Eastern Orthopedics and Sports Medicine

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Dr. Kenneth R Alleyne

Dr. Vip Nanavati

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Frequently Asked Questions

Knee Injuries Questions

I recently had arthroscopic surgery because my knee kept locking. A loose cartilage fragment was found and removed. Why wasn't the fragment seen on an X-ray or MRI?

When I was in high school 25 years ago, I injured my knee while playing soccer. Two years later, after repeated buckling of my knee, I was told I had an anterior cruciate ligament injury. My daughter currently plays soccer in high school. It seems as though this knee injury is more common with my daughter's soccer team than when I played. Why is this so?

I am 49 years old and tore the anterior cruciate ligament in my left knee while snow skiing. Two years ago, my older brother, who was 48 at the time, tore his ACL. He was not offered the option of surgical repair. He was told to strengthen his thigh muscles and to quit sports. I have great concern about following in his footsteps. I am active and love sports. Can surgery be done at my age?

I have had chronic knee and back pain from arthritis for years. My friend lent me her magnet to see if I could get some pain relief. The magnet seemed to help my back pain but not my knee pain. Do magnets really work or is this psychological?

I am trying to decide whether to have an operation on my knee. I tore my anterior cruciate ligament in a snow-skiing accident. My concern is that my insurance will pay for the surgery, but for not more than two physical therapy visits after surgery. What would you advise?

I am thinking about having arthroscopic surgery on my knee for a meniscus cartilage tear. Could you explain why several incisions are made instead of one and what the locations would be?

When I was young, my kneecaps used to slip out of place. After high school I seemed to have outgrown this problem. At age 35, my kneecaps sound like sand paper when I walk. I have pain if I climb a lot of stairs, kneel or watch a long movie. What can I do to prevent things from getting worse?

Two years ago my meniscus cartilage tear in my knee was fixed. Doctors used an arthroscope to pass a suture into the joint to repair the tear. An extra incision was needed to tie the knots to complete the repair. I have been told there is a new technique that repairs the tear using small pegs, which eliminates the extra incision.

I am scheduled for a knee joint replacement. Because I am younger than the average patient, 55 years old, I am told I may need a second operation years later when certain parts wear out. Which part will most likely wear out?

Three years ago, I had a swollen knee that was drained by my doctor. The joint fluid was found to have gout. About a year later, I had two separate occasions where I developed a swollen knee after playing golf. An MRI showed a meniscus cartilage tear in each knee. Could the gout have caused the meniscus tears or was it my consistently bad golf game?

I am 55 years old with osteoarthritis of the right knee. No treatments have given me much relief. I have heard of a new treatment involving hyaluronic acid, which is available in Europe. What do you think of this treatment?

After six arthroscopic procedures on my knee, I have no meniscus cartilage. There is a loss of movement and the pain makes my tennis and golf activities unbearable but I do not want to give up those activities. My doctor says I have advanced arthritis. At 64, what are my options?

My husband is concerned with a clicking noise on the outside of my right knee. I have recently noticed pain accompanies the clicking and snapping when I go for long walks. What could this be?

I have just had an MRI done this week which showed the following findings: There is a full thickness radial tear through the posterior horn of the medial meniscus with the tear extending to the inferior articular surface. There is an additional partial thickness radial tear through the posterior horn of the lateral meniscus which extends to the superior articular surface. There is no associated meniscal cyst formation with either meniscal tear. I am 39 years old. I fell 3 years ago on a tile floor. My left leg went under my body as I sat on it when I fell. Is it repairable?

I had arthroscopic surgery 1 1/2 years ago on my right knee. Since the operation, I have maintained a steady exercise program of biking, swimming and weights without going to extremes. However, none of this has helped the pain I have in the front of my knee when going up and down stairs. Is there something I should be aware of to help eliminate or reduce my pain?

My son plays basketball year-round. He complained of pain in the lower front portion of his left knee all last year. He no longer has pain, but he has a hard bump where it used to hurt. Should I be concerned?

