Compared to the days of our parents and grandparents, many people in the United States remain physically active and participate in demanding athletic events well into their 50s, 60s and 70s. This increased activity does have many health benefits, but also can result in increased risk of injuries. In addition, there are individuals who would like to remain active with increasing age, but are limited by knee problems.
Many simple sprains and strains require only symptomatic treatment and respond well without the need for extensive diagnostic studies. A sign of a more serious injury is presence of swelling in the knee, particularly if this comes on within several hours after the injury. The presence of a snap or pop that occurs at the time of a twisting injury accompanied by rapid swelling is also suggestive of a significant injury. Rapid swelling that occurs within several hours after injury is usually due to bleeding within the joint. A smaller percentage of patients may have tears of the knee cartilages or chip fractures inside the joint.
Not all patients who have an acute injury with swelling or bleeding inside the joint require surgery. After physical examination, X-ray films are the next step in diagnosis. An MRI can provide additional information about the internal structures in the knee. In general, it is better to wait until the swelling has subsided and the patient has gained his or her range of motion. It should be remembered that a decision to repair a torn ligament is not made on the basis of an MRI diagnosis, but instead on the presence of symptomatic instability of the knee that can be demonstrated on physical examination. Even modest weight reduction may aid in relieving symptoms.
Younger patients who have early arthritis should first be offered nonsurgical options. Several large randomized studies have shown that exercise can reduce pain and improve function with patients with arthritis. Exercise must be sustained because beneficial effects are lost six months after an exercise program is terminated. Some individuals can be helped with knee bracing. This works best in patients who do not have significant bow-legged or knock-kneed deformities. Some individuals may also benefit from lateral or outer wedges in the shoes with early arthritis on the inner side of the knee.
Nonsteroidal anti-inflammatory medications - NSAIDs - are often used to reduce pain and inflammation resulting from early arthritis of the knee. These include medications such as aspirin, Aleve and Advil. There are also a number of NSAIDs that can be obtained by prescription from a physician. There are no studies that distinguish a clear advantage of one particular medication over another.
Steroid injections into the joint are commonly used in the treatment of osteoarthritis in the knee. These generally include a combination of a steroid as well as a local anesthetic. In general, steroid injections are used with greater caution in the younger patient. The American Academy of Orthopaedic Surgeons has stated that for patients with well-established arthritis, injections can probably be given at three to four-month intervals. Again, this is more applicable to the older patient with more severe arthritis than to the younger patient with minimal changes.
Arthroscopy involves looking into the joint with a tube or telescope. An excellent view of the joint can generally be obtained. This aids in diagnosis and can also help the patient in having a prognosis as to what future activities he or she may be capable of carrying out. How the surgeon is able to help the patient depends on what is found inside the knee. Mechanical symptoms, such as catching and locking, that result from torn and unstable semilunar cartilages can often be treated effectively by arthroscopic trimming or removal of a torn cartilage.
For a patient with disabling arthritis that has failed nonsurgical treatments, total knee replacement can provide good relief of pain and improvement in function. In younger patients it is usually reserved as a final treatment option. Advances in designs have led to survivorship of 90 percent at 10 to 15 years. Patients who have total knee replacements at a younger age must consider the real possibility that they may require a revision surgery during their lifetime. Revisions can be successfully carried out, but a revision surgery is generally a more involved and complex procedure. Patients often ask what they will be able to do after having a knee replacement. In a survey of the Knee Society in 1999 activities such as racquetball, squash, soccer, singles tennis, volleyball, football, basketball and jogging were not recommended. Low impact aerobics, bowling, golf, dancing, horseback riding, walking and swimming were recommended or allowed. There was no conclusion regarding downhill skiing. Cross-country skiing, tennis and road cycling were allowed with experience.
Everyone wants to remain active. However, if you are experiencing knee pain or have concerns about your knees contact Trinity Orthopaedics for assistance at 574-8333.
Richard Bergstrom, M.D., an orthopaedic surgeon, is affiliated with Trinity Orthopaedics.