae

Treatment focuses on emphasizing full range of motion and strength. Rehabilitation will also address any muscle imbalances that may be contributing to the patellofemoral pain.

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Patellar Malalignment

Patellar malalignment occurs when the patella does not contact the femur in an ideal position. The patella can sit too high or too far toward the outer (lateral) side of the knee. People who have patellofemoral pain often complain of pain after sitting for prolonged periods and with stair climbing.

Treatment of Patellar Malalignment

Problems with the alignment of the patella may require surgery. This can be determined on an individual basis after an evaluation by Dr. Shelbourne or Dr. Urch. Rehabilitation focuses on restoring full, symmetric range of motion and strength.

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Patellar Subluxation/Dislocation

Some people experience episodes where their patella will dislocate, or slip to the side. The injury is usually followed by swelling, stiffness, and pain. It is important to have a thorough knee examination to assess for any damage that may have occurred at the time of the dislocation.

Treatment of Patellar Subluxation/Dislocation

At first, treatment will focus on minimizing the swelling, walking normally without a limp, and restoring full range of motion. Once range of motion is full and the swelling has resolved, treatment will focus on strengthening. Sometimes surgery is needed after a patellar dislocation. This can be determined on an individual basis after your evaluation.

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Tendonitis

Overview

Sports that involve a lot of running, jumping, and kicking can lead to pain in the front of the knee.

Adolescents often develop this pain during or after growth spurts. Bone growth occurs faster than soft tissue growth, resulting in tightness in the tendon across the front of the knee joint. This tightness combined with repetitive movements can result in tendonitis.

The tendon in the front of your knee is called the patellar tendon. This tendon connects the quadriceps muscle to the shin bone (tibia). This tendon can be divided into two areas: the quadriceps tendon and the patellar tendon. The quadriceps tendon is above the knee cap (patella) and the patellar tendon is below the knee cap. When the quadriceps muscle tightens, it pulls on the tendon and the knee straightens. This muscle is used during many activities including: squatting, stair climbing, kicking, running, and jumping.

Osgood Schlatter disease occurs in the lower part of the tendon where it attaches to the shin bone. Contraction of the quadriceps muscle pulls on the tendon and the bone where the tendon inserts. Repetitive stress through this area can cause a bump to form on the front of the shin bone.

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Sinding Larson Johansson disease is similar to Osgood Schlatter disease, but occurs in a different location. Sinding Larson Johansson disease occurs just below the knee cap (patella). A bump can sometimes be felt just below the knee cap.

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Patellar tendinitis

Patellar tendinitis is when the tendon gets irritated. It is different from the above conditions because it does not happen near the insertion of the tendon into the bone.

The above conditions result in similar symptoms such as:

Pain in the front of the knee with running, jumping, kneeling, squatting, or climbing stairs
Pain during full flexion (bending) of the knee
Pain in both knees
May be able to feel a bump in the area that is tender/painful

An evaluation by Dr. Shelbourne or Dr. Urch can help isolate the specific cause of your symptoms.

Treatment

Rehabilitation to improve flexibility in the muscles around your knee often helps alleviate symptoms. Sometimes surgery is needed to remove the damaged part of the tendon. Rehabilitation is necessary to allow for a return to normal activities following surgery. Rehabilitation focuses on restoring full, symmetric range of motion and strength.

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Arthrofibrosis

Overview

“Arthro” means joint and “fibrosis” means the formation of scar tissue. Therefore, arthrofibrosis is the abnormal or excessive growth of scar tissue. In the knee joint, this causes stiffness and loss of range of motion. Arthrofibrosis can occur after knee surgery or trauma. Appropriately directed rehabilitation can prevent the occurrence of arthrofibrosis.

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Symptoms of Arthrofibrosis

Decreased range of motion compared to the other knee after surgery/trauma

Treatment of Arthrofibrosis

The non-operative treatment of arthrofibrosis focuses on rehabilitation to regain range of motion. An Elite Seat or Flex Seat may be prescribed for daily treatments to regain your full range of motion. Other range of motion exercises will also be prescribed. If range of motion is not regained through non-operative treatment methods, surgery may be needed. Scar tissue can be removed during a knee arthroscopy.

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Knee Anatomy

Learning about normal knee anatomy will help you to better understand your knee condition. Many of the structures in the knee are named for their location. Learning some of the medical terminology will help you to understand the knee anatomy. The following terms are often used in anatomy:

Anterior: refers to a structure toward the front of the body
Posterior: refers to a structure toward the back of the body
Midline: an imaginary line running down the center of the body
Medial: refers to a structure closer to the midline (the medial side of the knee is the inner side of the knee)
Lateral: refers to a structure farther away from the center of the body (the lateral side of the knee is the outer side of the knee)

The knee joint consists of the femur (thigh bone) and the tibia (shin bone). The patella (knee cap) is located on the front of the knee joint. The joint surfaces of these bones are lined with articular cartilage. Articular cartilage provides a smooth joint surface. The knee joint is a synovial joint. Synovial joints are surrounded by a joint capsule and filled with a fluid called synovial fluid. Synovial fluid lubricates the joint.

Two cartilage cushions called menisci separate the tibia (shin bone) and the femur (thigh bone). Menisci is the plural term for meniscus. The two menisci are the medial meniscus and the lateral meniscus. The menisci serve two important roles. First, they help make the tibia and the femur fit together better. Second, the menisci act as cushions to distribute the impact of weight bearing across the joint surface.

There are 4 main ligaments that provide stability to the knee:
• Anterior Cruciate Ligament ( ACL )
   • Keeps the tibia (shin bone) from moving forward on the femur (thigh bone)
• Posterior Cruciate Ligament ( PCL )
   • Keeps the tibia (shin bone) from moving backward on the femur (thigh bone)
• Medial Collateral Ligament ( MCL )
   • Prevents the knee from buckling inward
• Lateral Collateral Ligament (LCL)
   • Prevents the knee from buckling outward

The quadriceps muscle is located on the front of the thigh. When the quadriceps muscle tightens, the knee extends (straightens). The quadriceps connect to the tibia (shin bone) via a long tendon across the front of the knee joint. The patella (knee cap) sits within this tendon. This tendon is divided into two parts. The quadriceps tendon attaches the quadriceps muscle to the top of the patella. The patellar tendon attaches the patella to the tibia. (Identify both quadriceps tendon and patellar tendon on diagram).

Another major muscle group near the knee is the hamstring muscle group. The hamstring group is made up of three muscles that cross the back of the knee. These muscles form the muscle mass along the back of the thigh.

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