I am 60 and was diagnosed with knee osteoarthritis five years ago. Each year I have an X-ray. The last X-ray led my doctor to recommend a knee replacement. What do you look for on X-rays to make someone a candidate for surgery?

I took an early retirement from the Postal Service because of knee pain. I am otherwise in good health, but am crippled with arthritis and barely able to walk one block with a cane. I have decided to have an artificial knee replacement next fall. What can I do to prepare for this surgery?

Q: I recently had arthroscopic surgery because my knee kept locking. A loose cartilage fragment was found and removed. Why wasn't the fragment seen on an X-ray or MRI?

Locking can occur with meniscus cartilage tears, ligament tears or floating loose bodies. Because your particular problem was cartilage and not bone, it would not be seen on a plain X-ray. Some loose bodies are made of a combination of bone and cartilage. The bone content of these can be partially seen to identify the problem. Your history of locking would lead me to suspect a loose body present if no ligament instability or meniscus cartilage tear was seen during clinical examination of your knee. An MRI study has the capability of spotting a loose body. The images that are developed by MRI are created by the comparative difference of water content of each tissue. Cartilage has different amounts of water content than bone. These two tissues, side by side, would be clearly distinct. If the cartilage loose body had the same water content as the tissue it was lying on and had an unusually flat shape, it might not be seen on the MRI because of the lack of contrast.

Q: When I was in high school 25 years ago, I injured my knee while playing soccer. Two years later, after repeated buckling of my knee, I was told I had an anterior cruciate ligament injury. My daughter currently plays soccer in high school. It seems as though this knee injury is more common with my daughter's soccer team than when I played. Why is this so?

Your observation is correct. There are many reasons why anterior cruciate knee injuries are more prevalent in women soccer players today as compared to when you played 25 years ago. Women's participation in sports has dramatically increased since Title IX of the Education Act was passed in 1972 by Congress. Just by sheer numbers, more injuries will occur because you have more girls participating. You mention that your knee injury was confirmed after two years. Sports medicine research during the years has identified several maneuvers that a trained examiner can use to make an accurate diagnosis of an ACL or anterior cruciate ligament injury. Confirmation of knee injuries suspicious for an ACL tear is now possible with an MRI. Twenty-five years ago, ACL injuries often went undiagnosed for years, as in your case. There seems to be a gender disparity with ACL injuries, especially among soccer players. As the speed, level of play and intensity of women's soccer advances, we have seen a 5-to-1 ratio in ACL injuries when compared to their male counterparts. Several biomechanical factors are thought to be responsible. A wider pelvis and an increased ability to hyperextend the knee is thought to influence the position of the knee during landing. Men tend to rely more on their muscles to restrain joint forces, whereas women depend more on their ligaments for supporting and restraining forces of the knee. Researchers think that emphasis should be placed on training techniques to improve the strength and endurance of thigh muscle groups in women to reduce these injuries. Research is under way to develop training programs to reduce the number of ACL injuries in women athletes and to identify factors associated with increased risk for injury.

Q: I am 49 years old and tore the anterior cruciate ligament in my left knee while snow skiing. Two years ago, my older brother, who was 48 at the time, tore his ACL. He was not offered the option of surgical repair. He was told to strengthen his thigh muscles and to quit sports. I have great concern about following in his footsteps. I am active and love sports. Can surgery be done at my age?

The anterior cruciate ligament, or ACL, is an important stabilizing structure in your knee for sports such as skiing and tennis. In the past, when an ACL tear occurred at your age, nonsurgical treatment was advised. This included avoiding sports that require pivoting and abrupt changes in direction, utilizing a brace for athletic activity and physical therapy. Without this ligament, instability and knee buckling can result. Buckling episodes, where the knee gives way, have the potential for causing further injury to the knee joint. In time, arthritis also can develop. A brace can offer some prevention against instability and buckling. Arthroscopic surgery can restore stability to your knee by reconstructing the anterior cruciate ligament. Age is a consideration, but a relatively minor factor in the decision-making process. If you are healthy, with few arthritic changes in your knee, and have a desire to continue sports but cannot because of your instability, surgery should be considered. Each case needs to be evaluated individually.

