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Knee pain

Definition


Disease: Knee pain Knee pain
Category: Bones, joints, muscles diseases

Disease Definition:

The cause of knee pain could be either an injury such as a torn cartilage or a ruptured ligament, or it could be certain medical conditions, such as infection, arthritis and gout. Knee pain is a common reason that people visit their doctors or the emergency room.

 

Although some serious knee injuries such as a ruptured ligament or tendon usually require surgical repair, however, most relatively minor cases of knee pain respond well to self-care measures.

 

There are certain steps that could be taken to reduce the risk of injury or disease, but not every knee problem could be prevented, particularly if the person is active.
 

Work Group:


Symptoms, Causes

Symptoms:

Any of the ligaments, tendons or fluid-filled sacs called bursae that surround the knee joint could be affected by a knee injury, in addition to the bones, cartilage and ligaments that form the joint itself. The signs and symptoms of knee problems could vary widely because of the knee's complexity, the number of structures involved, the amount of use it gets over a lifetime, in addition to the range of injuries and diseases that can cause knee pain.

 

These are some of the most common knee injuries in addition to their signs and symptoms:

Ligament injuries:

Ligaments are tough bands of tissue that connect the thighbone (femur) to the lower leg bones (tibia and fibula). There are four ligaments in the knee. Two of them are collateral ligaments, one on the inside, called medial collateral ligament, and one on the outside called lateral collateral ligament. The other two ligaments are inside the knee and as they stretch diagonally from the bottom of the thighbone to the top of the shinbone (tibia) they cross each other. The back of the shinbone is connected by the PCL (posterior cruciate ligament), and the front of the shinbone is connected by the ACL (anterior cruciated ligament). A fall or contact trauma could cause a tear in one of these ligaments, and end up causing:

 

  • A popping sound
  • Immediate pain that worsens when walking or bending the knee
  • A feeling that the knee may buckle or give way
  • An inability to bear weight on the injured knee.
Tendinitis (tendon injuries):

Irritation and inflammation of one or more tendons, which are the thick, fibrous cords that attach muscles to bones, is called tendinitis. Inflammation in the patellar tendon that connects the quadriceps muscle on the front of the thigh to the larger lower leg bone (tibia) is more likely to occur in athletes, such as cyclists, skiers and runners. These are some of the signs and symptoms that a person may experience in case his/her knee pain is caused by tendinitis:

 

  • Pain in one or both knees
  • An inability to completely extend or straighten the knee
  • Swelling in the front of the knee or just below the kneecap
  • Worsening pain when jumping, running, squatting or climbing stairs.
Meniscus injuries:

The C-shaped piece of cartilage that curves within the knee joint is called the meniscus. These injuries usually involve tears in the cartilage, which could occur in various places and configurations. These are some of its signs and symptoms:

 

  • Pain
  • An inability to straighten the knee completely, the knee may feel like it has been locked in place
  • Mild to moderate swelling that occurs slowly, as long as 24 to 36 hours after the injury.
Bursitis:

Some injuries could lead to bursitis, which is inflammation in the bursae, the small sacs of fluid that cushion the outside of the knee joint so that tendons and ligaments glide smoothly over the joint. Some of the signs and symptoms of bursitis may include:

 

  • Redness
  • Swelling
  • Warmth
  • Pain, even at rest
  • In case the bursa that is over the kneecap bone (prepatellar bursa) becomes infected, the person may experience fever, pain and swelling
  • Aching or stiffness when walking
  • Considerable pain when kneeling or going up and down stairs.
Loose body:

In some cases, a piece of bone or cartilage could break off and float in the joint space due to an injury or degeneration of bone or cartilage. This does not have to create problems, unless if the loose body interferes with knee joint movement, which could cause pain and a locked joint.

