“Dr. Cook my knee hurts” is probably the single most common complaint I hear in my office. Pair that with countless years of medical school and you end up becoming pretty familiar with the human knee. Since these injuries are so common, I thought I’d write a blog post explaining some of these injuries and how we treat them!
Lets start with the basics. Each knee has three bones, two menisci, four primary ligaments, and several lesser ligaments that don’t feel so “lesser” if they happen to be the injured party. If you’re lucky enough to have two knees, then you have twice the exposure. Most of my patients feel quite blessed that they don’t have three knees!
The menisci are the most vulnerable structures in the knee. They are cartilage cushions that sit between the femur and tibia on the medial and lateral sides of the joint. They help to spread out the contact forces so that the bones don’t rub together. Loss of these menisci dramatically increases the likelihood of arthritis. These days we go to great lengths to preserve as much meniscus tissue as we can. When possible, we repair torn meniscus with sutures or implantable anchors. Only about a third of the typical meniscus has a blood supply, and when the avascular part is torn the healing potential drops significantly. In these cases we trim the torn portion of the meniscus which helps to relieve the common complaints of pain, locking, giving way, and swelling. Trimming a torn meniscus also helps to stabilize it and prevents the tear from getting worse. Because the menisci are cartilage structures they are not visible on x-rays. The diagnosis of a tear is often made clinically and then further evaluated by an MRI scan. MRIs often confirm the diagnosis and are helpful to search for associated pathology. They also seem to make the insurance companies very happy when we recommend surgery.
Articular cartilage is the other type of cartilage in the knee. The bones that come together to form a joint are coated with a layer of spongy white articular cartilage very much like the rubber surface of a tire. Pathology or loss of this coating on the bone is the very essence of arthritis. Arthritis often causes pain, swelling, and stiffness, and curiously moving the knee can often make it feel better. We counsel patients with arthritis to try anti-inflammatory medications, get to their ideal body weight, and to pursue exercise that is low impact such as swimming and biking. Yes we want you exercising! Sometimes a knee brace can also be helpful and we stock several varieties.
Knee joint injections are also a great way to treat knee pain. There are three different options for knee joint injections. Cortisone, Hyaluronic acid, and Platelet Rich Plasma.
Cortisone is quick, easy, relatively inexpensive, but like a fine wine you can have too much of a good thing! Cortisone can be harmful if used too frequently, and often doesn’t last as long as we would like, but is usually covered by insurance. Hyaluronic acid injections are more expensive, sometimes covered by insurance, usually last longer, and don’t have a significant downside other than the occasional inflammatory reaction.
Platelet rich plasma, or PRP, is the exciting new option for arthritis patients. We have seen cases where it has worked better and lasted longer than the other two options. Patients also love the fact that PRP is “all natural”. We gather the patient’s own platelets by drawing their blood, separating the platelets from the plasma, and then injecting those platelets into the knee. Because biologic solutions are our new frontier, insurance companies consider this experimental and do not cover PRP, however it can be paid for by HSA funds.
The majority of patients these days have high deductible insurance plans and in a given year do not meet their deductible–so they end up paying for their health expenses out of pocket anyway. In a way it’s actually refreshing. Since insurance companies don’t cover PRP they cannot make you endure a lot of hassles in obtaining permission to receive it! When the conservative options fail we turn to the surgical treatment of articular cartilage disorders. Arthroscopic debridement or pick condroplasty is common and other options include various types of transplants and even replacement with an artificial joint.
Ligament tears do not necessarily change your life forever, but will certainly disrupt things for awhile. Some ligaments such as the MCL respond favorably to knee bracing and rehabilitation, while others are a bit trickier. The most famous of the ligament tears is the ACL. Young and active patients will routinely have these surgically treated, and many middle aged weekend warriors opt for surgery as well. Some senior patients may not need their ACL for basketball or soccer anymore, but find that their knee gives way unpredictably with normal daily activities. These patients can also benefit from an ACL reconstruction. My personal record is an ACL reconstruction on a delightful gentleman who was 65 at the time of his surgery.
When people inquire if I take care of knee problems I tell them “Yes I read that book too!” (as you can tell from this brief overview it was a pretty thick book). If you have any problems with your knees I encourage you to seek help. I would be honored to see you and share with you what I have learned about this awesome joint. For more information please call us at 615-771-1116.