Q: I have had chronic knee and back pain from arthritis for years. My friend lent me her magnet to see if I could get some pain relief. The magnet seemed to help my back pain but not my knee pain. Do magnets really work or is this psychological?

Magnetotherapy is the latest treatment being touted as a cure for what ails you. It has been recommended for treatment of sore muscles, chronic back pain, tennis elbow and lactic acid burn during and after workouts. The theory of how magnets work is based on two principles. More than 100 years ago, blood was found to have an electrical charge. Studies at the Massachusetts Institute of Technology showed that magnets increase the blood flow of an electrically charged fluid such as blood. Proponents of magnetotherapy explained that the increased blood flow from magnets hastens the healing process and speeds the removal of lactic acid and other harmful blood products in the tissues. Nerve fibers are also known to have an electrical charge. It is thought that magnets produce an electromagnetic impulse that is thought to block pain. One thing that most experts agree on is that use of magnets appears to be safe. But, there are several contradictions for those who have pacemakers, pregnancy, or serious bleeding after surgery. The use of magnets for pain treatment is unconfirmed. One of the main reasons for this attitude among clinicians and physicians is the lack of scientific research.

Q: I am trying to decide whether to have an operation on my knee. I tore my anterior cruciate ligament in a snow-skiing accident. My concern is that my insurance will pay for the surgery, but for not more than two physical therapy visits after surgery. What would you advise?

I cannot emphasize enough the importance of post-operative physical therapy after anterior cruciate ligament knee surgery. Physical therapy helps control swelling, reduce pain and restore the range of motion and strength of the knee. A well-trained surgeon who is capable of performing this technical surgery is half of the equation for a successful result. The other half of the equation is a well-trained and motivating physical therapist. One, without the other, often leads to poor results. Two post-operative visits are inadequate for the majority of patients who undergo this surgery. The important guidance by the physical therapist cannot be delivered to the patient in two visits. I would advise that you contact your insurance carrier to have them reconsider the post-operative limit of two visits for a surgery of this magnitude. Do not proceed with surgery if adequate therapy is not available.

Q: I am thinking about having arthroscopic surgery on my knee for a meniscus cartilage tear. Could you explain why several incisions are made instead of one and what the locations would be?

Arthroscopic surgery typically requires two incisions. Each incision is about 1/4-inch in size. These small incisions are called portal incisions, as in a point of entry. Two incisions are made in front of the knee called portals. Each portal incision is used to insert the arthroscope. The other front portal is used to pass instruments into the knee to perform the surgery on the meniscus cartilage.

Q: When I was young, my kneecaps used to slip out of place. After high school I seemed to have outgrown this problem. At age 35, my kneecaps sound like sand paper when I walk. I have pain if I climb a lot of stairs, kneel or watch a long movie. What can I do to prevent things from getting worse?

The symptoms that you have described are consistent with chondromalacia of the patella, or kneecap. Persons with chondromalacia have a softening and fraying of the patellar cartilage surface. The sandpaper sounds with stair-climbing discomfort and movie theater knee pain is classic for chondromalacia of the patella. Your condition is probably a byproduct of the patellar instability you described from your youth. A more subtle case of instability probably persists, causing the chondromalacia to progress. I would advise you to be evaluated for patellar instability and maltracking. Treatment would be physical therapy and a rehabilitation program to improve the tone and strength in your quadriceps muscle, or thigh muscles. Braces can assist with the patellar stability during exercise and sports. Only when nonoperative treatment is exhausted is surgery considered.

Q: Two years ago my meniscus cartilage tear in my knee was fixed. Doctors used an arthroscope to pass a suture into the joint to repair the tear. An extra incision was needed to tie the knots to complete the repair. I have been told there is a new technique that repairs the tear using small pegs, which eliminates the extra incision.