Dislocated kneecap:

If the triangular bone called the patella that covers the front of the knee slips out of place mostly to the outside of the knee, this condition occurs. In this case, the kneecap is likely to move excessively from side to side with a visible dislocation. Some of the signs and symptoms of a dislocated kneecap may be:

 

  • Swelling
  • Difficulty walking or straightening the knee
  • Intense pain
Osgood-schlatter disease:

This is an overuse syndrome that usually affects athletic teens and preteens. Some of its signs and symptoms may be:

 

  • Swelling
  • Tenderness at the bony prominence called the tibial tuberosity, which is located just below the kneecap
  • Pain, which gets worse with activity, such as jumping and running.

 

This discomfort may linger for a few months and may continue recurring until the teen or preteen stops growing.

Iliotibial band syndrome:

In case the ligament that extends from the outside of the pelvic bone to the outside of the tibia, called the iliotibial band, becomes so tight that it rubs against the outer portion of the femur, this condition occurs. The people most affected with this are distance runners. Some of the signs and symptoms of this condition may include:

 

  • Pain that initially goes away with rest from running, however, it may persist in time when walking or going up and down stairs.
  • A sharp, burning pain on the outer side of the knee, which begins after longer distance runs.

 

The person won't experience swelling, and his/her range of motion will be likely normal with this type of knee injury.

Hyperextended knee:

When the knee extends beyond its normally straightened position and bends back on itself, this condition occurs. In some cases, the damage is relatively minor, and when the person tries to extend the knee they may experience pain and swelling. However, this condition could also cause a partial or complete ligament tear, particularly in the ACL.

Septic arthritis:

When the knee joint becomes infected, it could cause swelling, pain and redness. Usually, before the onset of pain, there's no trauma. Fever usually accompanies this condition.

Gout and pseudogout:

One type of arthritis called gout could cause some of these signs and symptoms:

 

  • Swelling
  • Redness
  • Intense knee pain that comes on suddenly and without warning, usually at night. Typically, the pain lingers for five to ten days. Over one to two weeks, the discomfort subsides gradually, and leaves the knee joints apparently normal and free of pain.

 

Occurring mostly in adults, pseudogout (chondrocalcinosis) is another condition that could cause some of these signs and symptoms:

 

  • Severe inflammation
  • Intermittent attacks of sudden pain and swelling in the knees or other large joints.
Rheumatoid arthritis:

This condition could affect almost any joint in the body, including the knees. This type is the most debilitating of the more than 100 types of arthritis. These are some of the common signs and symptoms of this condition:

 

  • Swelling
  • Pain
  • In some cases, a low-grade fever and malaise, which is a general sense of not feeling well
  • Aching and stiffness, particularly when getting up in the morning, or after periods of inactivity
  • Loss of motion in the knees and eventually deformity of the knee joints

 

Rheumatoid arthritis tends to vary in severity and may come and go despite the fact that it is a chronic disease. Periods of increased disease activity called flares usually alternate with periods of remission.

Osteoarthritis:

Osteoarthritis is the most common type of arthritis, and is also called degenerative arthritis. When the cartilage in the knee deteriorates with use and age, this wear-and-tear condition occurs. Usually, osteoarthritis develops gradually. Some of its signs and symptoms may include:

 

  • Swelling
  • Pain that varies in severity, particularly when standing or walking
  • Loss of flexibility in the knee joints.
  • Creaking or popping sounds
  • Stiffness, particularly in the morning and after being active.
Patellofemoral pain, or chondromalacia of the patella:

This term refers to pain arising between the patella and the femur, which is the underlying thighbone. This condition is quite common in older adults occurring as a result of arthritis of the kneecap, in athletes, and in young adults who have a slight misalignment of the kneecap. Some of the signs and symptoms of this condition may be:

 

  • A grating or grinding sensation which could occur when the knee is extended.
  • Pain and tenderness in the front of the knee that gets worse when sitting for long periods, climbing or descending stairs or getting up from a chair.

