Athletes from all sports can benefit from chiropractic treatment. Adjustments can help treat injuries from high-impact sports i.e. wrestling, football and hockey. Athletes that get routine adjustments may notice improved athletic performance, improved range of motion along with flexibility and increased blood flow. Because spinal adjustments will reduce the irritation of the nerve roots between the vertebrae, the healing time from minor injuries can be shortened, which improves performance. Both high-impact and low-impact athletes can benefit from routine spinal adjustments. For high-impact athletes, it increases performance and flexibility and lowers the risk for injury for low-impact athletes i.e. tennis players, bowlers and golfers. Chiropractic is a natural way to treat and prevent different injuries and conditions that impact athletes. According to Dr. Jimenez, excessive training or improper gear, among other factors, are common causes for injury. Dr. Jimenez summarizes the various causes and effects of sports injuries on the athlete as well as explaining the types of treatments and rehabilitation methods that can help improve an athlete’s condition. For more information, please feel free to contact us at (915) 850-0900 or text to call Dr. Jimenez personally at (915) 540-8444.
The knee is one of the most complex joints in the human body, consisting of the thigh bone, or femur, the shin bone, or tibia, and the kneecap, or patella, among other soft tissues. Tendons connect the bones to the muscles while ligaments connect the bones of the knee joint. Two wedge-shaped pieces of cartilage, known as the meniscus, provide stability to the knee joint. The purpose of the article below is to demonstrate as well as discuss the anatomy of the knee joint and its surrounding soft tissues.
Abstract
Context: Information regarding the structure, composition, and function of the knee menisci has been scattered across multiple sources and fields. This review contains a concise, detailed description of the knee menisci—including anatomy, etymology, phylogeny, ultrastructure and biochemistry, vascular anatomy and neuroanatomy, biomechanical function, maturation and aging, and imaging modalities.
Evidence Acquisition: A literature search was performed by a review of PubMed and OVID articles published from 1858 to 2011.
Results: This study highlights the structural, compositional, and functional characteristics of the menisci, which may be relevant to clinical presentations, diagnosis, and surgical repairs.
Conclusions: An understanding of the normal anatomy and biomechanics of the menisci is a necessary prerequisite to understanding the pathogenesis of disorders involving the knee.
Keywords:knee, meniscus, anatomy, function
Introduction
Once described as a functionless embryonic remnant,162 the menisci are now known to be vital for the normal function and long-term health of the knee joint.§ The menisci increase stability for femorotibial articulation, distribute axial load, absorb shock, and provide lubrication and nutrition to the knee joint.4,91,152,153
Injuries to the menisci are recognized as a cause of significant musculoskeletal morbidity. The unique and complex structure of menisci makes treatment and repair challenging for the patient, surgeon, and physical therapist. Furthermore, long-term damage may lead to degenerative joint changes such as osteophyte formation, articular cartilage degeneration, joint space narrowing, and symptomatic osteoarthritis.36,45,92 Preservation of the menisci depends on maintaining their distinctive composition and organization.
Anatomy of Menisci
Meniscal Etymology
The word meniscus comes from the Greek word mēniskos, meaning “crescent,” diminutive of mēnē, meaning “moon.”
Meniscal Phylogeny and Comparative Anatomy
Hominids exhibit similar anatomic and functional characteristics, including a bicondylar distal femur, intra-articular cruciate ligaments, menisci, and asymmetrical collateral.40,66 These similar morphologic characteristics reflect a shared genetic lineage that can be traced back more than 300 million years.40,66,119
In the primate lineage leading to humans, hominids evolved to bipedal stance approximately 3 to 4 million years ago, and by 1.3 million years ago, the modern patellofemoral joint was established (with a longer lateral patellar facet and matching lateral femoral trochlea).164 Tardieu investigated the transition from occasional bipedalism to permanent bipedalism and observed that primates contain a medial and lateral fibrocartilaginous meniscus, with the medial meniscus being morphologically similar in all primates (crescent shaped with 2 tibial insertions).163 By contrast, the lateral meniscus was observed to be more variable in shape. Unique in Homo sapiens is the presence of 2 tibial insertions—1 anterior and 1 posterior—indicating a habitual practice of full extension movements of the knee joint during the stance and swing phases of bipedal walking.20,134,142,163,168
Embryology and Development
The characteristic shape of the lateral and medial menisci is attained between the 8th and 10th week of gestation.53,60 They arise from a condensation of the intermediate layer of mesenchymal tissue to form attachments to the surrounding joint capsule.31,87,110 The developing menisci are highly cellular and vascular, with the blood supply entering from the periphery and extending through the entire width of the menisci.31 As the fetus continues to develop, there is a gradual decrease in the cellularity of the menisci with a concomitant increase in the collagen content in a circumferential arrangement.30,31 Joint motion and the postnatal stress of weightbearing are important factors in determining the orientation of collagen fibers. By adulthood, only the peripheral 10% to 30% have a blood supply.12,31
Despite these histologic changes, the proportion of tibial plateau covered by the corresponding meniscus is relatively constant throughout fetal development, with the medial and lateral menisci covering approximately 60% and 80% of the surface areas, respectively.31
Gross Anatomy
Gross examination of the knee menisci reveals a smooth, lubricated tissue (Figure 1). They are crescent-shaped wedges of fibrocartilage located on the medial and lateral aspects of the knee joint (Figure 2A). The peripheral, vascular border (also known as the red zone) of each meniscus is thick, convex, and attached to the joint capsule. The innermost border (also known as the white zone) tapers to a thin free edge. The superior surfaces of menisci are concave, enabling effective articulation with their respective convex femoral condyles. The inferior surfaces are flat to accommodate the tibial plateau (Figure 1).28,175
Medial meniscus. The semicircular medial meniscus measures approximately 35 mm in diameter (anterior to posterior) and is significantly broader posteriorly than it is anteriorly.175 The anterior horn is attached to the tibia plateau near the intercondylar fossa anterior to the anterior cruciate ligament (ACL). There is significant variability in the attachment location of the anterior horn of the medial meniscus. The posterior horn is attached to the posterior intercondylar fossa of the tibia between the lateral meniscus and the posterior cruciate ligament (PCL; Figures 1 and and2B).2B). Johnson et al reexamined the tibial insertion sites of the menisci and their topographic relationships to surrounding anatomic landmarks of the knee.82 They found that the anterior and posterior horn insertion sites of the medial meniscus were larger than those of the lateral meniscus. The area of the anterior horn insertion site of the medial meniscus was the largest overall, measuring 61.4 mm2, whereas the posterior horn of the lateral meniscus was the smallest, at 28.5 mm2.82
The tibial portion of the capsular attachment is the coronary ligament. At its midpoint, the medial meniscus is more firmly attached to the femur through a condensation in the joint capsule known as the deep medial collateral ligament.175 The transverse, or “intermeniscal,” ligament is a fibrous band of tissue that connects the anterior horn of the medial meniscus to the anterior horn of the lateral meniscus (Figures 1 and and2A2A).
Lateral meniscus. The lateral meniscus is almost circular, with an approximately uniform width from anterior to posterior (Figures 1 and and2A).2A). It occupies a larger portion (~80%) of the articular surface than the medial meniscus (~60%) and is more mobile.10,31,165 Both horns of the lateral meniscus are attached to the tibia. The insertion of the anterior horn of the lateral meniscus lies anterior to the intercondylar eminence and adjacent to the broad attachment site of the ACL (Figure 2B).9,83 The posterior horn of the lateral meniscus inserts posterior to the lateral tibial spine and just anterior to the insertion of the posterior horn of the medial meniscus (Figure 2B).83 The lateral meniscus is loosely attached to the capsular ligament; however, these fibers do not attach to the lateral collateral ligament. The posterior horn of the lateral meniscus attaches to the inner aspect of the medial femoral condyle via the anterior and posterior meniscofemoral ligaments of Humphrey and Wrisberg, respectively, which originate near the origin of the PCL (Figures 1 and and22).75
Meniscofemoral ligaments. The literature reports significant inconsistencies in the presence and size of meniscofemoral ligaments of the lateral meniscus. There may be none, 1, 2, or 4.‖ When present, these accessory ligaments transverse from the posterior horn of the lateral meniscus to the lateral aspect of the medial femoral condyle. They insert immediately adjacent to the femoral attachment of the PCL (Figures 1 and and22).
In a series of studies, Harner et al measured the cross-sectional area of the ligaments and found that the meniscofemoral ligament averaged 20% of the size of the PCL (range, 7%-35%).69,70 However, the size of the insertional area alone without knowledge of the insertional angle or collagen density does not indicate their relative strength.115 The function of these ligaments remains unknown; they may pull the posterior horn of the lateral meniscus in an anterior direction to increase the congruity of the meniscotibial fossa and the lateral femoral condyle.75
Ultrastructure and Biochemistry
Extracellular Matrix
The meniscus is a dense extracellular matrix (ECM) composed primarily of water (72%) and collagen (22%), interposed with cells.9,55,56,77 Proteoglycans, noncollagenous proteins, and glycoproteins account for the remaining dry weight.¶ Meniscal cells synthesize and maintain the ECM, which determines the material properties of the tissue.
The cells of the menisci are referred to as fibrochondrocytes because they appear to be a mixture of fibroblasts and chondrocytes.111,177 The cells in the more superficial layer of the menisci are fusiform or spindle shaped (more fibroblastic), whereas the cells located deeper in the meniscus are ovoid or polygonal (more chondrocytic).55,56,178 Cell morphology does not differ between the peripheral and central locations in the menisci.56
Both cell types contain abundant endoplasmic reticulum and Golgi complex. Mitochondria are only occasionally visualized, suggesting that the major pathway for energy production of fibrochondrocytes in their avascular milieu is probably anaerobic glycolysis.112
Water
In normal, healthy menisci, tissue fluid represents 65% to 70% of the total weight. Most of the water is retained within the tissue in the solvent domains of proteoglycans. The water content of meniscal tissue is higher in the posterior areas than in the central or anterior areas; tissue samples from surface and deeper layers had similar contents.135
Large hydraulic pressures are required to overcome the drag of frictional resistance of forcing fluid flow through meniscal tissue. Thus, interactions between water and the matrix macromolecular framework significantly influence the viscoelastic properties of the tissue.
Collagens
Collagens are primarily responsible for the tensile strength of menisci; they contribute up to 75% of the dry weight of the ECM.77 The ECM is composed primarily of type I collagen (90% dry weight) with variable amounts of types II, III, V, and VI.43,44,80,112,181 The predominance of type I collagen distinguishes the fibrocartilage of menisci from articular (hyaline) cartilage. The collagens are heavily cross-linked by hydroxylpyridinium aldehydes.44
The collagen fiber arrangement is ideal for transferring a vertical compressive load into circumferential “hoop” stresses (Figure 3).57 Type I collagen fibers are oriented circumferentially in the deeper layers of the meniscus, parallel to the peripheral border. These fibers blend the ligamentous connections of the meniscal horns to the tibial articular surface (Figure 3).10,27,49,156 In the most superficial region of the menisci, the type I fibers are oriented in a more radial direction. Radially oriented “tie” fibers are also present in the deep zone and are interspersed or woven between the circumferential fibers to provide structural integrity (Figure 3).# There is lipid debris and calcified bodies in the ECM of human menisci.54 The calcified bodies contain long, slender crystals of phosphorous, calcium, and magnesium on electron-probe roentgenographic analysis.54 The function of these crystals in not completely understood, but it is believed that they may play a role in acute joint inflammation and destructive arthropathies.
Noncollagenous matrix proteins, such as fibronectin, contribute 8% to 13% of the organic dry weight. Fibronectin is involved in many cellular processes, including tissue repair, embryogenesis, blood clotting, and cell migration/adhesion. Elastin forms less than 0.6% of the meniscus dry weight; its ultrastructural localization is not clear. It likely interacts directly with collagen to provide resiliency to the tissue.**
Proteoglycans
Located within a fine meshwork of collagen fibrils, proteoglycans are large, negatively charged hydrophilic molecules, contributing 1% to 2% of dry weight.58 They are formed by a core protein with 1 or more covalently attached glycosaminoglycan chains (Figure 4).122 The size of these molecules is further increased by specific interaction with hyaluronic acid.67,72 The amount of proteoglycans in the meniscus is one-eighth that of articular cartilage,2,3 and there may be considerable variation depending on the site of the sample and the age of the patient.49
By virtue of their specialized structure, high fixed-charge density, and charge-charge repulsion forces, proteoglycans in the ECM are responsible for hydration and provide the tissue with a high capacity to resist compressive loads.‡ The glycosaminoglycan profile of the normal adult human meniscus consists of chondroitin-6-sulfate (40%), chondroitin-4-sulfate (10% to 20%), dermatan sulfate (20% to 30%), and keratin sulfate (15%; Figure 4).65,77,99,159 The highest glycosaminoglycan concentrations are found in the meniscal horns and the inner half of the menisci in the primary weightbearing areas.58,77
Aggrecan is the major proteoglycan found in the human menisci and is largely responsible for their viscoelastic compressive properties (Figure 5). Smaller proteoglycans, such as decorin, biglycan, and fibromodulin, are found in smaller amounts.124,151 Hexosamine contributes 1% to the dry weight of ECM.57,74 The precise functions of each of these small proteoglycans on the meniscus have yet to be fully elucidated.