The arthroscopic technique you are referring to uses a small arrow-shaped peg that is called a meniscus arrow. Because of the size of meniscus arrows, they can be passed into the knee joint using a 1-inch incision and the arthroscope to direct and visualize their placement. Usually several meniscus arrows are required to stabilize and repair the meniscus tear. Meniscus arrows begin to dissolve after the healing process of the meniscus repair is well on its way. There has been a focus on saving the meniscus cartilage rather than removing it after it has been torn. Loss of the shock absorbing meniscus can precipitate pain and promote arthritis. Using the meniscus arrow to repair the meniscus tears has been a welcomed addition in the treatment of this common problem.

Q: I am scheduled for a knee joint replacement. Because I am younger than the average patient, 55 years old, I am told I may need a second operation years later when certain parts wear out. Which part will most likely wear out?

A knee replacement is made of metal and plastic components. Both components have the potential to fail, but the plastic component usually wears out and fails first. The plastic component is also known as polyethylene. It serves as a spacer between the metal components, which are applied to the tibia and femur. The polyethylene plastic component acts as a bearing surface between the metal components. Like a car tire, the plastic component undergoes a slow progress wear creating small particles of plastic debris. This plastic debris within the joint can stimulate inflammation and might cause loosening of the metal components. The initial prototype knee replacements have a 10- to 12-year average age of survival. Many factors influence the wear rate, such as level of activity, age and body weight. The newer knee replacements are expected to have better resistance against wear. Thus, the newer components are felt to have more longevity.

Q: Three years ago, I had a swollen knee that was drained by my doctor. The joint fluid was found to have gout. About a year later, I had two separate occasions where I developed a swollen knee after playing golf. An MRI showed a meniscus cartilage tear in each knee. Could the gout have caused the meniscus tears or was it my consistently bad golf game?

I have yet to meet a golfer who says that they have a consistently good game of golf. Golf swings come in all forms, but those with excessive pivoting and rotation in the lower extremities can generate high shear stresses. These stresses can result in enough force to tear a meniscus cartilage in your knee. People with gout will form crystals from a high level of uric acid. These crystals can form in the joint and cause inflammation. Over time, the acidic crystals can deposit within the meniscus cartilage causing the tissue to become stiffer. A stiffer meniscus cartilage is less resistant to twisting stresses, becoming more prone to tearing. The combination of poor technique and poorly controlled gout could have contributed to your meniscus cartilage tears. Use medications and diet to control your gout. Golfing lessons may improve your technique and reduce the excessive rotational stresses on your knee that can cause meniscal tears.

Q: I am 55 years old with osteoarthritis of the right knee. No treatments have given me much relief. I have heard of a new treatment involving hyaluronic acid, which is available in Europe. What do you think of this treatment?

Hyaluronic acid is a natural component of cartilage and joint fluid. It helps to maintain the structure of the cartilage tissue and also serves as a lubricant in joints. Studies indicate it suppresses joint inflammation. Recently, hyaluronic acid injections have been approved in this country. The use of hyaluronic acid first was used in veterinary medicine to treat osteoarthritis in dogs and horses. The use in humans has been extensively studied in Europe with reported improvements in overall condition in patients. Clinical trials in the United States showed that some patients experienced pain relief one week after the third injection of hyaluronic acid; for others, it was after the fifth. Pain relief often lasted for six months.

Q: After six arthroscopic procedures on my knee, I have no meniscus cartilage. There is a loss of movement and the pain makes my tennis and golf activities unbearable but I do not want to give up those activities. My doctor says I have advanced arthritis. At 64, what are my options?

Your diagnosis of advanced arthritis is probably the result of the loss of your shock-absorbing meniscal cartilage in your knee. Early stages of arthritic knee symptoms can be improved by losing any excess pounds and taking anti-inflammatory medications such as aspirin and ibuprofen products. However, prolonged use of these medications has side effects. Exercise that does not stress the knee joint with one's own body weight, such as swimming and bicycling, can assist in maintaining your knee range of motion and strength. If conservative treatment fails, knee-replacement surgery should be considered. Long-term studies have shown that knee-replacement surgery provides excellent relief of pain and restores function. Many individuals are able to return to activities such as golf and tennis. A decision toward knee-replacement surgery should be made after a thorough evaluation by your doctor and an explanation of the rehabilitation process as well as discussion on the expected outcome.