 

In case the knee pain isn't severe or disabling, a person could try some self-care measures such as icing, resting and elevating the affected knee. To reduce pain and inflammation, NSAIDs could be used. However, a doctor or a specialist in sports medicine or orthopedics should be seen in case an improvement isn’t noticed in three to seven days.

 

A more immediate medical care is required for some types of knee pain. A doctor should be called in case someone:

 

  • Has worrisome pain
  • Has marked knee swelling
  • Can't bear weight on the knee
  • Has a fever as well as swelling, redness and pain in the knee, which could be an indication of infection.
  • Notices an obvious deformity in the leg or knee
     

Causes:

Wherever two bones come together, a joint occurs. However, the joints are quite complex and provide the body with flexibility, a wide range of motion and support. These are the four types of joints:

 

  • Fixed
  • Pivot
  • Ball-and-socket
  • Hinge

 

The knees are hinge joints that work like the hinge of a door, and allow the joint to move backward and forward. The largest, heaviest and more complex hinge joints in the body are the knees. They twist and rotate, as well as bend and straighten. This makes them particularly vulnerable to damage, and because of this they sustain more injuries on average than other joints do.

 

A CLOSER LOOK AT THE KNEES:

Four bones that are held together by ligaments make up the knee. The top part of the joint consists of the thighbone (femur), and the lower part consists of two lower leg bones, the fibula and the tibia. The patella, which is the fourth bone, slides in a groove on the end of the femur.

 

Bones are connected to one another by ligaments, which are large bands of tissue. In the knee joint, four main ligaments link the femur to the tibia and when the knee moves through its arc of motion, they help stabilize it. These consist of the collateral ligaments along the inner (medial) and outer (lateral) sides of the knee and the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL), which cross each other as they stretch diagonally from the bottom of the thighbone to the top of the shinbone.

 

These are some of the other structures that are found in the knee:

Bursae:

The knee is surrounded by a number of these fluid-filled sacs which help cushion the knee joint, so that ligaments and tendons slide across it in a smooth way.

Tendons:

Tendons are fibrous bands of tissue that connect the muscles to bones. There are two important tendons in the knee that make it possible to straighten or extend the leg:

 

  • The quadriceps tendon, which connects the long quadriceps muscle on the front of the thigh to the patella
  • The patellar tendon, which connects the patella to the tibia.
Meniscus:

As mentioned before, this is the C-shaped cartilage that curves around the inside and outside of the knee and cushions the knee joint

 

All of these structures work together in a smooth way in most cases. However, this balance could be disrupted by injury and disease, causing decreased function, pain and muscle weakness.

 

Listed below are some of the common causes of knee pain and injuries:

 

  • Degeneration from aging
  • A blow to the knee due to a car accident, a fall or contact during sports.
  • Awkward landings from a fall or from jumping during sports, including basketball.
  • Repeated stress or overuse. This could occur either from playing sports, or if someone’s hobby or work requires doing the same activity over and over again
  • Rapidly growing bones, which are particularly susceptible to injury during sports.
  • Sudden pivoting, stopping, turning or cutting from side to side. During certain sports, these happen frequently.
     

Complications

Complications:

Although some knee injuries and medical conditions including osteoarthritis could cause joint damage, increasing pain and even disability when left untreated, however, not all knee pain is serious. People should know that having a knee injury, no matter how minor, makes them more susceptible to similar injuries in the future.
 

Treatments:

Breaking the cycle of inflammation that begins right after an injury is the key to treating many types of knee pain. Even a minor trauma could cause the body to release substances that lead to inflammation. Further damage is caused by the inflammation. This damage could trigger even more inflammation and so on. However, to end this cycle, people could use a few simple but effective self-care measures. They should start treating their injury right away in order to get the best results.

 

The self-care measures for an injured knee are commonly referred to by the acronym P.R.I.C.E., they include:

Protection:

The most effective way to protect the knee from further damage will depend on the type and severity of the injury. A compression wrap is usually sufficient for most minor injuries. However, for more-serious injuries, including a high-grade collateral ligament sprain or a torn ACL, crutches will be required, and in some cases, along with a brace, in order to help stabilize the joint with weight bearing.

