The Knee in Sports
by John W. Robertson, M.D., Seattle Sports Medicine and Orthopedic Physician Associates
by John W. Robertson, M.D., Seattle Sports Medicine and Orthopedic Physician Associates
Professional and recreational athletes know the knee is often injured from sudden trauma or from chronic overuse. How a diagnosis is made and treatment accomplished will dictate how soon one is able to get back in the game. Most knee problems, even those due to trauma are generally non-surgical in nature. With an accurate diagnosis and appropriate rehabilitation, a speedy return to sports is enhanced. Less than 10% of knee injuries require surgery for optimal results. Advances in arthroscopic surgery and rehabilitation techniques has decreased recovery time and improved long-term results.
There are 2 general categories of knee problems that can plague those who are active with their exercise or work.
1). Acute Knee Injury: Due to a direct blow by an opponent, or from a twisting or hyperextending motion, such as cutting sharply or landing from a jump awkwardly.
2). Overuse Injury: Gradual onset of pain from overuse of tissues around the knee, including tendons, cartilage or the joint lining.
Any athlete with an acute injury should be seen immediately, on the field, later on the sidelines, or in the training or emergency room. There is a momentary golden period with sudden trauma, prior to the surrounding muscles going into spasm when information can be gathered. Pain may prevent certain tests until icing or pain medications have been given.
Early Assessment of an Acute Injury Include
1). Initial History/Physical Exam: Rule out fractures, dislocations or injuries to the nerves and vessels.
2). Comprehensive Exam: Focused on mechanism of injury, history of prior injuries, possible ligament or cartilage damage requiring intervention. Tests, including x-rays, bone scans, or MRI’s may help with diagnosis.
The Most Common Acute Ligament Sprain is to the Anterior Cruciate Ligament (ACL) Injury Type
1). Twisting
2). Cutting
3). Landing from a jump incorrectly
Symptoms
1). Popping Sensation
2). Dramatic Swelling
Treatment Options for Acute Pain Include
1). Analgesics (ibuprofen or Naprosyn)
2). Frequent Icing Control Pain/Swelling. 15 minutes several times a day is recommended.
3). Additional Treatment Dictated by the Nature/Severity of the Injury.
Decision Factors Prior to Surgery Include
1). Age
2). Activity Goals
3). Associated Injuries
4). Pre-Existing Arthritis
Timing of surgical intervention is dictated by the amount of swelling and stiffness present. Rehab progresses more quickly if the knee has regained any lost range of motion prior to surgery.
An injury at a ski destination is best treated after the early swelling and stiffness resolves which may take weeks. This also allows the patient to be followed by a surgeon who is present for post-operative rehabilitation and surgery.
The main problem with an ACL repair is not surgery, but the rehabilitation process, which can encompass months before the athlete returns to running and other sports. Ligament or cartilage injuries may require surgery or simply a thoughtful rehabilitation program. Individualized physical therapy programs, emphasizing daily exercises, leads to the most efficient return to pre-injury activity levels.
Chronic Overuse Injury Include
Patellofemoral Pain/Patellofemoral Arthralgia (PFA) :Pain at the front of the knee involving the kneecap (patella).The patellofemoral joint is where the patella "tracks" in the groove formed by the thigh bone (femur).
The Goal is to Determine if the Problem is
1). Pain: Increases with activity such as stair or hill running, prolonged sitting or driving.
2). Instability: Sense of "giving way" or "going out of joint"
3). Both
The patella can slip out of the groove to the outside (lateral) portion of the knee and be very painful. The 1st incident usually is the result of a twisting injury and swells quickly, similar to an ACL injury. Subsequent insults can be much less traumatic and create similar pain and unstable feelings.
The patella and the femoral groove are lined with a smooth white surface (articular cartilage), the stuff noted on the ends of the turkey drumstick at Thanksgiving. Cartilage can be injured with a direct blow from falling on the knee or from hitting the dashboard in an auto accident. Less dramatic injuries may occur with running, jumping, dancing or hiking, particularly downhill.
Predisposition to PFA stems from anatomical alignment problems or training errors that can cause other soft tissue inflammation such as tendinitis or bursitis. A thorough understanding of biomechanical alignment and harmful training programs is essential to the development of a successful rehab program.
During the physical exam
1). Site of Pain Determined
2). Anatomic Alignment Assessed
3). Strength and Flexibility Assessed
Occasionally the cause of knee pain is from the hip especially in children. Knee pain is often referred from the lumbar spine in all age groups.
Knee Structures that can Cause Pain Include
1). Articular Cartilage
2). Joint Lining
3). Surrounding Support Structures to include Ligaments
4). Tendon Attachments
5). Superficial Nerves
Alignment Issues Leading to Increased Force Across the Patellofemoral Joint
1). Flat Feet Causing Excessive Pronation. Prescription orthotics may improve pronation, but cost ($250 approximate) can be prohibitive.
2). Pronounced Bowing of Legs or "Knock-Kneed"
3). Abnormal Tendon Attachment at the Patella to the Upper Leg or Tibia
4). Tight Supporting Tissue Holding the Patella in Place
The presence of a crunching sensation (crepitation) when extending the knee with or without pain, suggests damage to the articular cartilage of the patella or femur.
Careful taping of the knee done by professionals (PT’s, Trainers, MD’s) can help stabilize excessive patellar motion during activity and reduce subsequent pain.
Several muscle groups affect knee function
1). Quadriceps (Front of Thigh)
2). Hamstrings (Back of Thigh)
3). Iliotibial Band (Outside of Thigh from Hip to Knee)
4). Gastrocnemius (1 of 2 Calf Muscles)
5). External Rotators of the Hip, including the Piriformis.
Imbalance of the muscle groups can lead to abnormal biomechanics at the knee. Careful assessment of flexibility can determine their role and lead to effective home stretching programs which attempt correction of any deficits.
Imbalance in the strength of the quads can result in pain. Exercises to balance quadriceps contractions may irritate and should be implemented with caution at the direction of a skilled physical therapist or athletic trainer. Biofeedback is often used to reeducate those with unbalanced quadriceps contractions.
Treatment Options for Acute Pain Include
1). Analgesics (ibuprofen or Naprosyn)
2). Frequent Icing Control Pain/Swelling. 15 minutes several times a day is recommended.
3). Patient Education Includes: activities to avoid and slow progression to previous activity levels to prevent recurrent symptoms.
Best knee outcomes result from a diagnosis leading to a well thought out and effective treatment program. Staying fit and maintaining a careful supplemental strength and flexibility program are the best ways to remain symptom free and in the game.