Matrix Glycoproteins
Meniscal cartilage contains a range of matrix glycoproteins, the identities and functions of which have yet to be determined. Electrophoresis and subsequent staining of the polyacrylamide gels reveals bands with molecular weights varying from a few kilodaltons to more than 200 kDa.112 These matrix molecules include the link proteins that stabilize proteoglycan–hyaluronic acid aggregates and a 116-kDa protein of unknown function.46 This protein resides in the matrix in the form of disulfide-bonded complex of high molecular weight.46 Immunolocalization studies suggest that it is predominantly located around the collagen bundles in the interterritorial matrix.47
The adhesive glycoproteins constitute a subgroup of the matrix glycoproteins. These macromolecules are partly responsible for binding with other matrix molecules and/or cells. Such intermolecular adhesion molecules are therefore important components in the supramolecular organization of the extracellular molecules of the meniscus.150 Three molecules have been identified within the meniscus: type VI collagen, fibronectin, and thrombospondin.112,118,181
Vascular Anatomy
The meniscus is a relatively avascular structure with a limited peripheral blood supply. The medial, lateral, and middle geniculate arteries (which branch off the popliteal artery) provide the major vascularization to the inferior and superior aspects of each meniscus (Figure 5).9,12,33-35,148 The middle geniculate artery is a small posterior branch that perforates the oblique popliteal ligament at the posteromedial corner of the tibiofemoral joint. A premeniscal capillary network arising from the branches of these arteries originates within the synovial and capsular tissues of the knee along the periphery of the menisci. The peripheral 10% to 30% of the medial meniscus border and 10% to 25% of the lateral meniscus are relatively well vascularized, which has important implications for meniscus healing (Figure 6).12,33,68 Endoligamentous vessels from the anterior and posterior horns travel a short distance into the substance of the menisci and form terminal loops, providing a direct route for nourishment.33 The remaining portion of each meniscus (65% to 75%) receives nourishment from synovial fluid via diffusion or mechanical pumping (ie, joint motion).116,120
Bird and Sweet examined the menisci of animals and humans using scanning electron and light microscopy.23,24 They observed canal-like structures opening deep into the surface of the menisci. These canals may play a role in the transport of fluid within the meniscus and may carry nutrients from the synovial fluid and blood vessels to the avascular sections of the meniscus.23,24 However, further study is needed to elucidate the exact mechanism by which mechanical motion supplies nutrition to the avascular portion of the menisci.
Neuroanatomy
The knee joint is innervated by the posterior articular branch of the posterior tibial nerve and the terminal branches of the obturator and femoral nerves. The lateral portion of the capsule is innervated by the recurrent peroneal branch of the common peroneal nerve. These nerve fibers penetrate the capsule and follow the vascular supply to the peripheral portion of the menisci and the anterior and posterior horns, where most of the nerve fibers are concentrated.52,90 The outer third of the body of the meniscus is more densely innervated than the middle third.183,184 During extremes of flexion and extension of the knee, the meniscal horns are stressed, and the afferent input is likely greatest at these extreme positions.183,184
The mechanoreceptors within the menisci function as transducers, converting the physical stimulus of tension and compression into a specific electrical nerve impulse. Studies of human menisci have identified 3 morphologically distinct mechanoreceptors: Ruffini endings, Pacinian corpuscles, and Golgi tendon organs.‡‡ Type I (Ruffini) mechanoreceptors are low threshold and slowly adapting to the changes in joint deformation and pressure. Type II (Pacinian) mechanoreceptors are low threshold and fast adapting to tension changes.§§ Type III (Golgi) are high-threshold mechanoreceptors, which signal when the knee joint approaches the terminal range of motion and are associated with neuromuscular inhibition. These neural elements were found in greater concentration in the meniscal horns, particularly the posterior horn.
The asymmetrical components of the knee act in concert as a type of biological transmission that accepts, transfers, and dissipates loads along the femur, tibia, patella, and femur.41 Ligaments act as an adaptive linkage, with the menisci representing mobile bearings. Several studies have reported that various intra-articular components of the knee are sensate, capable of generating neurosensory signals that reach spinal, cerebellar, and higher central nervous system levels.‖‖ It is believed that these neurosensory signals result in conscious perception and are important for normal knee joint function and maintenance of tissue homeostasis.42
The meniscus is cartilage which provides structural and functional integrity to the knee. The menisci are two pads of fibrocartilaginous tissue which spread out friction in the knee joint when it undergoes tension and torsion between the shin bone, or tibia, and the thigh bone, or femur. The understanding of the anatomy and biomechanics of the knee joint is essential towards the understanding of knee injuries and/or conditions. Dr. Alex Jimenez D.C., C.C.S.T. Insight
Biomechanical Function
The biomechanical function of the meniscus is a reflection of the gross and ultrastructural anatomy and of its relationship to the surrounding intra-articular and extra-articular structures. The menisci serve many important biomechanical functions. They contribute to load transmission,¶¶ shock absorption,10,49,94,96,170 stability,51,100,101,109,155 nutrition,23,24,84,141 joint lubrication,102-104,141 and proprioception.5,15,81,88,115,147 They also serve to decrease contact stresses and increase contact area and congruity of the knee.91,172
Meniscal Kinematics
In a study on ligamentous function, Brantigan and Voshell reported the medial meniscus to move an average 2 mm, while the lateral meniscus was markedly more mobile with approximately 10 mm of anterior-posterior displacement during flexion.25 Similarly, DePalma reported that the medial meniscus undergoes 3 mm of anterior-posterior displacement, while the lateral meniscus moves 9 mm during flexion.37 In a study using 5 cadaveric knees, Thompson et al reported the mean medial excursion to be 5.1 mm (average of anterior and posterior horns) and the mean lateral excursion, 11.2 mm, along the tibial articular surface (Figure 7).165 The findings from these studies confirm a significant difference in segmental motion between the medial and lateral menisci. The anterior and posterior horn lateral meniscus ratio is smaller and indicates that the meniscus moves more as a single unit.165 Alternatively, the medial meniscus (as a whole) moves less than the lateral meniscus, displaying a greater anterior to posterior horn differential excursion. Thompson et al found that the area of least meniscal motion is the posterior medial corner, where the meniscus is constrained by its attachment to the tibial plateau by the meniscotibial portion of the posterior oblique ligament, which has been reported to be more prone to injury.143,165 A reduction in the motion of the posterior horn of the medial meniscus is a potential mechanism for meniscal tears, with a resultant “trapping” of the fibrocartilage between the femoral condyle and the tibial plateau during full flexion. The greater differential between anterior and posterior horn excursion may place the medial meniscus at a greater risk of injury.165
The differential of anterior horn to posterior horn motion allows the menisci to assume a decreasing radius with flexion, which correlates to the decreased radius of curvature of the posterior femoral condyles.165 This change of radius allows the meniscus to maintain contact with the articulating surface of both the femur and the tibia throughout flexion.
Load Transmission
The function of the menisci has been clinically inferred by the degenerative changes that accompany its removal. Fairbank described the increased incidence and predictable degenerative changes of the articular surfaces in completely meniscectomized knees.45 Since this early work, numerous studies have confirmed these findings and have further established the important role of the meniscus as a protective, load-bearing structure.
Weightbearing produces axial forces across the knee, which compress the menisci, resulting in “hoop” (circumferential) stresses.170 Hoop stresses are generated as axial forces and converted to tensile stresses along the circumferential collagen fibers of the meniscus (Figure 8). Firm attachments by the anterior and posterior insertional ligaments prevent the meniscus from extruding peripherally during load bearing.94 Studies by Seedhom and Hargreaves reported that 70% of the load in the lateral compartment and 50% of the load in the medial compartment is transmitted through the menisci.153 The menisci transmit 50% of compressive load through the posterior horns in extension, with 85% transmission at 90° flexion.172 Radin et al demonstrated that these loads are well distributed when the menisci are intact.137 However, removal of the medial meniscus results in a 50% to 70% reduction in femoral condyle contact area and a 100% increase in contact stress.4,50,91 Total lateral meniscectomy results in a 40% to 50% decrease in contact area and increases contact stress in the lateral component to 200% to 300% of normal.18,50,76,91 This significantly increases the load per unit area and may contribute to accelerated articular cartilage damage and degeneration.45,85
Shock Absorption
The menisci play a vital role in attenuating the intermittent shock waves generated by impulse loading of the knee with normal gait.94,96,153 Voloshin and Wosk showed that the normal knee has a shock-absorbing capacity about 20% higher than knees that have undergone meniscectomy.170 As the inability of a joint system to absorb shock has been implicated in the development of osteoarthritis, the meniscus would appear to play an important role in maintaining the health of the knee joint.138
Joint Stability
The geometric structure of the menisci provides an important role in maintaining joint congruity and stability.## The superior surface of each meniscus is concave, enabling effective articulation between the convex femoral condyles and flat tibial plateau. When the meniscus is intact, axial loading of the knee has a multidirectional stabilizing function, limiting excess motion in all directions.9
Markolf and colleagues have addressed the effect of meniscectomy on anterior-posterior and rotational knee laxity. Medial meniscectomy in the ACL-intact knee has little effect on anterior-posterior motion, but in the ACL-deficient knee, it results in an increase in anterior-posterior tibial translation of up to 58% at 90o of flexion.109 Shoemaker and Markolf demonstrated that the posterior horn of the medial meniscus is the most important structure resisting an anterior tibial force in the ACL-deficient knee.155 Allen et al showed that the resultant force in the medial meniscus of the ACL-deficient knee increased by 52% in full extension and by 197% at 60° of flexion under a 134-N anterior tibial load.7 The large changes in kinematics due to medial meniscectomy in the ACL-deficient knee confirm the important role of the medial meniscus in knee stability. Recently, Musahl et al reported that the lateral meniscus plays a role in anterior tibial translation during the pivot-shift maneuver.123
Joint Nutrition and Lubrication
The menisci may also play a role in the nutrition and lubrication of the knee joint. The mechanics of this lubrication remains unknown; the menisci may compress synovial fluid into the articular cartilage, which reduces frictional forces during weightbearing.13
There is a system of microcanals within the meniscus located close to the blood vessels, which communicates with the synovial cavity; these may provide fluid transport for nutrition and joint lubrication.23,24
Proprioception
The perception of joint motion and position (proprioception) is mediated by mechanoreceptors that transduce mechanical deformation into electric neural signals. Mechanoreceptors have been identified in the anterior and posterior horns of the menisci.*** Quick-adapting mechanoreceptors, such as Pacinian corpuscles, are thought to mediate the sensation of joint motion, and slow-adapting receptors, such as Ruffini endings and Golgi tendon organs, are believed to mediate the sensation of joint position.140 The identification of these neural elements (located mostly in the middle and outer third of the meniscus) indicates that the menisci are capable of detecting proprioceptive information in the knee joint, thus playing an important afferent role in the sensory feedback mechanism of the knee.61,88,90,158,169
Maturation and Aging of The Meniscus
The microanatomy of the meniscus is complex and certainly demonstrates senescent changes. With advancing age, the meniscus becomes stiffer, loses elasticity, and becomes yellow.78,95 Microscopically, there is a gradual loss of cellular elements with empty spaces and an increase in fibrous tissue in comparison with elastic tissue.74 These cystic areas can initiate a tear, and with a torsional force by the femoral condyle, the superficial layers of the meniscus may shear off from the deep layer at the interface of the cystic degenerative change, producing a horizontal cleavage tear. Shear between these layers may cause pain. The torn meniscus may directly injure the overlying articular cartilage.74,95
Ghosh and Taylor found that collagen concentration increased from birth to 30 years and remained constant until 80 years of age, after which a decline occurred.58 The noncollagenous matrix proteins showed the most profound changes, decreasing from 21.9% ± 1.0% (dry weight) in neonates to 8.1% ± 0.8% between the ages of 30 to 70 years.80 After 70 years of age, the noncollagenous matrix protein levels increased to 11.6% ± 1.3%. Peters and Smillie observed an increase in hexosamine and uronic acid with age.131
McNicol and Roughley studied the variation of meniscal proteoglycans in aging113; small differences in extractability and hydrodynamic size were observed. The proportions of keratin sulfate relative to chondroitin-6-sulfate increased with aging.146
Petersen and Tillmann immunohistochemically investigated human menisci (ranging from 22 weeks of gestation to 80 years), observing the differentiation of blood vessels and lymphatics in 20 human cadavers. At the time of birth, nearly the entire meniscus was vascularized. In the second year of life, an avascular area developed in the inner circumference. In the second decade, blood vessels were present in the peripheral third. After 50 years of age, only the peripheral quarter of the meniscal base was vascularized. The dense connective tissue of the insertion was vascularized but not the fibrocartilage of the insertion. Blood vessels were accompanied by lymphatics in all areas.†††
Arnoczky suggested that body weight and knee joint motion may eliminate blood vessels in the inner and middle aspects of the menisci.9 Nutrition of meniscal tissue occurs via perfusion from blood vessels and via diffusion from synovial fluid. A requirement for nutrition via diffusion is the intermittent loading and release on the articular surfaces, stressed by body weight and muscle forces.130 The mechanism is comparable with the nutrition of articular cartilage.22
Magnetic Resonance Imaging of The Meniscus
Magnetic resonance imaging (MRI) is a noninvasive diagnostic tool used in the evaluation, diagnosis, and monitoring of the menisci. MRI is widely accepted as the optimal imaging modality because of superior soft tissue contrast.
On cross-sectional MRI, the normal meniscus appears as a uniform low-signal (dark) triangular structure (Figure 9). A meniscal tear is identified by the presence of an increased intrameniscal signal that extends to the surface of this structure.