Rest:

To reduce the repetitive strain on the knee, the injury should be given time to heal and prevent further damage, the person should take a break from their normal activities. In the case of a minor injury, a day or two may be enough, however, in the case of a more severe damage, a longer recovery time will be needed.

Ice:

Ice is a staple for most acute injuries because it reduces both pain and inflammation. A person may be recommended applying ice to the injured knee three times a day, for about 20 minutes each. One thing that works well is a pack of frozen peas because it covers the whole knee. To protect the skin, the person could also use an ice pack wrapped in thin fabric. Despite the fact that ice therapy is generally safe and effective, however, because of the risk of damage to the nerves and skin, the ice shouldn’t be left on longer than recommended.

Compression:

Compression maintains knee alignment and stability in addition to preventing fluid buildup (edema). A person should use a lightweight compression bandage that is breathable and self-adhesive. It shouldn't interfere with circulation, but it should be tight enough to support the knee.

Elevation:

Elevating the knee could help reduce swelling because gravity drains away fluids that might otherwise accumulate after an injury. The person should either sit in a recliner or try propping the injured leg on pillows.

 

ANTI-INFLAMMATORY MEDICATIONS:

To help relieve pain, NSAIDs could be used, such as naproxen, acetylsalicylic acid and ibuprofen .However, if someone takes NSAIDs for long periods or in amounts greater than the recommended dosage, they could have side effects.
NSAIDs have a limit to how much pain they can control because they have a ceiling effect. If two different kinds of NSAIDs are taken at the same time, it will not provide more relief, and it could actually increase the risk of side effects.

 

Someone may be recommended other options in case self-care measures are not enough to control pain and swelling and promote healing in an injured knee. These other options may include:

 

PHYSICAL THERAPY:

Strengthening the muscles around the knee and helping the patient regain knee stability is the major goal of physical therapy. Based on the type of the injury, training will probably focus on the muscles in the back of the thigh called the hamstrings, the muscles in the front of the thigh called quadriceps, as well as the calf, ankle and hip. Some of the exercises could be done at home. However, others should be performed in an athletic club, fitness center or clinic, because they require the use of weight machines, treadmills or exercise bicycles. 

 

The patient will work on re-establishing full range of motion in the knee during the early stages of rehabilitation. After that, he/she will progress to hip-, ankle- and knee-strengthening exercises combined with training in order to improve balance and stability. Eventually, they will work activities, including exercises to help them prevent further injury or they will work on training specific to their sport.

 

The patient may be back to their normal daily activities in as little as two to four weeks, depending on the type of their injury. However, the patient should follow the prescribed exercise program in order to maintain maximum knee stability.

 

TREATING UNDERLYING MEDICAL CONDITIONS:

The patient will probably be prescribed disease-modifying antirheumatic drugs (DMARDs) in case the cause of their knee pain is some other medical condition, such as gout or rheumatoid arthritis. These are some of the commonly used DMARDs:

 

  • Leflunomide
  • Methotrexate
  • Sulfasalazine
  • Hydroxychloroquine

 

DMARDs could be used in combination with other drugs known as biologics. Some examples are:

 

  • Infliximab
  • Entanercept
  • Anakinra
  • Adalimumab

 

SURGICAL OPTIONS:

Most knee injuries don't have one single best treatment. Based on many factors, it will be decided whether surgical treatment is right or not. These factors include:

 

  • The patient’s lifestyle, including which sports they play
  • The type of injury and amount of damage to the knee
  • The patient’s willingness to modify their activities and sports
  • In case the patient doesn’t have surgery, the risk of future injury or damage.
  • The patient’s motivation to work through rehabilitation to strengthen their knee after surgery.

 

In case the injury requires surgery, the operation doesn’t have to be performed immediately. Mostly, it will be best to wait until the swelling goes down and the patient regains strength as well as full range of motion in their knee.

