Naples Orthopedic Surgeon - Dr. Robert J. Zehr » Knees

Doing many quad sets and hamstring stretches helps, but I still have knee pain. Is there anything new I can try?

admin — Thu, 02 Feb 2012 11:00:50 +0000

I’ve had knee pain since I was 13 (I’m now 18). The doctor calls it patellofemoral pain syndrome. I’ve done a million quad sets and hamstring stretches. It helps but I still have pain when I try to increase my training schedule for track and field events. Is there anything new I can try?

Treatment for patellofemoral pain syndrome (PFPS) has traditionally relied on quadriceps strength training. Some patients also benefit from neuromuscular training, which focuses more on motor control than improving strength.

So far no one has found a “one size fits all” kind of program. Some people seem to get better with one type of exercise while others have less pain and more function with other types of training.

Some time ago researchers saw that hip strength may be an important key to PFPS. One by one studies have been done to confirm this suspicion. Most recently physical therapists at the Nicholas Institute of Sports and Medicine and Athletic Trauma in New York City studied hip strength and flexibility as it relates to PFPS.

They found that 60 percent of patients with PFPS got better after a six-week training program. Exercises to improve hip flexor strength and flexibility resulted in decreased pain and improved function.

The goal was to prevent inward rotation of the thighbone (femoral rotation). Maintaining good alignment of the patella as it moves up and down over the knee reduces the tension on the soft tissues around the knee. This new treatment approach may help you as well!

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com. The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of a visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

My teammate thinks my knee pain may be as a result of tight hip flexors. How do I check for this myself?

admin — Tue, 31 Jan 2012 11:00:56 +0000

I’ve been having knee pain whenever I do running or squatting drills during football training. One of my other teammates says tight hip flexors can cause this problem. How do I check myself for this?

There are several tests used to measure hip flexor flexibility. An athletic trainer, physical therapist, or orthopedic surgeon can test you.

One test is called the Thomas flexion test. You lie down on your back on a table with a firm surface. The crease of your buttock should be at the edge of the table. Bring both knees up to your chest. Keeping your back flat on the table, lower one leg until it is straight out. Lower that leg toward the tabletop as much as you can without arching your low back or letting your pelvic bone tilt.

A tight hip flexor muscle will keep you from lowering your leg all the way down to the table. A flexible person will be able to get to a horizontal (normal) or beyond horizontal position (hyperflexible). The physical therapist uses a tool called a goniometer to measure the hip angle during this test.

Another test is the Ober test used to measure flexibility of the iliotibial band (ITB). This band of fascial tissue comes down along the side of the leg from hip to knee. For this test, you lie on your side with the leg in question on top. The lower leg can be bent to help support you on the table.

The upper leg is bent 90 degrees at the knee. The therapist lifts the leg away from the body to a horizontal position and then extends it backwards slightly. The leg is then lowered toward the table until it starts to rotate or can’t go any further.

A normal amount of motion allows the leg to be placed in the horizontal position. With a tight ITB, the leg stays up and won’t drop down towards the table. The extra flexible person can touch the knee to the table.

About 10 years ago I had ACL surgery. Now, all of a sudden, I’m having painful grinding in the joint. What’s happening?

admin — Fri, 27 Jan 2012 11:00:24 +0000

About 10 years ago I had an ACL repair. Everything’s been just fine and now all of a sudden, I’m having painful grinding behind my kneecap and in the joint. What’s happening?

Researchers at the Steadman-Hawkins Research Foundation in Vail, Colorado have been researching this very problem. They noticed some of their ACL patients were just fine for 10 years — a perfect outcome. Then all of a sudden, they developed arthritis.

They think the problem may be a lack of mobility between the patellar tendon and the tibia (lower leg bone). A condition referred to as patella infera may be part of the problem. With patella infera, there is a permanent shortening of the patellar ligament. The kneecap sits too low in relation to femur (thighbone). The result can be a severely limited range of motion of the knee joint.

Patella infera is a common complication of injury or surgery to the knee joint. It usually doesn’t show up until much time has passed after injury and/or surgical repair.

Treatment options include physical therapy to manually release the kneecap and/or surgery to revise the soft tissues around the knee. If the joint degeneration has gone too far for conservative care to be successful, then total knee replacement may be needed.