Several studies have evaluated the clinical utility of MRI for meniscal tears. In general, MRI is highly sensitive and specific for tears of the meniscus. The sensitivity of MRI in detecting meniscal tears ranges from 70% to 98%, and the specificity, from 74% to 98%.48,62,105,107,117 The MRI of 1014 patients before an arthroscopic examination had an accuracy of 89% for pathology of the medial meniscus and 88% for the lateral meniscus.48 A meta-analysis of 2000 patients with an MRI and arthroscopic examination found 88% sensitivity and 94% accuracy for meniscal tears.105,107
There have been discrepancies between MRI diagnoses and the pathology identified during arthroscopic examination.‡‡‡ Justice and Quinn reported discrepancies in the diagnosis of 66 of the 561 patients (12%).86 In a study of 92 patients, discrepancies between the MRI and arthroscopic diagnoses were noted in 22 of the 349 (6%) cases.106 Miller conducted a single-blind prospective study comparing clinical examinations and MRI in 57 knee examinations.117 He found no significant difference in sensitivity between the clinical examination and MRI (80.7% and 73.7%, respectively). Shepard et al assessed the accuracy of MRI in detecting clinically significant lesions of the anterior horn of the meniscus in 947 consecutive knee MRI154 and found a 74% false-positive rate. Increased signal intensity in the anterior horn does not necessarily indicate a clinically significant lesion.154
Conclusions
The menisci of the knee joint are crescent-shaped wedges of fibrocartilage that provide increased stability to the femorotibial articulation, distribute axial load, absorb shock, and provide lubrication to the knee joint. Injuries to the menisci are recognized as a cause of significant musculoskeletal morbidity. Preservation of the menisci is highly dependent on maintaining its distinctive composition and organization.
In conclusion, the knee is the largest and most complex joint in the human body. However, because the knee can commonly become damaged as a result of an injury and/or condition, it’s essential to understand the anatomy of the knee joint in order for patients to receive proper treatment. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
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175. Warren RF, Arnoczky SP, Wickiewiez TL. Anatomy of the knee. In: Nicholas JA, Hershman EB, editors. , eds. The Lower Extremity and Spine in Sports Medicine. St Louis: Mosby; 1986:657-694
176. Watanabe AT, Carter BC, Teitelbaum GP, et al. Common pitfalls in magnetic resonance imaging of the knee. J Bone Joint Surg Am. 1989;71:857-862 [PubMed]
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The knee is the largest joint in the human body, where the complex structures of the lower and upper legs come together. Consisting of three bones, the femur, the tibia, and the patella which are surrounded by a variety of soft tissues, including cartilage, tendons and ligaments, the knee functions as a hinge, allowing you to walk, jump, squat or sit. As a result, however, the knee is considered to be one of the joints that are most prone to suffer injury. A knee injury is the prevalent cause of knee pain.
A knee injury can occur as a result of a direct impact from a slip-and-fall accident or automobile accident, overuse injury from sports injuries, or even due to underlying conditions, such as arthritis. Knee pain is a common symptom which affects people of all ages. It may also start suddenly or develop gradually over time, beginning as a mild or moderate discomfort then slowly worsening as time progresses. Moreover, being overweight can increase the risk of knee problems. The purpose of the following article is to discuss the evaluation of patients presenting with knee pain and demonstrate their differential diagnosis.
Determining the underlying cause of knee pain can be difficult, in part because of the extensive differential diagnosis. As discussed in part I of this two-part article,1 the family physician should be familiar with knee anatomy and common mechanisms of injury, and a detailed history and focused physical examination can narrow possible causes. The patient’s age and the anatomic site of the pain are two factors that can be important in achieving an accurate diagnosis (Tables 1 and 2).
Children and Adolescents
Children and adolescents who present with knee pain are likely to have one of three common conditions: patellar subluxation, tibial apophysitis, or patellar tendonitis. Additional diagnoses to consider in children include slipped capital femoral epiphysis and septic arthritis.
Patellar Subluxation
Patellar subluxation is the most likely diagnosis in a teenage girl who presents with giving-way episodes of the knee.2 This injury occurs more often in girls and young women because of an increased quadriceps angle (Q angle), usually greater than 15 degrees.
Patellar apprehension is elicited by subluxing the patella laterally, and a mild effusion is usually present. Moderate to severe knee swelling may indicate hemarthrosis, which suggests patellar dislocation with osteochondral fracture and bleeding.
Tibial Apophysitis
A teenage boy who presents with anterior knee pain localized to the tibial tuberosity is likely to have tibial apophysitis or Osgood- Schlatter lesion3,4 (Figure 1).5 The typical patient is a 13- or 14-year-old boy (or a 10- or 11-year-old girl) who has recently gone through a growth spurt.
The patient with tibial apophysitis generally reports waxing and waning of knee pain for a period of months. The pain worsens with squatting, walking up or down stairs, or forceful contractions of the quadriceps muscle. This overuse apophysitis is exacerbated by jumping and hurdling because repetitive hard landings place excessive stress on the insertion of the patellar tendon.
On physical examination, the tibial tuberosity is tender and swollen and may feel warm. The knee pain is reproduced with the resisted active extension or passive hyperflexion of the knee. No effusion is present. Radiographs are usually negative; rarely, they show avulsion of the apophysis at the tibial tuberosity. However, the physician must not mistake the normal appearance of the tibial apophysis for an avulsion fracture.
Patellar Tendonitis
Jumper’s knee (irritation and inflammation of the patellar tendon) most commonly occurs in teenage boys, particularly during a growth spurt2 (Figure 1).5 The patient reports vague anterior knee pain that has persisted for months and worsens after activities such as walking down stairs or running.
On physical examination, the patellar tendon is tender, and the pain is reproduced by resisted knee extension. There is usually no effusion. Radiographs are not indicated.
Slipped Capital Femoral Epiphysis
A number of pathologic conditions result in referral of pain to the knee. For example, the possibility of slipped capital femoral epiphysis must be considered in children and teenagers who present with knee pain.6 The patient with this condition usually reports poorly localized knee pain and no history of knee trauma.
The typical patient with slipped capital femoral epiphysis is overweight and sits on the examination table with the affected hip slightly flexed and externally rotated. The knee examination is normal, but hip pain is elicited with passive internal rotation or extension of the affected hip.
Radiographs typically show displacement of the epiphysis of the femoral head. However, negative radiographs do not rule out the diagnosis in patients with typical clinical findings. Computed tomographic (CT) scanning is indicated in these patients.
Osteochondritis Dissecans
Osteochondritis dissecans is an intra-articular osteochondrosis of unknown etiology that is characterized by degeneration and recalcification of articular cartilage and underlying bone. In the knee, the medial femoral condyle is most commonly affected.7
The patient reports vague, poorly localized knee pain, as well as morning stiffness or recurrent effusion. If a loose body is present, mechanical symptoms of locking or catching of the knee joint also may be reported. On physical examination, the patient may demonstrate quadriceps atrophy or tenderness along the involved chondral surface. A mild joint effusion may be present.7
Plain-film radiographs may demonstrate the osteochondral lesion or a loose body in the knee joint. If osteochondritis dissecans is suspected, recommended radiographs include anteroposterior, posteroanterior tunnel, lateral, and Merchant’s views. Osteochondral lesions at the lateral aspect of the medial femoral condyle may be visible only on the posteroanterior tunnel view. Magnetic resonance imaging (MRI) is highly sensitive in detecting these abnormalities and is indicated in patients with a suspected osteochondral lesion.7
A knee injury caused by sports injuries, automobile accidents, or an underlying condition, among other causes, can affect the cartilage, tendons and ligaments which form the knee joint itself. The location of the knee pain can differ according to the structure involved, also, the symptoms can vary. The entire knee may become painful and swollen as a result of inflammation or infection, whereas a torn meniscus or fracture may cause symptoms in the affected region. Dr. Alex Jimenez D.C., C.C.S.T. Insight
Adults
Overuse Syndromes
Anterior Knee Pain. Patients with patellofemoral pain syndrome (chondromalacia patellae) typically present with a vague history of mild to moderate anterior knee pain that usually occurs after prolonged periods of sitting (the so-called “theater sign”).8 Patellofemoral pain syndrome is a common cause of anterior knee pain in women.
On physical examination, a slight effusion may be present, along with patellar crepitus on the range of motion. The patient’s pain may be reproduced by applying direct pressure to the anterior aspect of the patella. Patellar tenderness may be elicited by subluxing the patella medially or laterally and palpating the superior and inferior facets of the patella. Radiographs usually are not indicated.
Medial Knee Pain. One frequently overlooked diagnosis is medial plica syndrome. The plica, a redundancy of the joint synovium medially, can become inflamed with repetitive overuse.4,9 The patient presents with acute onset of medial knee pain after a marked increase in usual activities. On physical examination, a tender, mobile nodularity is present at the medial aspect of the knee, just anterior to the joint line. There is no joint effusion, and the remainder of the knee examination is normal. Radiographs are not indicated.
Pes anserine bursitis is another possible cause of medial knee pain. The tendinous insertion of the sartorius, gracilis, and semitendinosus muscles at the anteromedial aspect of the proximal tibia forms the pes anserine bursa.9 The bursa can become inflamed as a result of overuse or a direct contusion. Pes anserine bursitis can be confused easily with a medial collateral ligament sprain or, less commonly, osteoarthritis of the medial compartment of the knee.
The patient with pes anserine bursitis reports pain at the medial aspect of the knee. This pain may be worsened by repetitive flexion and extension. On physical examination, tenderness is present at the medial aspect of the knee, just posterior and distal to the medial joint line. No knee joint effusion is present, but there may be slight swelling at the insertion of the medial hamstring muscles. Valgus stress testing in the supine position or resisted knee flexion in the prone position may reproduce the pain. Radiographs are usually not indicated.
Lateral Knee Pain. Excessive friction between the iliotibial band and the lateral femoral condyle can lead to iliotibial band tendonitis.9 This overuse syndrome commonly occurs in runners and cyclists, although it may develop in any person subsequent to activity involving repetitive knee flexion. The tightness of the iliotibial band, excessive foot pronation, genu varum, and tibial torsion are predisposing factors.
The patient with iliotibial band tendonitis reports pain at the lateral aspect of the knee joint. The pain is aggravated by activity, particularly running downhill and climbing stairs. On physical examination, tenderness is present at the lateral epicondyle of the femur, approximately 3 cm proximal to the joint line. Soft tissue swelling and crepitus also may be present, but there is no joint effusion. Radiographs are not indicated.
Noble’s test is used to reproduce the pain in iliotibial band tendonitis. With the patient in a supine position, the physician places a thumb over the lateral femoral epicondyle as the patient repeatedly flexes and extends the knee. Pain symptoms are usually most prominent with the knee at 30 degrees of flexion.
Popliteus tendonitis is another possible cause of lateral knee pain. However, this condition is fairly rare.10
Trauma
Anterior Cruciate Ligament Sprain. Injury to the anterior cruciate ligament usually occurs because of noncontact deceleration forces, as when a runner plants one foot and sharply turns in the opposite direction. Resultant valgus stress on the knee leads to anterior displacement of the tibia and sprain or rupture of the ligament.11 The patient usually reports hearing or feeling a “pop” at the time of the injury and must cease activity or competition immediately. Swelling of the knee within two hours after the injury indicates rupture of the ligament and consequent hemarthrosis.
On physical examination, the patient has a moderate to severe joint effusion that limits the range of motion. The anterior drawer test may be positive, but can be negative because of hemarthrosis and guarding by the hamstring muscles. The Lachman test should be positive and is more reliable than the anterior drawer test (see text and Figure 3 in part I of the article1).
Radiographs are indicated to detect possible tibial spine avulsion fracture. MRI of the knee is indicated as part of a presurgical evaluation.
Medial Collateral Ligament Sprain. Injury to the medial collateral ligament is fairly common and is usually the result of acute trauma. The patient reports a misstep or collision that places valgus stress on the knee, followed by the immediate onset of pain and swelling at the medial aspect of the knee.11
On physical examination, the patient with medial collateral ligament injury has point tenderness at the medial joint line. Valgus stress testing of the knee flexed to 30 degrees reproduces the pain (see text and Figure 4 in part I of this article1). A clearly defined endpoint on valgus stress testing indicates a grade 1 or grade 2 sprain, whereas complete medial instability indicates full rupture of the ligament (grade 3 sprain).
Lateral Collateral Ligament Sprain. Injury of the lateral collateral ligament is much less common than the injury of the medial collateral ligament. Lateral collateral ligament sprain usually results from varus stress to the knee, as occurs when a runner plants one foot and then turns toward the ipsilateral knee.2 The patient reports acute onset of lateral knee pain that requires prompt cessation of activity.
On physical examination, point tenderness is present at the lateral joint line. Instability or pain occurs with varus stress testing of the knee flexed to 30 degrees (see text and Figure 4 in part I of this article1). Radiographs are not usually indicated.
Meniscal Tear. The meniscus can be torn acutely with a sudden twisting injury of the knee, such as may occur when a runner suddenly changes direction.11,12 Meniscal tear also may occur in association with a prolonged degenerative process, particularly in a patient with an anterior cruciate ligament-deficient knee. The patient usually reports recurrent knee pain and episodes of catching or locking of the knee joint, especially with squatting or twisting of the knee.
On physical examination, a mild effusion is usually present, and there is tenderness at the medial or lateral joint line. Atrophy of the vastus medialis obliquus portion of the quadriceps muscle also may be noticeable. The McMurray test may be positive (see Figure 5 in part I of this article1), but a negative test does not eliminate the possibility of a meniscal tear.
