The cartilage within the knee is known as a meniscus and there is a meniscus on both and inside (medial) and outside (lateral) of each knee.
A tear in the meniscus can occur in anyone, and is usually the result of a trauma that twists the knee beyond its normal threshold. In young athletes it may require significant forces to create a tear. In older individuals a fairly innocuous stress on the knee may be all it takes to tear a meniscus that has degenerated with age.
- Pain and occasionally a ‘pop’ at the moment of the tear
- Pain and swelling that increases over 2-3 days
- Restricted knee that may catch or lock
- Although still able to walk, knee feels unstable and may ‘give way’
MAKING A DIAGNOSIS
- Physical diagnosis often shows tenderness along the joint on the side of the damaged cartilage
- Various orthopedic stress tests place tension on the meniscus and reproduce pain
- X-rays will show the space where the meniscus sits between the bones of the knee, but will not show the soft tissue of the meniscus itself.
- Magnetic resonance imaging (MRI) is the most sophisticated way of imaging the meniscus to determine if a tear is present.
How the meniscal tear is treated depends on the location, size and type of tear. It is also dependent on the age of the individual and the physical demands they have on their knee. If pain settles and the knee returns to a stable state, non-surgical management may be effective.
INITIAL ACUTE PHASE
- Rest – reduce weight bearing, use crutches if necessary
- Ice – 15min x3/day or more for several days. Ice wrapped up in damp tea-towel and placed onto skin. Continue to ice after activity.
- Compression – elastic bandage to reduce swelling
- Elevation – rest leg up on chair or higher to reduce pooling of fluid
- Rehabilitative exercise – gradual return to activity. Straight-kick swimming and cycling with a high seat are very good forms of knee rehab. See Exercise/Knee
In younger individuals, athletes and those with larger tears, surgery may be the best way.
This is one of the most commonly performed surgeries and is usually performed using a camera (arthroscope) through a small incision in the knee. Individuals may be walking soon after, but full recovery may take 6-12mths. Rehabilitation is still necessary after surgery.
Jumper’s Knee (Patella Tendonitis)
JUMPER’S KNEE (PATELLA TENDINOPATHY)
The patella tendon originates at the base of the kneecap (patella) and attaches into the bump immediately below (tibial tuberosity). The tendon can become inflamed, especially in athletes who play jumping sports, such as basketball and volleyball.
When the thigh muscle (quadriceps) contracts it exerts a pull on the patella, and hence the patella tendon, causing the knee to straighten. This is the action that occurs when jumping or kicking. Patella tendinitis is an acute condition. If the pain is low grade, but has been present for a long period, it is called Patella Tendinosis.
Diagnosis is usually made on the clinical presentation of pain, tenderness and swelling directly over the patella tendon. X-rays may be used to rule out degeneration of the joints or Osgood Schlatter’s Disease. Occasionally some calcification may be shown in the tendon itself.
ACUTE INITIAL PHASE
- Rest – avoid jumping sports
- Ice – 15mins x3/day
- Strapping or bracing over the patella tendon
- Gentle stretching – especially of the quadriceps, but being careful not to irritate the patella tendon
- Chiropractic adjustments to correct imbalance in the pelvis, hips, knees and feet.
- Strengthening exercise – see Exercise/Knee
- Chiropractic care
Patella tendinopathy is usually a self-limiting disorder that responds well to conservative management.
OSGOOD SLATTER’S DISEASE
Osgood Schlatter’s is a knee condition that most commonly affects adolescent boys. It produces pain and swelling at the site of the attachment of the patella tendon into the tibial tuberosity (bony bump under the kneecap). Like patella tendinopathy, this is commonly associated with running or jumping activities.
The condition was named after the two physicians that defined the disease in 1903, Dr. Robert Osgood and Dr. Carl Schlatter.
Osgood Schlatter’s occurs at a time when the growth plates are still open. The pulling of the tendon during activity causes inflammation and micro fractures.
As a result of the inflammation, increased calcium is laid down so that even after the condition has fully settled, the individual is left with a larger ‘bump’ over the tibial tuberosity.
History and clinical physical examination is usually all that is required to make a diagnosis. This can be confirmed by X-ray, which will show classic features of inflammation.
Osgood Schlatter’s will completely settle once the growth plates on the tibia (shin bone) close.
Until that time the condition is managed in much the same way as Patella Tendinitis.
OSTEOARTHRITIS OF KNEE
The knee is one of the most common joints to be afflicted with osteoarthritis (OA), which is a wear and tear joint degeneration that leads to breakdown of cartilage.
The condition develops slowly over many years and is more commonly see in people over the age of 60yrs. Previous knee injury may predispose and individual to OA later in life.
In severe cases joint replacement surgery may be required, though usually conservative management yields good results for reducing pain and improving strength and mobility.
Cycling with the bike seat on the high range of comfortable (so knee almost straightens out during the downward phase) and straight kick swimming are both good exercises for OA of the knee. This is provided the degeneration has not progressed to far.
For more information see section on Arthritis.
Patella Tracking Dysfunction
PATELLA TRACKING DISORDER
Also known as Patellofemoral Syndrome, Patellar Tracking Disorder (PTD) is a condition that affects the alignment of the kneecap (patella).
The misaligned patella typically shifts to the outside of the leg.
The result is a patella that no longer slides in the normal groove at the end of the thigh bone, causing the cartilage at the back of the patella to become irritated and breakdown.
Typically pain is bought on when bending the knee while weight bearing, such as squatting or walking up or down stairs.
CAUSES OF PTD
- FAULTY ALIGNMENT
This can be caused by faulty alignment of the thigh bone (femur) with the shin bone (tibia), such as that seen with over-pronation of the foot.
- FAULTY MUSCLE BALANCE
Another cause is an altered balance of tension between the muscles on the inside and outside of the thigh. Typically the muscle immediately above and inside the knee called the Vastas Medialis Obliquus (VMO) is weak or slow to contract. In contrast, the fibrous band immediately above and outside the knee called the Iliotibial Band (ITB) is to tight.
In some cases the shape of the patella from birth is mis-shaped and therefore does not slide in the grove of the femur.
The shift of the patella to the outside of the leg is subtle. This small shift combined with tens of thousands of knee movements eventually causes pain.
This is unlike a patella dislocation where a trauma to the knee causes the patella to dislocate outwards. This is very painful and relief comes only after the patella is pushed back in place, often the individual with the dislocation!
MANAGEMENT OF PTD
In most cases individuals respond well to conservative management. This includes:
- Rest, Ice, Compression and Elevation (RICE) in the early phases.
- Orthotics to correct over-pronation, if required
- Exercises to strengthen the VMO
- Foam roller massage of ITB
- Chiropractic care to correct pelvic and lower limb imbalance
EXERCISE TO STRENGTHEN YOUR VMO
- TERMINAL KNEE EXTENSION
To strengthen your VMO, sit on the edge of a chair with feet hanging. Turn one foot outwards and straighten knee slowly, tightening the inner knee muscle (VMO) as you fully extend. Hold this tight for 5 seconds then relax fully. Repeat 5 times.
- FAULTY ALIGNMENT