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Tendon problems

Diseases of tendons (tendinopathy) may affect tendons around the knee. This causes pain, swelling and restriction of knee movement. This condition tends to be chronic and is usually due to over-use or repetitive minor trauma. Tendinopathy usually responds well to conservative treatment. The mainstay is physiotherapy and eccentric stretching. Surgery is rarely required.



Ultrasound scan of Patella Tendinopathy

Ultrasound scan of the patella tendon showing a typical appearance of patella tendinopathy

Patella Tendinopathy

This is an overuse injury. It is also known as jumper’s knee. Previously thought to be an inflammatory condition, it is now accepted to be a degenerative wear and tear process. Patients complain of pain at the front of the knee, made worse by jumping or hopping. Diagnosis is clinical but can be confirmed with MRI or Ultrasound scans. Treatment is often prolonged and may involve intensive physiotherapy, injections (STEROID/ACP - autologous condition plasma) and ultrasound shock wave therapy. If symptoms don't settle with these conservative measures, surgery may be indicated especially if the lesion is very localised.




Quadriceps Tendinopathy

This is less common than patella tendinopathy and tends to be seen in a slightly older age group. It occurs at the attachment of the quadriceps tendon to the top of the patella. It tends to cause tenderness and pain on contraction of the quadriceps muscle. Diagnosis is confirmed by ultrasound and/or MRI scans. Principles of treatment are similar to those for patella tendinopathy.

Knee problems in children

X-ray of ACL Avulsion

X-ray of the knee showing a fragment of bone in the middle of the knee. This represents a pull-off (avulsion) of the ACL from its insertion in the middle of the knee.

Ligament avulsions

When an adult damages their anterior cruciate ligament following trauma, the tear tends to occur in the middle of the ligament. In children and adolescents the attachment of ligament to bone is a point of weakness. A ligament injury in a child tends to lead to the ligament being pulled off from its attachment with a fragment of bone. This can occur in both ACL and PCL injuries. This pattern of injury has a significant impact on treatment as it may be possible to re-attach the bone fragment with its attached ligament. Depending on the type and site of injury this may be carried out with key-hole surgery.


Ligament re-attachment can only be carried out in the first week or two after the injury. Any later than this, and the ACL/PCL will need to be reconstructed in the same fashion as in adults.

 

Osteochondroses

This is a group of conditions affecting the growing skeleton and lining of joints (articular cartilage) It commonly affects the knee. Multiple causes may be to blame such as genetics, poor blood supply and excessive stress on the cartilage.

 

In the knee, a number of conditions have been described which occur as a result of excessive pulling on tendons near their attachment to bone. This most commonly area affected is where the patella tendon inserts on to the shin bone and is called Osgood-Schlatter syndrome. The symptoms include a bony prominence where the tendon inserts on to the shin which is tender. The other commonly effected area is where the patella tendon takes its origin from the lower part of the patella. The pull on the patella tendon at this point causes localised pain. This condition is called Sinding-Larsen-Johansson syndrome. Both conditions have a good prognosis and settle down with avoidance of aggravating activities, muscle strengthening and flexibility exercises. In less than 5% of patients surgery may be required.

 

Patients with Osgood-Schlatter syndrome are left with bony prominence on the front of thier shin bone for the rest of their lives.



Arthritis

X-ray of Narrowed Medial Compartment

X-ray of the knee showing loss of joint space in the inner/medial aspect of knee with normal outer/lateral compartment

Osteoarthritis of the Knee / Wear and Tear

Arthritis usually occurs over months and years. This process is called wear and tear or degenerative osteoarthritis. With trauma to the knee, it is possible to damage focal areas within the knee joint - this is called traumatic osteoarthritis. Both processes are associated with pain and swelling in the knee and cause difficulty with activities of day to day living such as : walking, stair climbing, bending, squatting and kneeling. The knee may also feel unstable and give way. There may be locking or catching and loss of the normal smooth movement of the knee, as individuals try to bend and straighten the knee. As the symptoms progress walking becomes increasingly more difficult and night symptoms may develop.



The treatment options depend on a number of factors including the severity of the patient's symptoms, their level of activity as well as the degree of wear and tear within the knee. If one compartment of the knee is affected in isolation this opens up several treatment options that are not available if the damage is more widespread. Some patients will settle down with a combination of physiotherapy, lifestyle modification and appropriate pain killers. Injections into the knee with steroid, glucosamine sulphate or ACP ( autologous conditioned platelets ) can also play a role in helping to settle down symptoms. If these non-surgical measures do not settle the symptoms down, then surgery may be required. A number of surgical options are available including re-alignment surgery ( osteotomy ) and knee replacement operation, including partial and total knee replacement operation

Normal Lateral Knee X-Ray
X-ray of Normal Lateral Knee

Normal Lateral Knee X-Ray

Osteoarthritis
Osteoarthritis

Osteoarthritis




Inflammatory arthritis

This is another type of arthritis, and includes a whole host of different conditions including Rheumatoid Arthritis, Psoriatic Arthritis and others. The symptoms are similar as are the treatment options. This is a much rarer form of arthritis than from simple wear and tear (degenerative osteoarthritis).