 

The patient should consider the benefits and risks of both nonsurgical rehabilitation and surgical reconstruction before making a decision, in relation to what's most important to them. In case they have cartilage damage that interferes with their range of motion (locked knee) or if the blood supply to their knee is severely compromised, nonsurgical treatment will not be an option.

 

Some of the surgical options include:

Arthroscopic surgery:

Based on the type of the injury, the joint damage may be examined and repaired by using an arthroscopic technique (arthroscopy), in which only a few small incisions are required. This method could be used to:

 

  • Reconstruct torn ligaments
  • Repair torn or damaged cartilage
  • Remove loose bodies from the knee joint
  • In some cases, correct damage from degenerative joint diseases, such as arthritis.

 

After an arthroscopic procedure, the patient will recover more quickly and with less discomfort than after an open surgery. Despite this, recovering from ligament and meniscus surgery takes a long time and requires a strong commitment to physical therapy.

Total knee replacement:

Also called total knee arthroplasty, the damaged bone and cartilage is cut away from the thighbone, shinbone and kneecap, and replaced with an artificial joint (prostheses), which is made of metal alloys, high-grade plastics and polymers. Knee problems associated with osteoarthritis, rheumatoid arthritis and other degenerative conditions such as osteonecrosis, a condition in which obstructed blood flow causes the bone tissue to die, could be improved with total knee arthroplasty.

 

A person might be a candidate for total knee replacement in case:

 

  • They have a severely damaged, arthritic knee that limits mobility and function
  • They are older than sixty, in good health and conservative measures have failed to improve their symptoms.
Partial knee replacement surgery:

A person might be a candidate for a partial knee replacement in case they have considerable knee damage from degenerative arthritis but still retain some healthy cartilage, and conservative measures, including lifestyle changes, physical therapy and medication have not helped their symptoms.
In a partial knee replacement, also called unicompartmental arthroplasty, only the most damaged portion of the knee is replaced with a prosthesis made of metal and plastic. The patient will have to stay at the hospital for only one night, and in most cases, this surgery could be done with a small incision. The patient will also heal more quickly than they would in the case of an entire knee replacement surgery. However, long-term results of this procedure may not be as good as those of a total knee replacement, and most people who choose knee replacement have damage too extensive for a partial knee replacement.

 

OTHER OPTIONS:

In the last few years, quite a few nonsurgical treatments for knee pain caused by arthritis have become available or been investigated. Although some are still in the experimental stage, however, others are used fairly routinely in order to control pain and inflammation. These new treatments include:

Corticosteroid injections:

When a corticosteroid drug is injected into the knee joint, it could help reduce the symptoms of an arthritis flare, as well as provide pain relief that lasts a few months. Between injections, the patient has to wait at least four months. However, these injections are not always effective, and have the same side effects as oral steroid medications, such as water retention, elevated blood sugar levels and an increased risk of infection.

Orthotics and bracing:

In order to shift the pressure away from the side of the knee most affected by osteoarthritis, arch supports, sometimes with wedges, are used on the inner or outer aspect of the heel. In order to help ease the pressure on the most arthritic side of the knee, a brace called an "unloader" brace could be used.

Topical painkillers:

The pain and stiffness of osteoarthritis may be relieved when certain ointments are applied to the skin. In people with osteoarthritis of the knee, a cream that contains cetylated fatty acids could improve mobility and function. Temporary relief could also be provided by another over-the-counter product called capsicum. This product is sold under several brand names. Significant pain relief could be provided by patches that contain the analgesic lidocaine.

Hyaluronic acid:

Found in healthy joints, this thick fluid when injected into damaged joints may ease pain and provide lubrication. Hyaluronic acid reduces inflammation; however, experts still aren't sure how it works. After taking a series of shots, the relief may last as long as six months to a year.
 

Prognosis:

Not available

Expert's opinion

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Dr. Samer Al-Jneidy Pediatrician

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