After ACL surgery, my doctor doesn’t think my motion is returning fast enough. What should I do differently?

admin — Wed, 25 Jan 2012 11:00:56 +0000

I had an ACL repair a week ago. The doctor doesn’t think I’m getting my motion back fast enough. What should I do differently?

Motion and mobility after ACL repair is a key factor in the long-term success of the operation. Studies show that without good motion, the joint is compressed and wears out faster. Ten years down the road, the patient develops degenerative arthritis and the ACL repair looks like a failure.

Patellar mobility (kneecap motion) is a key factor in regaining overall knee motion. It is always advised to get your motion back before you start strengthening exercises.

Your physical therapist or surgeon can assess patellar motion and teach you how to manually move it side to side, up and down, and along the diagonal planes of motion. This type of motion will help prevent scarring from occurring between the patellar tendon and the tibia and between the patella and the tibia.

Without an 80 percent return of motion early on, there’s a good chance another operation will be needed to release adhesions in the joint. You should have full motion by the end of six weeks. The right rehab program must match the type of surgery you had while regaining motion. Strength training comes after joint mobility is restored.

I’ve had surgery to repair my ACL. Why doesn’t this ligament heal itself like other tissues in the body?

admin — Mon, 23 Jan 2012 11:00:13 +0000

I tore my anterior cruciate ligament (ACL) and had to have surgery to reconstruct it. Why doesn’t this ligament heal itself like other tissues in the body?

Scientists studying the field of tissue engineering are very interested in knowing the answer to your question. If we can understand the normal pathways of tissue healing, then maybe we can find a way for ligaments like the ACL to repair itself.

The poor healing capacity of the ACL can be explained in part by its biology. First there is a very thin lining or sheath around the ACL. Once this sheath is disrupted, the blood supply to the ligament is decreased greatly.

Normal healing and repair depend on the formation of a hematoma. A hematoma is a collection of blood cells trapped in the tissues after trauma or injury. Somehow the presence of the hematoma sets up the right environment needed for tissue healing. Without a blood supply, there can be no hematoma formation.

The hematoma provides a base camp so-to-speak for local growth factors and chemicals to come and set up a mesh or scaffold. Cells fill in around the scaffold forming collagen and scar tissue. It looks like there’s a complex interchange between repair cells, growth chemicals, and the scaffold needed for healing. Without the hematoma to get the process started, ligaments don’t recover on their own.

What is spontaneous ostenonecrosis and what causes it?

admin — Thu, 19 Jan 2012 11:00:18 +0000

What is spontaneous ostenonecrosis and what causes it? My husband has been diagnosed with this problem in his left knee. We can’t figure it out.

You’re not alone in your questions. We know that osteonecrosis is the death of bone tissue. But spontaneous osteonecrosis (SON) is sudden, unexpected, and without known cause.

Some recent reports point to a possible increase in this condition in adults over age 60. At first doctors thought it was linked with arthroscopic surgery to remove a torn meniscus. But then five new cases were reported in patients who had meniscus degeneration but no surgery.

It appears that age-related wear and tear on the meniscus may be the start of the problem. But there are still many questions about what’s going on. For example, in one study of five patients, symptoms of knee pain were identified as medial meniscal degeneration.

At the time of the diagnosis, there were no changes in the bone seen on an MRI. The patients were all treated with physical therapy, exercise, and noninflammatory drugs. Two months later the symptoms increased. A second MRI showed osteonecrosis of the knee.

What happened in those two months between MRIs? Doctors just aren’t sure yet but further studies may offer some insight into SON.

I’m 62 and have been having some pain inside my right knee. Is this just age, or should it be checked by a doctor?

admin — Tue, 17 Jan 2012 11:00:58 +0000

I’m 62-years old and in reasonably good health. Lately I’ve been having some pain along the inside of my right knee. I’ve waited for it to go away. I’ve tried ibuprofen. It’s not getting worse but it’s not getting better. How do you know what’s just a sign of getting older and what should be checked out by a doctor?

Sometimes it’s impossible to tell the serious from the not-so-serious medical conditions. With aging come age-related changes in the body. With the knee, joint cartilage such as the meniscus starts to wear out. Early signs of arthritis start to set in.