Knee-cap instability

The kneecap (patella) sits in the V shaped groove at the bottom of the femur (thigh bone). Some patients, especially young women, develop patellar instability in adolescence. Their patellae are more susceptible to dislocation due to either a bony abnormality of the femur, or due to laxity of the ligaments which stabilise it. These patients are often "loose jointed". When the kneecap (patella) dislocates the ligaments stabilising it may be stretched further and torn. The key stabilising ligament is the medial patello-femoral ligament or MPFL. If the MPFL is torn, this predisposes the kneecap to further dislocations and can cause significant damage to the cartilage lining the under-surface of the kneecap.

 

If an individual has normal anatomy but sustains a significant injury to the knee cap region, the MPFL can rupture and the knee cap can subsequently dislocate. These individuals are then at risk of having further knee-cap dislocations in the future. Each time this occurs there is significant pain, swelling and difficulty in walking. It also causes repeated damage to the under-surface of the knee-cap. If left untreated, this instability will cause arthritis to this part of the knee. It is therefore important to stabilise the knee cap either through surgical or non-surgical measures in order to reduce the risk of long-term damage to the knee. The most commonly performed operation to stabilise the knee cap is an MPFL Reconstruction

but the whole of the muscle and tendon arrangement on the front of the knee is assessed as sometimes surgery is needed to these structures.

Stable Knee Cap
X-ray of Normal Patellofemoral Joint

X-ray of the patellofemoral joint showing a normal, central position of the patella (knee-cap) in its groove.

Unstable Knee Cap
X-ray of Tilted Patello-femoral Joint

X-ray of the patello-femoral joint showing a patella (kneecap) which is tilted to one side and an empty groove.

Meniscal tears

The menisci are half-moon shaped and act as shock absorbers. They are made up of a different type of cartilage  to the joint surface (articular) cartilage. Each knee has an inner or medial meniscus and an outer or lateral meniscus. The menisci sit between the thigh bone (femur) and the shin bone (tibia). They distribute the forces across the knee and allow the bones to glide smoothly on one other without friction. They also provide stability to the knee.


The menisci are either damaged as a result of a traumatic injury or as the result of wear and tear. The most common way to tear the meniscus is by a twisting motion on a bent knee. This may occur in combination with a ligament injury. 60% of patients who tear their anterior cruciate ligament (ACL) also damage one or both of their menisci at the same time. This is referred to as a traumatic meniscal tear. The more common, degenerative type of tear, can occur with very simple activity such as bending down to pick something up or with simple stair climbing.

 

Normal Meniscus
Normal Meniscus

Intra-operative picture showing a normal inner/medial meniscus in the centre of the knee joint.

Torn Meniscus
Torn Meniscus - Meniscal Tear

Intra-operative picture showing torn inner/medial meniscus sitting out of position in the centre of the knee joint.



Following a meniscal tear, a patient experiences pain (which is localised to the side of the knee joint where the tear has occurred). It is far more common to tear the inner or medial meniscus than the outer meniscus. Patients often point to the exact location of the tear, and they say "it hurts here!". Symptoms associated with this are pain, swelling, clicking and difficulty with walking or bending activity. If the tear is severe and a large fragment of the meniscus flips into the centre of the knee joint it may lead to "locking" and an inability to move the knee which effectively gets stuck. Although the medial/inner meniscus is more commonly injured tears of the lateral/outer meniscus are more significant.

 

The diagnosis of a meniscal tear involves an appropriate history from the patient, together with a clinical examination. An MRI scan may be useful to help both confirm the diagnosis and to determine what type of tear has occurred.

 

Loss of the meniscal shock absorber tissue leads to uneven weight distribution and excessive  force passing from one joint surface to the other within the knee. This leads to arthritis or wear and tear. Most meniscal tears require key-hole surgery. It is sometimes possible to repair a torn meniscus. Meniscal repair is a complex procedure and is best carried out by an experienced knee specialist. The results of meniscal repair surgery, even in the best hands, are 65% success for an isolated tear and 80% where there is an associated ligament rupture within the knee. If repair is not possible, then simple debridement of the tear is carried out to remove the damaged fragment and preserve as much of the meniscal tissue as possible and thereby retain its shock-absorbing function.

 

Mr Wilson during a knee consultation

Mr Wilson during a knee consultation

Mr Wilson examining a patient's knee

Key-hole  knee surgery

Key-hole knee surgery

Surgical team during knee arthroscopy

Anaesthetist - Dr Nick J looking over the drapes

Anaesthetist - Dr Nick J looking over the drapes

Orthopaedic consultation

Orthopaedic consultation

Anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction

Knee injection with PRP

Knee injection with PRP

Mr Wilson in surgery

Mr Wilson in surgery

Arthroscopic knee surgery

Arthroscopic knee surgery

Mr Wilson examining a patient's knee

Mr Wilson examining a patient's knee