Q: My husband is concerned with a clicking noise on the outside of my right knee. I have recently noticed pain accompanies the clicking and snapping when I go for long walks. What could this be?

There can be several reasons for the clicking noise in your knee. Commonly, a tendon or a thickened part of the knee joint capsule can slide over a prominent bone. The thickened area of your joint capsules are known as plica. A plica, with irritation, can become inflamed and enlarged to the size of a crayon. The enlarged plica can produce an audible snap as it passes over the femur bone when the knee is moved. The iliotibial band is a wide tendon that crosses the knee joint line on the outer aspect of the knee. Symptoms of pain and snapping can develop in runners related to this tendon, especially if they are running on a lot of incline or hilly terrain. A clicking sensation is also felt by individuals who have knee caps (patellae) in the wrong position. The patella slides into a groove in the femur as the knee moves from an extended position to flexion. If there is a tilt or a slight shift in the patella position as it engages the groove to slide over the femur, a snap or clicking sensation can occur. The incorrect alignment between the femoral groove and the patella can eventually wear down the cartilage surfaces. Another source of the symptoms which you have described can come from a meniscus cartilage tear. The meniscus cartilage is a shock-absorbing cartilage in the knee different from the cartilage directly applied to the bones of the knee joint. The meniscus cartilage is subjected to high twisting stresses. Tears in the meniscus cartilage can occur over time or with an acute injury. Symptoms of clicking and snapping associated with pain in the knee should be evaluated. A problem in its early stages can often be corrected before significant damage or injury is allowed to progress.

Q: I have just had an MRI done this week which showed the following findings: There is a full thickness radial tear through the posterior horn of the medial meniscus with the tear extending to the inferior articular surface. There is an additional partial thickness radial tear through the posterior horn of the lateral meniscus which extends to the superior articular surface. There is no associated meniscal cyst formation with either meniscal tear. I am 39 years old. I fell 3 years ago on a tile floor. My left leg went under my body as I sat on it when I fell. Is it repairable?

The criteria required for reparability of a meniscus tear include: tear pattern location and blood supply. Radial tears are not amenable to repairwhereas longitudinal shaped tears can be repaired if the blood supply is available. The outer periphery of the meniscus is where the majority of the blood supply of the meniscus is located. A longitudinal tear in the outer peripheral can be repaired. Some decisions can be made regarding reparability of a meniscus by examining an MRI. Ultimately, the decision whether a meniscus tear can be repaired is made during the arthroscopic evaluation.

Q: I had arthroscopic surgery 1 1/2 years ago on my right knee. Since the operation, I have maintained a steady exercise program of biking, swimming and weights without going to extremes. However, none of this has helped the pain I have in the front of my knee when going up and down stairs. Is there something I should be aware of to help eliminate or reduce my pain?

It sounds like you have chondromalacia of the patella, or kneecap. Chondromalacia is a softening of the cartilage under the kneecap. The cartilage becomes soft and eventually wears down from excessive frictional forces. Injuries such as a direct impact to the front of the knee can damage the underlying cartilage of the patella. Since this cartilage has a limited blood supply, the healing capacity is also limited. Traumatic impact is just one scenario in which the cartilage will soften and eventually wear down. The more common source of chondromalacia of the patella is instability and bad tracking of the patella. If the patella moves with a shifting pattern rather than a smooth glide, the cartilage will soften. This can bring on pain and giving way, especially with stair-climbing. I would advise you to review your exercise activities and eliminate any in which you perform repeated deep squatting and excessive pivoting. Raising your bicycle seat can help reduce some stress on the patella while cycling. Exercise that targets the quadriceps muscle of the thigh is important to maintain good alignment and tracking for the patella as the knee moves through a range of motion. You should consider trying a knee brace that has a doughnut-hole design in the front of the brace for the patella. The brace will help you stabilize the patella during your exercise. If activity modification, exercise and bracing fail to ease your symptoms, there are surgical procedures that can stabilize and realign the patella to reduce the stress on the cartilage surfaces.

