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Paging Dr. Frischer - Knees
WRITTEN BY :   Dr. Alan Frischer

Recently I visited with some dear old friends, and we spent much of the weekend discussing…knees! Three generations of this family, from the 89-year-old matriarch to the 17-year-old high school student, are suffering from serious chronic knee problems.
Our knees bear enormous weight and pressure while providing flexible movement, and consequently they are the most complex, the largest, and the most vulnerable joints in our body. When we walk, our knees support one and a half times our body weight; when climbing stairs they support three to four times our body weight, and when we squat they support roughly eight times our body weight!
In order to understand what can go wrong, let’s review the major players in our knees’ anatomy:
•The two knee joints connect the femur (the thighbone and longest bone) to the tibia (the second longest bone), and the kneecap to the femur. These two joints work together to form a hinge that not only allows the knee to bend and straighten, but also to rotate slightly and from side to side.
•Ligaments are strong, tough bands that attach bones to bones and give strength and stability to the knee. They are not particularly flexible; once stretched, they tend to stay stretched, and if stretched too far, they snap.
•Tendons connect muscles to bones. Tendons are elastic tissues that are part of the muscle, and they serve to stabilize the knee. There are two major tendons in the knee-the quadriceps and patellar.
•In a joint, bones would rub against bones if it weren’t for cartilage, connective tissue that covers the end of bones and protects them as the joint moves. Articular cartilage is a thin, tough, flexible, slippery surface, and is lubricated by synovial fluid. Medial and lateral meniscus cartilage absorbs shock.
•The two main muscle groups (quadriceps and hamstrings) in our legs keep our knees stable, aligned, and moving.
•The roughly 13 bursa in and around each knee are fluid filled sacs, which cushion the joint and reduce friction between muscles, bones, tendons and ligaments.
With this complicated system, pain can come from many sources, and symptoms come in many varieties. Pain might be dull or sharp; constant or off-and-on; mild to agonizing. The range of motion could be too much or too little. Here are a few of the more common complaints and symptoms:
Swelling: Swelling within the first hour of an injury indicates bleeding into the joint, but if it occurs from 2-24 hours after injury, it’s likely a result of the joint producing large amounts of synovial fluid in an attempt to lubricate the injured area. A different cause of swelling is bursitis. It was known as “housemaid’s knee” because it is associated with prolonged kneeling. The strain and trauma cause the bursa (closed, fluid-filled sacs) to become inflamed.
Pain and Tenderness: Pain that gets worse with activity often indicates tendonitis or a stress fracture. Pain and tenderness accompanied by swelling can be more serious, indicating a possible cartilage tear or a sprain. Pain after injury might also be caused by muscles spasms.
Locking: Locking suggests that a loose fragment (often cartilage) is keeping the knee from straightening. This particle may be as small as a grain of sand, or as large as a quarter.
Giving Way: Giving way can be caused by a kneecap that slips out of its groove for even a moment, or by weak leg muscles, or by an old injury to a ligament. The result is a lack of stability. If the cartilage of the meniscus is torn, it may not heal. Pieces may become trapped and cause instability, fluid buildup, and pain. Injuries to a ligament are common in sporting events where the foot is planted and the body is pushed forward. Often a click is felt at time of injury, followed by pain, instability, and swelling.
Snaps, Crackles and Pops: Sometimes these noises are caused by loose particles floating inside the knee, and they may be harmless. Another common cause, most commonly found in teenagers and women, is a dislocating kneecap – one that often slips out of its socket. A pop resulting from trauma could indicate a torn ligament. Crackling, grinding or grating may indicate arthritis – most commonly, osteoarthritis, rheumatoid arthritis, or gout. Chondromalacia also shows these symptoms, follows a prior injury or dislocation, and results in a softening and breakdown of the tissue that lines the kneecap.
For the vast majority of knee problems, treatment consists of R.I.C.E. (Rest, Ice, Compression, and Elevation). For many, physical therapy and anti-inflammatory medication provide relief and healing.
Some repairable injuries, such as a torn meniscus, require arthroscopic surgery. A small scope is inserted into the knee and all surgical functions are performed through the scope. Knee replacements are generally reserved for cases of very advanced degenerative arthritis, where the cartilage is completely worn out and bone rubs against bone.
As is true for so many conditions, if you are suffering from knee pain and see no significant improvement over time, seek the guidance of your personal physician.
Dr. Alan Frischer is former chief of staff and former chief of medicine at Downey Regional Medical Center. Write to him in care of this newspaper at 8301 E. Florence Ave., Suite 100, Downey, CA 90240.

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Published: November 24, 2011 – Volume 10 – Issue 32



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