Plain-film radiographs usually are negative and seldom are indicated. MRI is the radiologic test of choice because it demonstrates most significant meniscal tears.
Infection
Infection of the knee joint may occur in patients of any age but is more common in those whose immune system has been weakened by cancer, diabetes mellitus, alcoholism, acquired immunodeficiency syndrome, or corticosteroid therapy. The patient with septic arthritis reports abrupt onset of pain and swelling of the knee with no antecedent trauma.13
On physical examination, the knee is warm, swollen, and exquisitely tender. Even slight motion of the knee joint causes intense pain.
Arthrocentesis reveals turbid synovial fluid. Analysis of the fluid yields a white blood cell count (WBC) higher than 50,000 per mm3 (50 109 per L), with more than 75 percent (0.75) polymorphonuclear cells, an elevated protein content (greater than 3 g per dL [30 g per L]), and a low glucose concentration (more than 50 percent lower than the serum glucose concentration).14 Gram stain of the fluid may demonstrate the causative organism. Common pathogens include Staphylococcus aureus, Streptococcus species, Haemophilus influenza, and Neisseria gonorrhoeae.
Hematologic studies show an elevated WBC, an increased number of immature polymorphonuclear cells (i.e., a left shift), and an elevated erythrocyte sedimentation rate (usually greater than 50 mm per hour).
Older Adults
Osteoarthritis
Osteoarthritis of the knee joint is a common problem after 60 years of age. The patient presents with knee pain that is aggravated by weight-bearing activities and relieved by rest.15 The patient has no systemic symptoms but usually awakens with morning stiffness that dissipates somewhat with activity. In addition to chronic joint stiffness and pain, the patient may report episodes of acute synovitis.
Findings on physical examination include decreased range of motion, crepitus, a mild joint effusion, and palpable osteophytic changes at the knee joint.
When osteoarthritis is suspected, recommended radiographs include weight-bearing anteroposterior and posteroanterior tunnel views, as well as non-weight-bearing Merchants and lateral views. Radiographs show joint-space narrowing, subchondral bony sclerosis, cystic changes, and hypertrophic osteophyte formation.
Crystal-Induced Inflammatory Arthropathy
Acute inflammation, pain, and swelling in the absence of trauma suggest the possibility of a crystal-induced inflammatory arthropathy such as gout or pseudogout.16,17 Gout commonly affects the knee. In this arthropathy, sodium urate crystals precipitate in the knee joint and cause an intense inflammatory response. In pseudogout, calcium pyrophosphate crystals are the causative agents.
On physical examination, the knee joint is erythematous, warm, tender, and swollen. Even minimal range of motion is exquisitely painful.
Arthrocentesis reveals clear or slightly cloudy synovial fluid. Analysis of the fluid yields a WBC count of 2,000 to 75,000 per mm3 (2 to 75 109 per L), a high protein content (greater than 32 g per dL [320 g per L]), and a glucose concentration that is approximately 75 percent of the serum glucose con- centration.14 Polarized-light microscopy of the synovial fluid displays negatively birefringent rods in the patient with gout and positively birefringent rhomboids in the patient with pseudogout.
Popliteal Cyst
The popliteal cyst (Baker’s cyst) is the most common synovial cyst of the knee. It originates from the posteromedial aspect of the knee joint at the level of the gastrocnemio-semimembranous bursa. The patient reports insidious onset of mild to moderate pain in the popliteal area of the knee.
On physical examination, palpable fullness is present at the medial aspect of the popliteal area, at or near the origin of the medial head of the gastrocnemius muscle. The McMurray test may be positive if the medial meniscus is injured. Definitive diagnosis of a popliteal cyst may be made with arthrography, ultrasonography, CT scanning, or, less commonly, MRI.
The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.
In conclusion, although the knee is the largest joint in the human body where the structures of the lower extremities meet, including the femur, the tibia, the patella, and many other soft tissues, the knee can easily suffer damage or injury and result in knee pain. Knee pain is one of the most common complaints among the general population, however, it commonly occurs in athletes. Sports injuries, slip-and-fall accidents, and automobile accidents, among other causes, can lead to knee pain.
As described in the article above, diagnosis is essential towards determining the best treatment approach for each type of knee injury, according to their underlying cause. While the location and the severity of the knee injury may vary depending on the cause of the health issue, knee pain is the most common symptom. Treatment options, such as chiropractic care and physical therapy, can help treat knee pain. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
1. Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: part I. History, physical examination, radiographs, and laboratory tests. Am Fam Physician 2003;68:907-12.
2. Walsh WM. Knee injuries. In: Mellion MB, Walsh WM, Shelton GL, eds. The team physician’s hand- book. 2d ed. St. Louis: Mosby, 1990:554-78.
3. Dunn JF. Osgood-Schlatter disease. Am Fam Physi- cian 1990;41:173-6.
4. Stanitski CL. Anterior knee pain syndromes in the adolescent. Instr Course Lect 1994;43:211-20.
5. Tandeter HB, Shvartzman P, Stevens MA. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician 1999;60: 2599-608.
6. Waters PM, Millis MB. Hip and pelvic injuries in the young athlete. In: DeLee J, Drez D, Stanitski CL, eds. Orthopaedic sports medicine: principles and practice. Vol. III. Pediatric and adolescent sports medicine. Philadelphia: Saunders, 1994:279-93.
7. Schenck RC Jr, Goodnight JM. Osteochondritis dis- secans. J Bone Joint Surg [Am] 1996;78:439-56.
8. Ruffin MT 5th, Kiningham RB. Anterior knee pain: the challenge of patellofemoral syndrome. Am Fam Physician 1993;47:185-94.
Knee pain is a common health issue among athletes and the general population alike. Although symptoms of knee pain can be debilitating and frustrating, knee pain is often a very treatable health issue. The knee is a complex structure made up of three bones: the lower section of the thighbone, the upper region of the shinbone, and the kneecap.
Powerful soft tissues, such as the tendons and ligaments of the knee as well as the cartilage beneath the kneecap and between the bones, hold these structures together in order to stabilize and support the knee. However, a variety of injuries and/or conditions can ultimately lead to knee pain. The purpose of the article below is to evaluate patients with knee pain.
Knee pain accounts for approximately one-third of musculoskeletal problems seen in primary care settings. This complaint is most prevalent in physically active patients, with as many as 54 percent of athletes having some degree of knee pain each year.1 Knee pain can be a source of significant disability, restricting the ability to work or perform activities of daily living.
The knee is a complex structure (Figure 1),2 and its evaluation can present a challenge to the family physician. The differential diagnosis of knee pain is extensive but can be narrowed with a detailed history, a focused physical examination and, when indicated, the selective use of appropriate imaging and laboratory studies. Part I of this two-part article provides a systematic approach to evaluating the knee, and part II3 discusses the differential diagnosis of knee pain.
History
Pain Characteristics
The patient’s description of knee pain is helpful in focusing the differential diagnosis.4 It is important to clarify the characteristics of the pain, including its onset (rapid or insidious), location (anterior, medial, lateral, or posterior knee), duration, severity, and quality (e.g., dull, sharp, achy). Aggravating and alleviating factors also need to be identified. If knee pain is caused by an acute injury, the physician needs to know whether the patient was able to continue activity or bear weight after the injury or was forced to cease activities immediately.
Mechanical Symptoms
The patient should be asked about mechan- ical symptoms, such as locking, popping, or giving way of the knee. A history of locking episodes suggests a meniscal tear. A sensation of popping at the time of injury suggests liga- mentous injury, probably complete rupture of a ligament (third-degree tear). Episodes of giving way are consistent with some degree of knee instability and may indicate patellar sub- luxation or ligamentous rupture.
Effusion
The timing and amount of joint effusion are important clues to the diagnosis. Rapid onset (within two hours) of a large, tense effusion suggests rupture of the anterior cru- ciate ligament or fracture of the tibial plateau with resultant hemarthrosis, whereas slower onset (24 to 36 hours) of a mild to moderate effusion is consistent with meniscal injury or ligamentous sprain. Recurrent knee effusion after activity is consistent with meniscal injury.
Mechanism of Injury
The patient should be questioned about specific details of the injury. It is important to know if the patient sustained a direct blow to the knee, if the foot was planted at the time of injury, if the patient was decelerating or stopping suddenly, if the patient was landing from a jump, if there was a twisting component to the injury, and if hyperextension occurred.
A direct blow to the knee can cause serious injury. The anterior force applied to the proximal tibia with the knee in flexion (e.g., when the knee hits the dashboard in an automobile accident) can cause injury to the posterior cruciate ligament. The medial collateral ligament is most commonly injured as a result of direct lateral force to the knee (e.g., clipping in football); this force creates a val- gus load on the knee joint and can result in rupture of the medial collateral ligament. Conversely, a medial blow that creates a varus load can injure the lateral collateral ligament.
Noncontact forces also are an important cause of knee injury. Quick stops and sharp cuts or turns create significant deceleration forces that can sprain or rupture the anterior cruciate ligament. Hyperextension can result in injury to the anterior cruciate ligament or posterior cruciate ligament. Sudden twisting or pivoting motions create shear forces that can injure the meniscus. A combination of forces can occur simultaneously, causing injury to multiple structures.
Medical History
A history of knee injury or surgery is important. The patient should be asked about previous attempts to treat knee pain, including the use of medications, supporting devices, and physical therapy. The physician also should ask if the patient has a history of gout, pseudogout, rheumatoid arthritis, or other degenerative joint diseases.
Knee pain is a common health issue which can be caused by sports injuries, automobile accident injuries, or by an underlying health issue, such as arthritis. The most common symptoms of knee injury include pain and discomfort, swelling, inflammation and stiffness. Because treatment for knee pain varies according to the cause, it’s essential for the individual to receive proper diagnosis for their symptoms. Chiropractic care is a safe and effective, alternative treatment approach which can help treat knee pain, among other health issues.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
Physical Examination
Inspection and Palpation
The physician begins by comparing the painful knee with the asymptomatic knee and inspecting the injured knee for erythema, swelling, bruising, and discoloration. The mus- culature should be symmetric bilaterally. In particular, the vastus medialis obliquus of the quadriceps should be evaluated to determine if it appears normal or shows signs of atrophy.
The knee is then palpated and checked for pain, warmth, and effusion. Point tenderness should be sought, particularly at the patella, tibial tubercle, patellar tendon, quadriceps tendon, anterolateral and anteromedial joint line, medial joint line, and lateral joint line. Moving the patient’s knee through a short arc of motion helps identify the joint lines. Range of motion should be assessed by extending and flexing the knee as far as possible (normal range of motion: extension, zero degrees; flex- ion, 135 degrees).5
Patellofemoral Assessment
An evaluation for effusion should be conducted with the patient supine and the injured knee in extension. The suprapatellar pouch should be milked to determine whether an effusion is present.
Patellofemoral tracking is assessed by observing the patella for smooth motion while the patient contracts the quadriceps muscle. The presence of crepitus should be noted during palpation of the patella.
The quadriceps angle (Q angle) is determined by drawing one line from the anterior superior iliac spine through the center of the patella and a second line from the center of the patella through the tibial tuberosity (Figure 2).6 A Q angle greater than 15 degrees is a predisposing factor for patellar subluxation (i.e., if the Q angle is increased, forceful contraction of the quadriceps muscle can cause the patella to sublux laterally).
A patellar apprehension test is then performed. With fingers placed at the medial aspect of the patella, the physician attempts to sublux the patella laterally. If this maneuver reproduces the patient’s pain or a giving-way sensation, patellar subluxation is the likely cause of the patient’s symptoms.7 Both the superior and inferior patellar facets should be palpated, with the patella subluxed first medially and then laterally.
Cruciate Ligaments
Anterior Cruciate Ligament. For the anterior drawer test, the patient assumes a supine position with the injured knee flexed to 90 degrees. The physician fixes the patient’s foot in slight external rotation (by sitting on the foot) and then places thumbs at the tibial tubercle and fingers at the posterior calf. With the patient’s hamstring muscles relaxed, the physician pulls anteriorly and assesses anterior displacement of the tibia (anterior drawer sign).
The Lachman test is another means of assessing the integrity of the anterior cruciate ligament (Figure 3).7 The test is performed with the patient in a supine position and the injured knee flexed to 30 degrees. The physician stabilizes the distal femur with one hand, grasps the proximal tibia in the other hand, and then attempts to sublux the tibia anteriorly. Lack of a clear end point indicates a positive Lachman test.
Posterior Cruciate Ligament. For the posterior drawer test, the patient assumes a supine position with knees flexed to 90 degrees. While standing at the side of the examination table, the physician looks for posterior displacement of the tibia (posterior sag sign).7,8 Next, the physician fixes the patient’s foot in neutral rotation (by sitting on the foot), positions thumbs at the tibial tubercle, and places fingers at the posterior calf. The physician then pushes posteriorly and assesses for posterior displacement of the tibia.
Collateral Ligaments
Medial Collateral Ligament. The valgus stress test is performed with the patient’s leg slightly abducted. The physician places one hand at the lateral aspect of the knee joint and the other hand at the medial aspect of the distal tibia. Next, valgus stress is applied to the knee at both zero degrees (full extension) and 30 degrees of flexion (Figure 4)7. With the knee at zero degrees (i.e., in full extension), the posterior cruciate ligament and the articulation of the femoral condyles with the tibial plateau should stabilize the knee; with the knee at 30 degrees of flexion, application of valgus stress assesses the laxity or integrity of the medial collateral ligament.