Q: My son plays basketball year-round. He complained of pain in the lower front portion of his left knee all last year. He no longer has pain, but he has a hard bump where it used to hurt. Should I be concerned?

You are describing a condition called Osgood-Schlatter disease. It is not really a disease, but rather an overuse syndrome related to the growth process. Just under the patella or kneecap is a short, wide tendon called the patellar tendon, which attaches to the front of the tibia bone just below the joint line. When the knee is straightening, tension is placed on the patellar tendon attachment site. As a youngster, this attachment site has an underlying growth plate. Excessive running and jumping during the adolescent growth phase can irritate and stimulate this growth plate. This stimulation can produce more bone growth resulting in a pointed prominence of bone. The good news is that these symptoms usually disappear by age 17 in boys and age 16 in girls, but the bony prominence persists into adult life. Osgood-Schlatter disease does not affect the function and stability of the knee. But if the resulting bony prominence in front of the knee is large, prolonged kneeling may be uncomfortable.

Q: I am 60 and was diagnosed with knee osteoarthritis five years ago. Each year I have an X-ray. The last X-ray led my doctor to recommend a knee replacement. What do you look for on X-rays to make someone a candidate for surgery?

Osteoarthritis is the wear-and-tear type of arthritis, with specific X-ray findings used to determine the severity of disease. This information, the history of disabling symptoms, as well as the examination determine need for surgery. As the arthritis advances, the cartilage on the ends of the two bones forming the joint wears. This is reflected by a narrowing of the joint space on an X-ray. Bone spurs called osteophytes are bony projections that emerge from the edges of the joint margin. The osteophytes can be imaged on X-rays and are a marker for the degree of arthritic changes. Thinning of the joint cartilage weakens ability to absorb shock. Thus, the bone just under the cartilage becomes denser because of added stress. Increased bone density at the joint line can be seen on an X-ray and is a feature of advancing osteoarthritis. Cysts in bones surrounding the joint line are common, but not a unique feature of osteoarthritis. These findings can be seen as clear spaces in the bone adjacent to the joint line on an X-ray. It is important to remember that X-rays do not always mirror the degree of symptoms one experiences with osteoarthritis. Diagnosis is primarily done by history-taking and physical exam.

Q: I took an early retirement from the Postal Service because of knee pain. I am otherwise in good health, but am crippled with arthritis and barely able to walk one block with a cane. I have decided to have an artificial knee replacement next fall. What can I do to prepare for this surgery?

Preparing months ahead of an anticipated knee replacement surgery will help to speed your recovery. The regiment of stretching, exercise, knee motion, and walking after knee replacement surgery has been accelerated over the past 25 years. I would advise you not gain any weight. If you are overweight, try to lose weight. Additional pounds make it difficult to maneuver. Begin a progressive exercise program to increase your aerobic capacity. The more fit you are before surgery, the smoother your rehabilitation will be. Utilizing a pool for exercise has many advantages. It puts little stress on the arthritic joints and allows one to work against water resistance. Water helps to relax muscles so that stretching in a pool can increase your range of motion. You can also increase your fitness and aerobic capacity by exercising your upper extremities. An ergodyne machine, the equivalent of a bicycle for your upper extremities, is a great method of exercising when your knees are too painful to use the standard stationary bike. Straight leg raises where you lie on your back and lift your leg upward while maintaining your knee straight is an excellent exercise. This exercise produces little stress on the knee joint while working and toning your hip and thigh muscles. Studies have shown that aggressive postoperative rehabilitation reduces the risk of blood clots, pneumonia, and improves the knee function. Approaching a knee replacement surgery with a preoperative exercise program as well as shedding any unnecessary weight can enhance the recovery process. Preparing in this fashion will allow one to work aggressively to restore the knee function and walking capacity soon after surgery.

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