But most experts agree that early intervention can make a big difference in many kinds of problems. Don’t wait to see your doctor. An X-ray may be all that’s needed. In some cases an MRI is best. If conservative care doesn’t improve your symptoms, then a second MRI may be needed.

Recently several studies have documented cases of spontaneous osteonecrosis in adults over age 60 who had some meniscus degeneration. Osteonecrosis is the death of bone. Spontaneous means it came on suddenly with no warning and no known cause. These are the kinds of problems you want to avoid by checking with your doctor sooner than later.

Is it possible to predict who will and who won’t have a good result from a total knee replacement?

admin — Fri, 13 Jan 2012 11:00:18 +0000

My father-in-law is going to have a total knee replacement next week. Call me a pessimist but I think he’s going to have problems. He’s old (83 years old) and frail. Is it possible to predict who will and who won’t have a good result?

Researchers are studying many problems patients face with the idea of predicting who will have a good/poor result. The hope is to give the right care to each group to get the most benefit.

When it comes to total knee replacements (TKRs), there are quite a few studies already done on this topic. One of the most recent ones looked at over 200,000 patients who had a TKR between 1991 and 2001. Rates of infection, blood clots, and death were compiled. Factors such as age, gender, health, and type of insurance were matched against the data.

They reported that age over 65 was a risk factor for problems. Likewise, patients with more than one other health problem had worse outcomes. High blood pressure, diabetes, and a previous history of blood clot(s) are all risk factors for problems after surgery.

Previous studies have shown that surgeon experience makes a difference. Surgeons who do more TKRs have the best results. It turns out that hospitals have similar track records. High volume hospitals have the lowest death rate and rate of infection after TKRs.

Your father-in-law’s best chances for a good recovery depend on his health, his surgeon’s skill, and the type of hospital he will be staying at. Type of insurance seems to have an impact, too. Medicare patients have worse results than patients covered by private insurance.

Has anything much changed in ACL repairs over the years?

admin — Wed, 11 Jan 2012 11:00:06 +0000

ACL repairs have been around for a long time. I had one when I was a college athlete. Now my daughter who is a collegiate basketball player is having one. Has anything much changed over the years?

Anterior cruciate ligament (ACL) repairs have indeed been around for 30 years or more. Surgeons keep finding ways to improve it. In a recent review of ACL repairs, Dr. Ben Graf from the University of Wisconsin (Madison) gave a good summary of the last 30 years.

He said the first 10 years was spent proving ACL repairs were needed. The second 10 years worked on repairing it from the inside out. And the last decade has been looking at types of grafts (hamstring versus patellar tendon grafts).

The newest change is the use of a double-bundle repair to (maybe) replace the single-bundle method. No matter what kind of graft type used, there’s still a problem with early arthritis in the grafted knee. By studying normal anatomy, scientists think this may have to do with motion that is restricted by the ACL repair.

It seems that the standard single-bundle repair doesn’t allow the normal rotation of the tibia (lower leg bone). This type of motion is needed when an athlete pivots and shifts his or her weight to move in a different direction. The double-bundle repair attaches the tendon graft in two places instead of one. The idea is to mimic the anterior and posterior (front and back) attachments of the normal ACL.

But like many new things on the horizon, this one hasn’t been fully tested and approved. The next decade may bring many innovative changes. Improved technology and new surgical instruments will bring about these changes.

I had one knee replaced. Can I use the mininally invasive (MIS) method if I get the other knee replaced?

admin — Mon, 09 Jan 2012 11:00:40 +0000

I have rheumatoid arthritis that has bothered my knees for years. Two years ago I had the right knee replaced. I see now there’s an even better operation with a small incision that doesn’t cut through the muscle. If I have my other knee replaced, could I have it done with this new method?

You may be talking about the minimally invasive (MIS) quadriceps-sparing total knee replacement (TKR). In the standard TKR operation the quadriceps muscle in front of the knee and thigh is either split open or cut and moved out of the way while replacing the joint.

Problems can occur when the muscle is disrupted this way. Blood vessels and nerves can be cut causing swelling and weakness after the operation. Quadriceps sparing doesn’t avoid the muscle completely, but it reduces the amount of trauma by quite a bit.

Patients with rheumatoid arthritis who do not have osteoporosis can have this operation. Younger patients with normal weight and no knee deformity have the best chances of a good result from surgery.