Lateral Collateral Ligament. To perform the varus stress test, the physician places one hand at the medial aspect of the patient’s knee and the other hand at the lateral aspect of the distal fibula. Next, varus stress is applied to the knee, first at full extension (i.e., zero degrees), then with the knee flexed to 30 degrees (Figure 4).7 A firm end point indicates that the collateral ligament is intact, whereas a soft or absent end point indicates complete rupture (third-degree tear) of the ligament.
Menisci
Patients with injury to the menisci usually demonstrate tenderness at the joint line. The McMurray test is performed with the patient lying supine9 (Figure 5). The test has been described variously in the literature, but the author suggests the following technique.
The physician grasps the patient’s heel with one hand and the knee with the other hand. The physician’s thumb is at the lateral joint line, and fingers are at the medial joint line. The physician then flexes the patient’s knee maximally. To test the lateral meniscus, the tibia is rotated internally, and the knee is extended from maximal flexion to about 90 degrees; added compression to the lateral meniscus can be produced by applying valgus stress across the knee joint while the knee is being extended. To test the medial meniscus, the tibia is rotated externally, and the knee is extended from maximal flexion to about 90 degrees; added compression to the medial meniscus can be produced by placing varus stress across the knee joint while the knee is degrees of flexion. A positive test produces a thud or a click, or causes pain in a reproducible portion of the range of motion.
Because most patients with knee pain have soft tissue injuries, plain-film radiographs generally are not indicated. The Ottawa knee rules are a useful guide for ordering radiographs of the knee10,11.
If radiographs are required, three views are usually sufficient: anteroposterior view, lateral view, and Merchant’s view (for the patellofemoral joint).7,12 Teenage patients who report chronic knee pain and recurrent knee effusion require a notch or tunnel view (posteroanterior view with the knee flexed to 40 to 50 degrees). This view is necessary to detect radiolucencies of the femoral condyles (most commonly the medial femoral condyle), which indicate the presence of osteochondritis dissecans.13
Radiographs should be closely inspected for signs of fracture, particularly involving the patella, tibial plateau, tibial spines, proximal fibula, and femoral condyles. If osteoarthritis is suspected, standing weight-bearing radiographs should be obtained.
Laboratory Studies
The presence of warmth, exquisite tenderness, painful effusion, and marked pain with even slight range of motion of the knee joint is consistent with septic arthritis or acute inflammatory arthropathy. In addition to obtaining a complete blood count with differential and an erythrocyte sedimentation rate (ESR), arthro- centesis should be performed. The joint fluid should be sent to a laboratory for a cell count with differential, glucose and protein measure- ments, bacterial culture and sensitivity, and polarized light microscopy for crystals.
Because a tense, painful, swollen knee may present an unclear clinical picture, arthrocentesis may be required to differentiate simple effusion from hemarthrosis or occult osteochondral fracture.4 A simple joint effusion produces clear, straw-colored transudative fluid, as in a knee sprain or chronic meniscal injury. Hemarthrosis is caused by a tear of the anterior cruciate ligament, a fracture or, less commonly, an acute tear of the outer portion of the meniscus. An osteochondral fracture causes hemarthrosis, with fat globules noted in the aspirate.
Rheumatoid arthritis may involve the knee joint. Hence, serum ESR and rheumatoid factor testing are indicated in selected patients.
The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.
In conclusion, knee pain is a common health issue which occurs due to a variety of injuries and/or conditions, such as sports injuries, automobile accidents, and arthritis, among other problems. Treatment of knee pain depends largely on the source of the symptoms. Therefore, it is essential for the individual to seek immediate medical attention to receive a diagnosis.
Chiropractic care is an alternative treatment option which focuses on the treatment of a variety of injuries and/or conditions associated with the musculoskeletal and nervous system. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
1. Rosenblatt RA, Cherkin DC, Schneeweiss R, Hart LG. The content of ambulatory medical care in the United States. An interspecialty comparison. N Engl J Med 1983;309:892-7.
2. Tandeter HB, Shvartzman P, Stevens MA. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician 1999;60: 2599-608.
3. Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: part II. Differential diag- nosis. Am Fam Physician 2003;68:917-22
4. Bergfeld J, Ireland ML, Wojtys EM, Glaser V. Pin- pointing the cause of acute knee pain. Patient Care 1997;31(18):100-7.
6. Juhn MS. Patellofemoral pain syndrome: a review and guidelines for treatment. Am Fam Physician 1999;60:2012-22.
7. Smith BW, Green GA. Acute knee injuries: part I. History and physical examination. Am Fam Physi- cian 1995;51:615-21.
8. Walsh WM. Knee injuries. In: Mellion MB, Walsh WM, Shelton GL, eds. The team physician’s hand- book. 2d ed. St. Louis: Mosby, 1997:554-78.
9. McMurray TP. The semilunar cartilage. Br J Surg 1942;29:407-14.
10. Stiell IG, Wells GA, Hoag RH, Sivilotti ML, Cacciotti TF, Verbeek PR, et al. Implementation of the Ottawa knee rule for the use of radiography in acute knee injuries. JAMA 1997;278:2075-9.
11. Stiell IG, Greenberg GH, Wells GA, McKnight RD, Cwinn AA, Caciotti T, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med 1995;26:405-13.
12. Sartoris DJ, Resnick D. Plain film radiography: rou- tine and specialized techniques and projections. In: Resnick D, ed. Diagnosis of bone and joint disor- ders. 3d ed. Philadelphia: Saunders:1-40.
13. Schenck RC Jr, Goodnight JM. Osteochondritis dis- secans. J Bone Joint Surg [Am] 1996;78:439-56.
The tendons are powerful soft tissues which connect the muscles to the bones. One of these tendons, the quadriceps tendon, works together with the muscles found at the front of the thigh in order to straighten the leg. A quadriceps tendon rupture can affect an individual’s quality of life.
A quadriceps tendon rupture can be a debilitating injury and it usually requires rehabilitation and surgical interventions to restore knee function. These type of injuries are rare. Quadriceps tendon ruptures commonly occur among athletes who perform jumping or running sports.
Quadriceps Tendon Rupture Description
The four quadriceps muscles come together above the kneecap, or patella, to form the quadriceps tendon. The quadriceps tendon joins the quadriceps muscles into the patella. The patella is connected to the shinbone, or tibia, by the patellar tendon. Working collectively, the quadriceps muscles, the quadriceps tendon, and the patellar tendon, straighten the knee.
A quadriceps tendon rupture can be partial or complete. Many partial tears don’t completely disrupt the soft tissues. However, a full tear will divide the soft tissues into two parts. If the quadriceps tendon ruptures entirely, the muscle is no longer attached to the kneecap or patella. As a result, the knee is unable to straighten out when the quadriceps muscles contract.
Quadriceps Tendon Rupture Causes
A quadriceps tendon rupture frequently occurs due to an increased load on the leg where the foot is planted and the knee is somewhat flexed. By way of instance, when landing from an awkward jump, the power is too much for the soft tissues to bear, causing a partial or complete tear. Tears may also be due to falls, direct impacts to the knee, and lacerations or cuts.
A weakened quadriceps tendon is also more likely to rupture. Several factors may result in tendon weakness, including quadriceps tendinitis, the inflammation of the quadriceps tendon, called quadriceps tendinitis. Quadriceps tendinitis is one of the most common sports injuries in athletes who participate in sports or physicial activities which involve jumping.
Weakened soft tissues may also be brought on by diseases that interrupt blood flow to the knee or patella. Utilizing corticosteroids and some antibiotics have also been connected to weakness associated with quadriceps tendon ruptures. Immobilization for an extended period of time can also decrease strength in the quadriceps tendons. Finally, quadriceps tendon ruptures can occur due to dislocations and/or surgery.
Quadriceps Tendon Rupture Symptoms
A popping or tearing feeling is one of the most common symptoms associated with a quadriceps tendon rupture. Pain followed by swelling and inflammation of the knee might make the individual unable to straighten out their knee. Other symptoms of a quadriceps tendon rupture include:
An indentation at the top of the kneecap or patella of the affected site
Bruising
Tenderness
Cramping
Sagging or drooping of the kneecap or patella where the tendon tore
Difficulty walking because the knee is buckling or giving away
Quadriceps Tendon Rupture Evaluation
The healthcare professional will perform an evaluation to diagnose a quadriceps tendon rupture by first discussing the patient’s symptoms and medical history. After talking about the patient’s symptoms and medical history, the doctor will conduct a comprehensive evaluation of the knee.
To ascertain the precise cause of the patient’s symptoms, the healthcare professional will examine how well it is possible to stretch, or straighten, the knee. Although this area of the evaluation can be debilitating, it’s essential to diagnose a quadriceps tendon rupture.
To verify a quadriceps tendon rupture diagnosis, the doctor may order some imaging tests, like an x-ray or magnetic resonance imaging, or MRI, scan. The kneecap moves from place once the quadriceps tendon ruptures. This can be quite evident on a sideways x-ray perspective of the knee.
Complete tears may frequently be identified with x-rays alone. The MRI can reveal the quantity of tendon torn along with the positioning of the tear. From time to time, an MRI will also rule out another injury with similar symptoms. Diagnostic imaging is helpful in the evaluation of sports injuries.
The quadriceps tendon is the large tendon found just above the kneecap, or patella, which allows us to straighten out our knee. While the quadriceps tendon is a strong, fibrous cord which can withstand tremendous amounts of force, sports injuries or other health issues may lead to a quadriceps tendon rupture. Quadriceps tendon ruptures are debilitating problems which can affect a patient’s quality of life.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
Quadriceps Tendon Rupture Treatment
Non-Surgical Treatment
A majority of partial tears react well to non-surgical treatment approaches. The doctor may advise the patient to utilize a knee immobilizer or brace to allow the quadriceps tendon to heal. Crutches will help avoid placing weight onto the leg. A knee immobilizer or brace is used for 3 to 6 months.
Once the initial pain, swelling, and inflammation have decreased, alternative treatment options, such as chiropractic care and physical therapy, can be utilized. A doctor of chiropractic, or chiropractor, utilizes spinal adjustments and manual manipulations to carefully correct any spinal misalignments, or subluxations, which may be causing problems.
Furthermore, chiropractic care and physical therapy can provide lifestyle modifications, including physical activity and exercise programs to help speed up the recovery process. The patient may be recommended a variety of stretches and exercises to improve strength, flexibility and mobility. The healthcare professional will determine when it’s safe to return-to-play.
Surgical Treatment
Many individuals with complete tears require surgery to repair a quadriceps tendon rupture. Surgical interventions depend on the patient’s age, actions, and prior level of function. Surgery for quadriceps tendon ruptures involves re-attaching the tendon to the kneecap or patella. Surgery is carried out with regional spinal anesthetic or general anesthetic.
To reattach the tendon, sutures are put in the tendon and then threaded through drill holes at the kneecap. The stitches are attached in the base of the kneecap. The physician will tie the sutures to find the ideal tension in the kneecap or patella. This will also make sure that the place of the kneecap closely matches that of the uninjured patella or kneecap.
A knee immobilizer, brace or a long leg cast may be utilized following the surgery. The patient may be allowed to set weight on their leg by means of crutches. Stretches and exercises are added into a rehabilitation program by a chiropractor or physical therapist after a surgical intervention.
The precise timeline for chiropractic care and physical therapy following a surgery for those patients that require it will be individualized personally. The patient’s rehabilitation program will be contingent upon the kind of tear, their surgery, medical condition, along with other requirements.
Conclusion
The majority of patients can return to their original routines after recovering from a quadriceps tendon rupture. The individual’s return will be addressed very carefully by the healthcare professional. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
When dealing with a sports injury or a similar type of injury, many people are familiar with the R.I.C.E. protocol for injury care. R.I.C.E. stands for Rest, Ice, Compression, and Elevation and has long been used when treating everything from sprained ankles to banged up knees. With acute injury patients, experts recommend adding “P” for protection because of the protection of the area is vital in the healing process. It is crucial that this is implemented as soon after the injury as possible and it should be maintained for anywhere from 24 hours to 72 hours afterward. Of course, this depends on the severity of the injury.
P is for Protection: Injuries hurt and pain can be a good thing because it prevents you from further injuring that area. It encourages you to protect it.
It is essential to listen to your body and protect the injured area through full or partial immobilization and restricted use. The way you do this depends on the body part.
An arm or shoulder injury can be protected with the use of a sling. An ankle injury may require a brace or splint, and you may have to avoid or limit weight bearing for a while. This means using crutches a walker, or a cane.
R is for Rest: The body needs rest to heal. This could mean complete rest, but in many cases, it means what is known as “relative rest.” This means that it allows for enough rest to heal but is not entirely restrictive which could slow or inhibit recovery.
This means avoiding activities that are stressful to the area to the point that they cause pain or that they might compromise healing. Many times, though, some movement is a good thing, even beneficial. Some gentle movements can speed recovery.
Isometric contractions of the muscles and joints that surround the injury and even some range of motion exercises can help. The key is to keep the movements gentle and to listen to your body for guidance on how much and how far to push.
I is for Ice:Cryotherapy or cold treatments can come in the form of actual ice, or there can be other types such as a cold soak. When treating acute injuries at home, the best known, and probably most straightforward way is to put some crushed ice in a freezer bag with a zip lock closure and wrap it in a small towel to keep the pack from directly touching the skin.
Frozen vegetables, like green beans, peas, or edamame work well too – remember to use the towel as a barrier between the skin and the pack. You should not use the pack more than 10 to 15 minutes as a time. The recommended cycle is 10 to 15 minutes on and 1 to 2 hours off.
In some cases, you may not be able to apply ice directly to the site. In those cases, you can use the pack at the joint above the affected area. For instance, a tightly wrapped ankle can still benefit from ice, you just apply the ice pack to the back on the knee on the same leg.
C is for Compression: A compression wrap can offer mild support and reduce swelling. Typically, an elastic bandage is used to compress or apply pressure to the injured tissue.
When applying a compression bandage, start it several inches below the area that is injured. It should be applied directly to your skin.
Use some tension as you wrap, but not to the point that it cuts off circulation (characterized by tingling or numbness and the soft tissue should not change color). Wrap the bandage in a figure eight configuration or spiral, depending on the area, stopping a few inches above the injury.
E is for Elevation: When an injured joint or extremity is not elevated, fluid can pool in the area and swelling can occur. This can lead to increased pain and limited range of motion. Elevation helps prevent these things from happening and can even help to speed up recovery.
The key to elevation is positioning the injured area at a level that is above the heart. The most effective way to accomplish this is to keep the area elevated as much as possible while awake and prop it up with pillows while sleeping for at least the first 24 to 48 hours. Some injuries may require more time though, so listen to your body.
The knee is a made up of a variety of complex soft tissues. Enclosing the knee joint is a fold at its membrane known as the plica. The knee is encapsulated by a fluid-filled structure called the synovial membrane. Three of these capsules, known as the synovial plicae, develop around the knee joint throughout the fetal stage and are absorbed before birth.
However, during one research study in 2006, researchers found that 95 percent of patients undergoing arthroscopic surgery had remnants of their synovial plicae. Knee plica syndrome occurs when the plica becomes inflamed, generally due to sports injuries. This often takes place in the center of the kneecap, known as medial patellar plica syndrome.
What are the Symptoms of Knee Plica Syndrome?
The most common symptom of knee plica syndrome is knee pain, although a variety of health issues can also cause these symptoms. Knee pain associated with knee plica syndrome is generally: achy, instead of sharp or shooting; and worse when using stairs, squatting, or bending. Other symptoms of knee plica syndrome can also include the following:
a catching or locking sensation on the knee while getting up from a chair after sitting for an extended period of time,
difficulty sitting for extended intervals,
a cracking or clicking noise when bending or stretching the knee,
a feeling that the knee is slowly giving out,
a sense of instability on slopes and stairs,
and may feel swollen plica when pushing on the knee cap.
What are the Causes of Knee Plica Syndrome?
Knee plica syndrome is commonly caused as a result of an excess of stress or pressure being placed on the knee or due to overuse. This can be brought on by physical activities and exercises which require the individual to bend and extend the knee like running, biking, or utilizing a stair-climbing machine. An automobile accident injury or a slip-and-fall accident can also cause knee plica syndrome.
Knee plica syndrome, commonly referred to as medial patellar plica syndrome, is a health issue which occurs when the plica, a structure which surrounds the synovial capsule of the knee, becomes irritated and inflamed. Knee plica syndrome can occur due to sports injuries, automobile accident injuries, and slip-and-fall accidents, among other types of health issues. The symptoms of knee plica syndrome may commonly be mistaken for chondromalacia patella. Diagnostic imaging can help diagnose the problem to continue with treatment.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
How is Knee Plica Syndrome Diagnosed?
In order to diagnose medial patellar plica syndrome, the healthcare professional will first perform a physical examination. They will use the evaluation to rule out any other potential causes of knee pain, such as a torn meniscus, tendonitis, and broken bones or fractures. Be sure to talk to your doctor about any physical activities you participate in along with any recent health issues. The healthcare professional might also utilize an X-ray or MRI to have a better look at your knee.
What is the Treatment for Knee Plica Syndrome?
Most instances of medial patellar plica syndrome respond well to alternative treatment options, such as chiropractic care, physical therapy or even a physical activity or exercise plan at home. Chiropractic care uses spinal adjustments and manual manipulations to safely and effectively correct a variety of health issues associated with the musculoskeletal and nervous system. Moreover, chiropractic care and physical therapy can include a series of stretches and exercises to help restore strength, mobility, and flexibility to the hamstrings and quadriceps. These stretches and exercises are described below.
Quadriceps Strengthening
The medial plica is attached to the quadriceps, a major muscle on the thighs. An individual with weakened quadriceps has a higher chance of developing knee plica syndrome. You can strengthen your quadriceps by performing the stretches and exercises as follow:
quadriceps sets or muscle tightening
straight leg raises
leg presses
mini-squats
biking, swimming, walking, or use an elliptical machine.
Hamstring Stretching
The hamstrings are the muscles which extend down the back of the thighs, from the pelvis to the shin bone. These help flex the knee. Tight hamstrings place more stress and pressure on the front of the knee, or the plica. A chiropractor or physical therapist will guide the patient through numerous stretches and exercises which may help unwind the nerves. As soon as the patient learns these moves, they may perform them a few times each day to keep the muscles relaxed.
Corticosteroid Injections
Some healthcare professionals may provide corticosteroid injections for the knee if the pain and inflammation causes a restriction in function. Corticosteroid injections can help temporarily reduce painful symptoms, however, it’s essential for the patient to continue with treatment to heal knee plica syndrome. The painful symptoms may return when the corticosteroid burns off if not treated.
Surgery
If chiropractic care, physical therapy, or the treatment described above does not help heal knee plica syndrome, a procedure known as arthroscopic resection may be needed. To perform this process, the doctor will insert a small camera, called an arthroscope, via a tiny cut at the side of the knee. Small surgical instruments are then inserted through a second small cut to take out the plica or correct its position.
After surgery, your doctor will consult with a chiropractor or physical therapist for a rehabilitation program. Recovering from surgery for knee plica syndrome is dependent upon many factors, including the patient’s overall health and wellness. The patient may recover within a few days in case the knee has been changed. Remember to wair a few weeks before returning to a routine levels of exercise and physical activity.
Living with Knee Plica Syndrome
Plica syndrome is generally easy to treat with chiropractic care, physical therapy, and other treatment approaches, as described above. Should you need surgery, the approach is minimally invasive and requires less recovery compared to a number of different types of knee surgery.
Talk to your healthcare professional to determine the best treatment choice for your knee plica syndrome. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
EXTRA EXTRA | IMPORTANT TOPIC: El Paso, TX Chiropractor Recommended
Chondromalacia patellae, also referred to as runner’s knee, is a health issue in which the cartilage beneath the patella, or kneecap, becomes soft and ultimately degenerates. This problem is prevalent among young athletes, however, it may also develop in older adults who suffer from arthritis of the knee.
Sports injuries like chondromalacia patellae are frequently regarded as an overuse injury. Taking some time off from participating in physical activities and exercise may produce superior outcomes. In the instance that the individual’s health issues are due to improper knee alignment, rest may not offer pain relief. Symptoms of runner’s knee include knee pain and grinding sensations.
What Causes Chondromalacia Patellae?
The kneecap, or the patella, is generally found through the front of the knee joint. If you bend your knee, the rear end of your kneecap slips over the cartilage of your femur, or thigh bone, at the knee. Complex soft tissues, such as tendons and ligaments, connect the kneecap to the shinbone and thigh muscle. Chondromalacia patellae can commonly occur when any of these structures fail to move accordingly, causing the kneecap to rub against the thigh bone. Poor kneecap motion may result from:
Misalignment due to a congenital health issue
Weakened hamstrings and quadriceps, or the muscles of the thighs
Muscle imbalance between the adductors and abductors, the muscles on the inside and outside of the thighs
Continuous pressure to the knee joints from certain physical activities and exercise like running, skiing, or jumping
a direct blow or injury for a kneecap
Who is at Risk for Chondromalacia Patellae?
Below is an assortment of factors which may increase an individual’s chance for developing chondromalacia patellae.
Age
Adolescents and young adults have the highest risk for this health issue. During growth spurts, bones and muscles can often grow too rapidly, causing short-term muscle and bone imbalances in the human body.
Gender
Females are more likely than males to develop runner’s knee, because women generally possess less muscle mass than men. This may result in abnormal knee placement, and more lateral pressure on the kneecap.
Flat Feet
Individuals who have flat feet can add more strain to the knee joints as compared to individuals who have higher arches.
Past Injury
Previous injuries to the kneecap, including a dislocation, can raise the chance of developing chondromalacia patellae.
Increased Physical Activity
Increased levels of physical activities and exercise can place pressure on the knee joints, which may raise the risk for knee issues.
Arthritis
Runner’s knee may also be an indication of arthritis, a well-known problem causing pain and inflammation to the tissue and joint. Swelling can prevent the proper function of the knee and its complex structures.
What are the Symptoms of Chondromalacia Patellae?
Chondromalacia patellae will generally present as pain in the knee, called patellofemoral pain, accompanied by sensations of cracking or grinding when extending or bending the knee. Pain may worsen after sitting for an extended period of time or through physical activities and exercises that apply intense pressure for your knees, like standing. It’s essential for the individual to seek immediate medical attention if the symptoms of chondromalacia patellae, or runner’s knee, do not resolve on their own.
Diagnosis and Chondromalacia Patellae Grading
A healthcare professional will search for areas of pain and inflammation on the knee. They might also look at the way the kneecap aligns with the thigh bone. A misalignment may indicate the presence of chondromalacia patellae. The doctor may also perform a series of evaluations to ascertain the presence of this health issue.
The healthcare professional may also ask for any of the following tests to help diagnose chondromalacia patellae, including: x-rays to show bone damage or misalignments or arthritis; magnetic resonance imaging, or MRI, to see cartilage wear and tear; and arthroscopic examination, a minimally invasive procedure which involves inserting an endoscope and camera inside the knee joint.
Grading
There are four levels of chondromalacia patellae, ranging from grade 1 to 4, which characterize the level of the patient’s runner’s knee. Grade 1 is considered mild while grade 4 is considered severe.
Grade 1 indicates the softening of the cartilage in the knee region.
Grade 2 suggests a softening of the cartilage followed by abnormal surface features, the start of degeneration.
Grade 3 reveals the thinning of the cartilage together with active degeneration of the complex soft tissues of the knee.
Grade 4, or the most severe grade, demonstrates exposure of the bone through a substantial part of the cartilage Bone exposure means that bone-to-bone rubbing is most likely happening in the knee.
What is the Treatment for Chondromalacia Patellae?
The goal of treatment for chondromalacia patellae is to first decrease the strain being placed on the kneecap, or patella, and the femur, or thigh bone. Rest and the use of ice and heat agains the affected knee joint is generally the first line of treatment. The cartilage damage associated with runner’s knee may often repair itself with these remedies along.
Moreover, the healthcare professional may prescribe anti-inflammatory drugs and/or medications, such as ibuprofen, to decrease pain and inflammation around the knee joint. When tenderness, swelling, and pain persist, the following treatment options could be explored. As mentioned above, individuals should seek immediate medical attention if symptoms persist.
Chiropractic Care
Chiropractic care is a safe and effective, alternative treatment option which focuses on the diagnosis, treatment, and prevention of a variety of injuries and/or conditions associated with the musculoskeletal and nervous system, including chondromalacia patellae. Occasionally, knee pain may originate due to spinal misalignments or subluxations. A doctor of chiropractic, or chiropractor, will use spinal adjustments and manual manipulations to carefully restore the natural integrity of the spine.
Furthermore, a chiropractor may also recommend a series of lifestyle modifications, including nutritional advice and a physical activity or exercise guide to help ease symptoms associated with chondromalacia patellae. Rehabilitation may also focus on strengthening the quadriceps, hamstrings, adductors, and abductors to improve muscular strength, flexibility, and mobility. The purpos of muscle balance is also to assist in preventing knee misalignment, among other complications.
Surgery
Arthroscopic surgery might be required to inspect the joint and ascertain whether there is a misalignment of the knee. This operation involves inserting a camera in the knee joint through a very small incision. A surgical procedure can repair the issue. One common process is a lateral release. This surgery involves cutting a number of the ligaments to release tension and permit for more movement. Additional surgery may entail implanting the back of the kneecap, inserting a cartilage graft, or transferring the thigh muscle.
Chondromalacia patellae is characterized as the inflammation of the underside of the patella, or kneecap, caused by the softening of the cartilage surrounding the soft tissues of the knee joint. This well-known health issue is generally caused due to sports injuries in young athletes, although chondromalacia patellae may also occur in older adults with arthritis in the knee. Chiropractic care can help restore strength and balance to the knee joint and its surrounding soft tissues.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
How to Prevent Chondromalacia Patellae
A patient can ultimately lower their chance of developing runner’s knee, or chondromalacia patellae, by:
Avoiding repeated stress on the knees. In case the individual needs to spend time on their knees, they could wear kneepads.
Produce muscle balance by strengthening the quadriceps, hamstrings, abductors, and adductors.
Wear shoe inserts that correct flat feet. This may reduce the amount of pressure being placed on the knees to realign the kneecap, or patella.
Keeping a healthy body weight can also help prevent chondromalacia patellae. Following the nutritional advice and guidance from a healthcare profesional can help promote a healthy body weight. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
Osgood-Schlatter disease is a common cause of knee pain in growing adolescents. It is characterized by the inflammation of the site below the knee where the tendon from the kneecap, or the patellar tendon, attaches to the shinbone, or tibia. Osgood-Schlatter disease occurs during growth spurts when muscles, bones, tendons, and other tissues shift rapidly.
Physical activities can place additional stress on the bones, muscles, tendons and other complex structures of young athletes. Children and adolescents who participate in running and jumping sports have a higher chance of developing this condition. However, less active children and adolescents may also experience this well-known health issue.
In the majority of instances, Osgood-Schlatter disease will resolve on its own and the pain can be managed with over-the-counter drugs and/or medications. Stretches and exercises can also help improve strength, flexibility and mobility. Alternative treatment options, such as chiropractic care, can also help relieve pain and restore the patient’s well-being.
Osgood-Schlatter Disease Explained
The bones of children and adolescents have a special area where the bone grows, known as the growth plate. Growth plates are made up of cartilage, which harden into solid bone, when a child or adolescent is fully grown.
Some growth plates function as attachment sites for tendons, the strong soft tissues which connect muscles to bones. A bump, known as the tubercle, covers the growth plate at the end of the tibia. The set of muscles in the front of the thigh, or the quadriceps, then attaches to the tibial tubercle.
When a child or adolescent participates in physical activities, the quadriceps muscles pull the patellar tendon which then pulls the tibial tubercle. In some children and adolescents, this traction on the tubercle can cause pain and inflammation in the growth plate. The prominence, or bulge, of the tubercle may become pronounced as a result of this problem.
Osgood-Schlatter Disease Symptoms
Painful symptoms associated with Osgood-Schlatter disease are often brought on by running, jumping, and other sports-related pursuits. In some cases, both the knees have symptoms, although one knee might be worse. Common symptoms of Osgood-Schlatter disease also include:
Knee pain and tenderness in the tibial tubercle
Swelling in the tibial tubercle
Tight muscles at the front or back of the thigh
Osgood-Schlatter disease is the inflammation of the bone, cartilage and/or tendon at the top of the shinbone, or tibia, where the tendon attaches to the kneecap, or patella. Osgood-Schlatter disease is considered to be an overuse injury rather than a disorder or condition. Osgood-Schlatter disease is one of the most common causes of knee pain in children and adolescents. Although it can be very painful, the health issue generally goes away on its own within 12 to 24 months.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
Osgood-Schlatter Disease Diagnosis
Throughout the consultation, the healthcare professional will discuss the children or adolescent’s symptoms regarding their overall health and wellness. They will then conduct a comprehensive evaluation of the knee. This will consist of applying pressure to the tibial tubercle, which should be painful for a patient with Osgood-Schlatter disease. Additionally, the doctor may also ask the child or adolescent to walk, run, jump, or kneel to see whether symptoms are brought on by the movements. Furthermore, the healthcare professional may also order an x-ray of the patienet’s knee to help support their diagnosis or to rule out any other health issues.
Osgood-Schlatter Disease Treatment
Treatment for Osgood-Schlatter disease focuses on reducing pain and inflammation. This generally requires limiting physical activities until symptoms improve. Sometimes, rest may be necessary for many months, followed by treatment and rehabilitation program. However, participation may be safe to continue if the patient experiences no painful symptoms. The doctor may recommend additional treatment, including:
Stretchex and exercises. Stretches and exercises for the front and back of the thigh, or the quadriceps and the hamstring muscles, can help alleviate pain and prevent the disease from returning.
Non-steroidal anti-inflammatory drugs. Medications like ibuprofen and naproxen can also help reduce pain and inflammation.
Most symptoms will completely vanish when a child completes the adolescent growth spurt, around age 14 for girls and age 16 for boys. Because of this, surgery is often not recommended, although the prominence of the tubercle will remain. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
Sinding-Larsen-Johansson, or SLJ, syndrome is a debilitating knee condition that most commonly affects teens during periods of rapid growth. The kneecap, or patella, is attached to the shinbone, or tibia, from the patellar tendon. The tendon connects to an expansion plate at the bottom of the kneecap throughout growth.
Repetitive stress on the patellar tendon can make the growth plate within the knee become inflamed and irritated. SLJ mainly develops in children and adolescents between the ages of 10 and 15 because that is when most people experience growth spurts. SLJ is most common in young athletes due to excess or repetitive strain in the knee.
Causes of SLJ Syndrome
The large muscle group at the front of the upper leg is known as the quadriceps. When straightening the leg, the quadriceps pull to deliver the leg forward. This puts pressure on the growth plate at the bottom of the kneecap. During rapid growth, the bones and muscles don’t always grow at precisely the same rate.
Since the bones grow, tendons and muscles can get tight and stretched. This increases the strain around the patellar tendon and also on the growth plate it’s attached to. Repetitive or extra stress and pressure in this area can cause the growth plate to become irritated and painful. Matters that can contribute to growing SLJ syndrome are comprised of:
Sports that involve a lot of running and jumping, such as field and track or other sports such as football, gymnastics, basketball, lacrosse, and field hockey, can place stress on the knees.
Increased or incorrect physical activity can add strain on the knees. Improper form while training, shoes that don’t support the toes or an unusual way of jogging can increase chances of SLJ syndrome.
Tight or stiff quadriceps muscles can also lead to SLJ syndrome. Muscles that are more powerful and more elastic will work better, reducing the strain on the patellar and kneecap tendon.
Activities that place more pressure on the knees or demanding tasks for the knees, such as lifting heavy items, walking up and down stairs, and squatting can cause SLJ syndrome. If there’s already pain on the knee, then these movements may make it worse.
Symptoms of SLJ Syndrome
Symptoms demonstrating the presence of Sinding-Larsen-Johansson, or SLJ, syndrome include: pain at the front of the knee or near the bottom of the kneecap, as this is the main symptom of SLJ; swelling and tenderness around the kneecap; pain that increases with physical activities like jogging, climbing stairs, or leaping; pain that becomes more acute when kneeling or squatting; and a swollen or bony bump at the bottom of the kneecap.
Sinding-Larsen-Johansson, or SLJ, syndrome is medically referred to as a juvenile osteochondrosis which affects the patella tendon in the kneecap which attaches to the inferior pole of the patella in the shinbone. Commonly characterized by knee pain and inflammation, SLJ is considered an overuse knee injury rather than a traumatic injury. Sinding-Larsen-Johansson syndrome is similar to Osgood-Schlatter syndrome.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
Diagnosis of SLJ
Should you see a healthcare professional for knee problems, they will generally ask questions about how much pain the patient is experiencing and if they do any sports or other physical activities and exercises. Whether or not the patient has also had a recent growth spurt, the doctor will examine the patient’s knee for swelling and tenderness.
In very rare instances, the healthcare professional may also ask patients to acquire an X-ray or other imaging diagnostics, such as magnetic resonance imaging, or MRI, to rule out other health issues like fracture or disease.
Prevention of SLJ
The most significant way that patients can prevent getting SLJ is to stop doing physical activities which cause pain in the knee. The patient should limit themselves before the pain goes off.
It is crucial to warm up well and stretch before exercising, playing sports or engaging in any other physical activities. A jog around the track for a couple of minutes and some dynamic stretching is enough to warm up the body.
If the quadriceps muscles are tight, then you might want to do some specialized exercise and physical activity routines. Talk to your healthcare professional, such as a chiropractor or physical therapist, to discuss what’s best for you. Doing a few stretches and warm up exercises after sports or physical activities can help prevent SLJ syndrome from developing.
Treatment of SLJ
The first and most important way to treat SLJ is to stop any action that causes irritation in the knee. It’s essential for a patient to not resume any physical activities without first being cleared by a healthcare professional.
SLJ can be challenging to treat since it may not completely resolve before the bones have completely matured and the growth plates are completely shut. During physical activities, knee pain may come and go in the meantime. Other treatments to help ease SLJ syndrome include:
Use the RICE formula.
Rest. Limit physical activities as much as possible and keep weight off the knee. Walking must be kept to a minimum.
Ice. Apply ice or a cold compress to the affected area for 15 to 20 minutes every few hours. Repeat this for 2 to 3 days or until the painful symptoms have decreased.
Compress. Give the knee additional support with a strap, a band, or a ribbon. This will also help manage symptoms.
Elevate. Keep the knee higher than the heart to reduce swelling.
Take anti-inflammatory or painkilling drugs. Painkillers like acetaminophen and ibuprofen can help relieve pain and decrease swelling.
Begin a stretching and strengthening program. After the pain and tenderness on your knee have been gone, speak with your physician or sports injury professional about a physical rehabilitation program to strengthen the muscles of your leg and increase their flexibility and range of movement.
It’s easy to become impatient when sidelined by an injury, but the proper treatment can help build the strength needed for future physical activities. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
Patellar tendinitis is a common health issue characterized by the inflammation of the tendon which joins the kneecap, or patella, to the shinbone, or tibia. The knee pain associated with this problem may range from mild to severe depending on the circumstances of the knee injury.
Patellar tendinitis, or jumper’s knee, is a well-known sports injury among athletes who play in basketball and volleyball. Among recreational volleyball players, an estimated 14.4 percent of them have jumper’s knee, where the incidence is even higher for professional athletes. An estimated 40 to 50 percent of elite volleyball players have patellar tendinitis.
Causes of Patellar Tendinitis
Patellar tendinitis is caused by repetitive strain on the knee, most often from overuse in physical activities. Stress can create tears along the tendons which can cause inflammation in the complex structures of the knee.
Other contributing factors of patellar tendinitis include:
Tight or stiff leg muscles
Uneven leg muscle strength
Misaligned toes, ankles, and legs
Obesity
Sneakers without enough padding
Tough playing surfaces
Chronic health issues that weaken the tendon
Athletes have a higher chance of developing patellar tendinitis because running, jumping, and squatting put more force over the tendon. Running can place a force of as many as five times the body weight on the knees.
Intense physical activity for an extended amount of time has been previously associated with jumper’s knee. A 2014 research study noted that jump frequency was also a significant risk factor for amateur players.
Symptoms of Patellar Tendinitis
The initial symptoms of patellar tendinitis include pain, discomfort, and tenderness at the base of the kneecap or patella. Other symptoms of patellar tendinitis may include a burning sensation. For many patients, getting up from a squat or kneeling down can also be particularly debilitating.
The pain associated with patellar tendinitis may be irregular at first, manifesting immediately after participating in physical activities. Damage or injury to the tendon can also make the pain worse. Jumper’s knee can affect regular daily activities, such as climbing stairs or sitting in a vehicle.
Patellar tendinitis, also known as “jumper’s knee”, is a particularly common cause of pain and discomfort in the patellar region of many athletes. While it frequently occurs as a result of repetitive or continuous jumping, research studies have demonstrated that patellar tendinitis may be associated with stiff ankle movements and ankle sprains, among other sports injuries.
Dr. Alex Jimenez D.C., C.C.S.T. Insight
Patellar Tendinitis Diagnosis
At the start of a consultation, the healthcare professional will first ask the patient about their specific health issue. The doctor will then physically evaluate the patient’s knee, probe for where they are feeling pain, and test the assortment of knee motion by bending and extending the patient’s leg.
Furthermore, the healthcare professional may additionally order imaging diagnostics to find out if there’s any damage or injury to the tendon or even the bone. These tests can help rule out a broken bone, or fracture. The doctor may use an X-ray to look for a displaced or fractured kneecap, and an MRI or an ultrasound to reveal any harm to the soft tissue.
Patellar Tendinitis Treatment
Treatment for patellar tendinitis depends on the damage or injury to the knee. Conservative steps to reduce pain, such as rest or exercises are generally the first line of treatment. The healthcare professional will usually recommend a span of controlled rest, where they will prevent the patient from engaging in physical activities that put pressure on the knee.
Drugs and/or Medications
The healthcare professional may prescribe over-the-counter drugs and/or medications for short-term pain relief and inflammation reduction.
These can consist of:
Ibuprofen (Advil)
Naproxen sodium (Aleve)
cetaminophen (Tylenol)
If the patient’s symptoms are severe, the healthcare professional may recommend the use of corticosteroid injection in the area around the patellar tendon. This treatment is effective in reducing acute pain.
Another method of utilizing corticosteroid for patellar tendinitis is by spreading the medication over the affected knee and use a low electrical charge to push it through the skin, in a process known as iontophoresis.
Chiropractic Care and Physical Therapy
The goal of chiropractic care and physical therapy for patellar tendinitis is to reduce pain and inflammation, among other symptoms, as well as to strengthen the leg and thigh muscles with stretches and exercises.
If the patient’s symptoms are severe, even while resting, the doctor may recommend that you wear a brace and then use crutches to avoid additional damage or injury to the tendon. If the patient has no painful symptoms, then they can start participating in a physical therapy activities.
A rehabilitation program generally consists of:
A warm-up interval
Massage, heat or ice to the knee
Stretching exercises
Strengthening exercises
A doctor of chiropractic, or chiropractor, may use ultrasound and electrical stimulation to relieve the patient’s knee pain. A knee brace or taping of the knee might also help reduce pain by supporting the kneecap when engaging in physical activities. The healthcare professional may develop a workout program that may include a series of stretches and exercises.
Surgery
When other treatments are not effective in relieving painful symptoms associated with patellar tendinitis, the doctor may advise surgery to repair the patellar tendon. Traditional surgery involves opening the knee to scrape on the kneecap and tendon. More recently, arthroscopic surgery is used for this particular process. This surgical intervention involves making four small incisions in the knee and it has a shorter recovery time.
The recovery period for surgery varies per procedure. Some surgical intervention advise for immobilization with a cast. Others suggest an immediate rehabilitation program. Regardless of the level of damage and/or injury, it’s essential for patients to seek medical attention for their patellar tendinitis. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
Pain along the pelvis and groin region is known as osteitis pubis. Osteitis pubis develops through the inflammation of the pubic symphysis, or the joints of the major pelvic bones found at the front of the pelvis.
The pubic symphysis is a thin joint which generally provides very minimal motion. The joint retains the two sides of the pelvis together in the front, where they connect at the sacrum in the rear side of the pelvis.
Osteitis Pubis Symptoms
Osteitis pubis is commonly characterized by pain in the front of the pelvis. Other causes of pelvic pain, such as a strain or a sprain, are frequently confused and diagnosed as osteitis pubis. While many patients report painful symptoms on one side, the pain typically occurs in the middle of the pelvis. Other symptoms of osteitis pubis include limping and weakness.
Osteitis Pubis Causes
For some patients, the pubic symphysis itself can become irritated and inflamed, causing the well-known symptoms of osteitis pubis. Other common causes of osteitis pubis comprise of: sports injuries, particularly from football, hockey, and soccer; pregnancy; gynecologic or abdominal surgical interventions; and trauma or injury from accidents.
Osteitis pubis is known as the inflammation of the pubis symphysis which causes various degrees of lower abdominal, pelvic, and groin pain. Symptoms of osteitis pubis include pain and discomfort in the region of the pelvis when engaging in physical activities, and loss of flexibility. A variety of causes, including sports injuries, can cause osteitis pubis. Fortunately, rest alone can help treat this painful health issue.
Dr. Alex Jimenez D.C., C.C.S.T.
Osteitis Pubis Diagnosis
Diagnosis of osteitis pubis generally involves x-rays which demonstrate an irregular pubic symphysis with sclerotic, or thick, bone borders as a result of chronic inflammation. An MRI test is generally not required, however, it will help demonstrate the inflammation of the bone and the joint.
Additional tests may be performed to ensure there’s no infection in the bone which could also be causing symptoms similar to osteitis pubis. This complication is more of a concern for those patients who have had recent surgery or for those who are more prone to suffer from infections.
Osteitis Pubis Management
The most recommended treatment for osteitis pubis is rest. Since inflammation is the problem, the human body often only requires the joint to rest in order to heal correctly. Other treatment, however, consists of:
Rest
An essential treatment for osteitis pubis is rest as this will permit the intense inflammation in the pelvis and groin to subside. For many patients, rest alone is the only treatment necessary for their osteitis pubis. If the pain is severe, crutches or a cane may provide additional assistance.
Ice and Heat
Ice packs and heating pads are among the most commonly used remedies for inflammation. Make sure to follow the instructions of your healthcare professional before utilizing ice and heat for your osteitis pubis symptoms.
Chiropractic Care
Chiropractic care is a well-known, alternative treatment option for osteitis pubis. A doctor of chiropractic, or chiropractor, will utilize a variety of treatment methods and techniques, to help restore strength, mobility, and flexibility while rest is needed to subside the painful symptoms. Chiropractic care can also help correct any spinal misalignments which may be causing additional pain and discomfort for the patient.
Drugs and/or Medications
Nonsteroidal anti-inflammatory drugs and/or medications, commonly referred to as NSAIDs, are frequent prescriptions provided for patients with hip pain brought on by problems like arthritis, bursitis, and tendonitis.
Treatment of osteitis pubis may take some time to completely relieve the painful symptoms. The use of drugs and/or medications is demonstrated to be better than the other treatment options listed above, although attempts to heal osteitis pubis with cortisone injections have been tested.
Surgical interventions are generally not necessary for patients with osteitis pubis. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain is the most prevalent cause of disability worldwide and the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Sciatica is a collection of symptoms in the low back, which radiate down one or both legs. Sciatica is generally caused by the compression or irritation of the sciatic nerve, the largest nerve in the human body. One of the most common health issues that cause sciatic nerve pain is called piriformis syndrome. The piriformis muscle stretches from the front of the sacrum, the triangle-shaped bone between the hipbones on the pelvis.
The piriformis muscle extends to the top of the femur around the sciatic nerve. The femur, as previously mentioned, is the large bone in the upper leg. The piriformis muscle functions by helping the thigh move from side to side. A piriformis muscle spasm, or any other type of injury and/or condition along the piriformis muscle, can place pressure on the sciatic nerve and cause pain and discomfort. The result is piriformis syndrome.
Piriformis Syndrome Causes and Symptoms
Sciatic nerve pain, or sciatica, is one of the most prevalent symptoms of piriformis syndrome. The pain and discomfort, however, may be felt in another part of the body. This is known as referred pain. Other common symptoms of piriformis syndrome include tingling sensations and numbness; tenderness; difficulty sitting along with pain while sitting and pain in the buttocks and thighs with physical activities.
The piriformis muscle can easily become damaged or injured from periods of inactivity or an excessive amount of exercise. Some common causes of piriformis syndrome include overuse; repetitive movements involving the legs; sitting for lengthy periods of time; lifting heavy objects; and extensive stair climbing. Sports injuries or automobile accident injuries can also harm the piriformis muscle and cause it to compress the sciatic nerve.
Piriformis Syndrome Diagnosis
A doctor appointment for diagnosis of piriformis syndrome may include a review of the patient’s health history, their symptoms, and other probable causes of their pain and discomfort. If you recall straining a muscle during physical activity, be sure to share that information with your doctor. The doctor may also perform a physical exam. The patient will participate in a series of range of movements to determine the cause of symptoms.
Some imaging tests may also be essential to help rule out other causes of piriformis syndrome. A CT scan or an MRI scan may help the healthcare professional determine whether even a herniated disc or arthritis is causing the patient’s pain and discomfort. An ultrasound of the piriformis muscle may also be helpful in diagnosing the problem if it seems that piriformis syndrome is causing the patient’s overall symptoms.
Piriformis syndrome is a health issue associated with the compression or impingement of the sciatic nerve around the piriformis muscle. Symptoms may include pain and discomfort, tingling sensations and numbness along the low back, or sciatica. Chiropractic care is a well-known alternative treatment option which can help reduce the compression of the sciatic nerve and improve piriformis syndrome.
Dr. Alex Jimenez D.C., C.C.S.T.
Piriformis Syndrome Treatment
Piriformis syndrome may often not need any treatment to relieve its symptoms. Just avoiding the physical activities which caused the pain and discomfort to manifest and rest can help improve the health issue. If symptoms do persist, however, alternating between ice and heat can help decrease pain. Apply ice for 15 to 20 minutes then use a heating pad on the affected area. Try that every couple of hours to help relieve symptoms.
Over-the-counter painkillers may also help decrease pain and discomfort. The symptoms associated with piriformis syndrome can go away with no additional treatment, however, if it doesn’t, the patient might benefit from alternative treatment options, such as chiropractic care or physical therapy. Chiropractic care is a treatment approach which utilizes spinal adjustments and manual manipulations to treat a variety of injuries and/or conditions.
A chiropractor, or doctor of chiropractic, may also provide piriformis syndrome relief through the use of transcutaneous electrical nerve stimulator, or TENS, treatment. A TENS device is a handheld unit which sends electrical charges directly to the affected region of the piriformis muscle. The nerves are then stimulated by the electric energy, which interferes with pain signals being transmitted to the brain.
The chiropractor or physical therapist may also recommend a series of lifestyle modifications, including physical activity guidance and nutritional advice. Various stretches and exercises can help improve the strength, flexibility, and mobility of the piriformis muscle. In severe cases of piriformis syndrome, corticosteroid injections or even surgical interventions may be required to help alleviate the symptoms. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Chiropractic for Athletes with Back Pain
Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain is the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Athletic pubalgia is a debilitating health issue which affects the groin. The injury commonly happens through sports that use sudden changes of direction or intense twisting motions. Also referred to as a sports hernia, athletic pubalgia is characterized as a tear or strain in any soft tissue (muscle, tendon, ligament) of the abdominal or lower abdomen region.
Physiology of Athletic Pubalgia
The soft tissues most often affected by athletic pubalgia are the oblique muscles found in the lower abdomen, especially in the tendons that attach the oblique muscles to the pubic bone. In many instances, the joints that connect the thigh muscles to the pubic bone, known as the adductor muscles, are also stretched or torn as a result of athletic pubalgia.
Physical activities which involve planting the feet and twisting with maximum exertion can cause athletic pubalgia. A sports hernia is most prevalent in vigorous sports, such as hockey, soccer, wrestling, and football. Athletic pubalgia causes pain and discomfort in the groin region which typically gets better with rest but comes back with physical activity.
A sports hernia does not result in a visible bulge in the groin, such as the well-known inguinal hernia does. As time passes, athletic pubalgia can lead to an inguinal hernia, and abdominal organs can push against the diminished cells to form a visible bulge. Without treatment, this sports injury could lead to chronic, disabling pain and other symptoms.
Healthcare Professional Diagnosis
During the first consultation, a doctor will discuss the individual’s symptoms and how the injury happened. To diagnose athletic pubalgia, the healthcare professional will look for tenderness in the groin or above the pubis. Although a sports hernia may be related to an inguinal hernia, the doctor may not find any hernias during a physical examination.
Furthermore, to help determine the presence of athletic pubalgia, the healthcare professional will probably ask the patient to perform a sit-up or to bend the trunk against resistance. If you have a sports hernia, these tests will be painful. The doctor may also require x-rays or magnetic resonance imaging (MRI) to help determine whether you have athletic pubalgia. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Athletic pubalgia, also known as a hockey hernia, hockey groin, Gilmore’s Groin, sports hernia, or groin disruption, is a health issue of the pubic joint. It is a condition characterized by chronic groin pain in athletes and identified by a dilated ring of the inguinal canal. Soccer and ice hockey players are the athletes most commonly affected by athletic pubalgia, and both recreational and professional athletes can be impacted.
Athletic Pubalgia Symptoms
Symptoms of athletic pubalgia generally manifest as pain following physical activity, most frequently through hip extension, and twisting and turning movements. The painful symptoms usually radiate into the adductor muscle region and the testicles, although it is often difficult for the individual to pinpoint the exact location of the symptoms. Athletes with athletic pubalgia experience soreness and stiffness after physical activity.
Any exertion which increases intra-abdominal pressure, such as sneezing or coughing, as well as physical activity, can lead to pain. While pain in the stomach and pelvis can occur due to a variety of health issues, including injuries to the low back, or lumbar spine, the hip joint, the sacroiliac joint, and the abdomen, along with the genito-urinary system, diagnosis of athletic pubalgia demands skillful differentiation and evaluation.
Clinical Presentation of Athletic Pubalgia
The diagnosis of athletic pubalgia is based on the patient’s history, where healthcare professionals may also depend on the use of magnetic resonance imaging, or MRI. Symptoms can frequently be reproduced by certain movements, such as performing crunches or sit-ups. Pain associated with athletic pubalgia may also be elicited with the patient in a “frog posture,” in which the individual is supine with knees bent and heels together.
Many athletes experience concomitant fatigue or tearing of the adductor muscles or labral tears of the hip. If there is stiffness in the adductor muscles post-injury, painful symptoms can manifest. Alternative treatment options should be to restore normal movement after the adductor has begun to heal, normally 6 to 8 weeks post-injury. Moreover, sleeping in a prone position with the hip on the affected side flexed and externally rotated can offer relief to some athletes with athletic pubalgia.
The precise prevalence of this health issue is unknown. Conservative therapies, such as gentle stretching, may temporarily alleviate painful symptoms, however, definitive treatment options should be considered for long-term relief. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
The rectus femoris muscle attaches to the pelvis and just below the knee as it is one of four muscles found at the front part of the thigh. It functions by extending the knee and flexing the hip. The rectus femoris muscle is made up of fibers which adapt to quick action. Rectus femoris muscle strain is caused by forceful movements, such as kicking a ball or when beginning to sprint, and it is particularly vulnerable to stress and pressure.
Painful symptoms generally manifest at the top of the thigh after the rectus femoris muscle suffers a strain or tear. In severe cases, the health issue may even become noticeable if the tissue is completely ruptured. Fortunately, complete tears are rare. Healthcare professionals will commonly use an MRI scan to diagnose the extent of the sports injury. Proper diagnosis and treatment are essential. A rectus femoris muscle strain should not be rushed, as individuals who return-to-sport too soon may suffer re-injury.
Treatment for Rectus Femoris Strain
According to many healthcare professionals, when it comes to sports injuries to the rectus femoris muscle, it’s crucial to immediately apply the RICE principle (Rest, Ice, Compression, and Elevation) to the affected thigh. This treatment aims to decrease bleeding and inflammation to the muscle. Also, it will help reduce painful symptoms after the injury. Based on how much pain has been experienced, simple painkillers might be utilized, although it’s best to attempt to prevent the use of these.
Once movement is restored enough to allow the individual to walk using their regular range of motion, and once the swelling has gone down, then you will have recovered from the acute phase of the injury. It would then be an excellent time to engage in physical activity, without inflicting damage or stress to the quadriceps muscles. This can be performed on an exercise bicycle or through swimming, where the weight is kept off the limb. Stretches and gentle resistance exercises are crucial, as this will help to align the scar tissue that has formed during the healing process.
Recovery must be monitored so that improvements can be noted and the treatment shifted to help the rehabilitation process. It is hard to measure the length of time to complete recovery. It can take from six to eight weeks or even longer, although some people will commonly recover within one to four weeks. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Acute Back Pain
Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
