Knee pain is one of the most common problems we face. The knee is the largest and most complex joint in our body. It is located between the longest bones in our body, carries our body weight, and is exposed to a lot of damage due to being under load. Pain in the knee joint can be caused by problems in many structures, such as bones, menisci, ligaments, bursae, joint capsule, and muscles. Sometimes pain can also be seen radiating from other areas (such as the hip, back, and ankle).
When walking on a flat surface, 70% of the force acting on the knee is from the muscles, and 30% is from the patellofemoral joint reaction force. The amount of load acting on the joint increases with knee movements performed in activities such as running, sitting up and down, and climbing stairs.
What Are The Complaints In Knee Problems?
In knee problems, the patient’s reason for seeking medical attention should be carefully questioned. Several of the complaints such as pain, swelling, discoloration, restriction in the knee, feeling of locking or slipping, sound coming from the joint, and warmth may be present together.
Questions such as “How did the complaints start, how long have they been going on, has there been any trauma, is the complaint in both knees, or is it only in one knee?” are helpful in making a diagnosis.
If there is a history of trauma in the knee, there is a high probability of injury to the meniscus, ligament, or tendon. If the complaints are getting worse without trauma, overuse, and inflammatory diseases can be considered. In young patients, and in an athletic patient, meniscus, ligament and ligament injuries, and muscle strains come to mind first.
Locking in the knee can occur in cases such as osteochondral lesions, cruciate ligament rupture, bone avulsions, and meniscal compression. Many problems such as bursitis, synovial plica, patellar tendinitis, quadriceps tendinitis, Osgood-Schlatter syndrome, osteochondritis dissecans, Patellafemoral disorder, and meniscal disorders are involved in anterior knee pain.
What Are The Specific Problems In The Knee?
- Patellofemoral pain syndrome
- Iliotibial band syndrome
- Patellar and quadriceps tendinitis
- Osgood Schlatter disease
- Ligament injuries
- Anterior cruciate ligament injuries
- Posterior cruciate ligament injuries
- Medial collateral ligament injuries
- Lateral collateral ligament injuries
- Meniscus injuries
What Are The Basic Treatment Methods For Knee Pain?
- Ice therapy
- Aspiration of fluid and examination if necessary
- Correction of biomechanical deficiencies
- Provision of full flexibility and strength of the muscles
- Dynamic strengthening exercises
- Physical therapy applications
- Correction of foot problems
- Patellar bandaging
- Orthesis use
- Local joint and periarticular injection applications (PRP, hyaluronic acid, prolotherapy, ozone, etc.)
A patient with knee pain should first avoid putting weight on the knee and apply ice. In particular, in the case of new onset pain and swelling, applying cold treatment for 20 minutes, followed by 20 minutes of rest, for the first three to five days will help to reduce swelling more quickly. If the pain continues immediately, the patient should see a doctor, and after the necessary examinations and treatments, exercise should be started as soon as possible and regular exercise therapy is required.
Since muscles quickly weaken even with very short periods of rest, exercise is essential in the treatment of knee problems. People who continue to have swelling in the knee during the treatment process can continue cold application.
Local intra-articular ozone treatment is effective in early resolution of swelling. In addition, intra-articular and periarticular injection applications are beneficial to support the regeneration of articular cartilage, and to provide regeneration of other intra-articular structures and periarticular tissues.
Osteoarthritis Of The Knee
Osteoarthritis of the knee is a progressive degenerative disease that manifests itself with pain or functional loss in the knee. It is more common in overweight people or those who have had previous repetitive trauma. It is characterized by narrowing of the joint space and osteophytes.
Knee osteoarthritis usually has a slow onset, with the main symptom being pain in the knee. As time goes on, the joint space of the knee decreases. Joint cartilage damage occurs and laxity occurs in the joint ligaments. Varus deformity usually occurs in the knee along with loss of the medial joint space.
Knee osteoarthritis is often accompanied by hip osteoarthritis and spinal stenosis. Patients with pain that radiates from the back to the leg, especially lumbar radiculopathy at the L3 level, may present with pain in the knee area.
Patellofemoral pain may accompany arthritis and may present with similar findings.
It is difficult to localise the pain precisely, usually weight-bearing activities increase the pain, and activities such as getting up from a chair and climbing up and down stairs trigger pain. Patients report that pain decreases and functions improve when they take painkillers. Use of painkillers should be questioned. Physical examination may reveal sound during range of motion, decreased range of motion, and joint laxity.
There may be fluid increase in the joint. Routine laboratory tests are normal in making the diagnosis because no infection or inflammatory condition is expected in this disease. However, these tests are helpful for the exclusion of other diseases.
Direct radiography shows findings such as narrowing of the joint space, osteophytes, sclerosis and reveals sufficient findings for diagnosis. The main aim of treatment is to reduce pain and restore function. Treatment options include drug therapies, physical therapy, orthosis use, physical modalities, injections and surgical treatment. Many treatments can be used simultaneously.
Weight loss should be recommended in obese patients. In injection therapies, there are many treatment options such as PRP, hyaluronic acid injections, prolotherapy, ozone therapy. If there is fluid in the joint, corticosteroid injection may be helpful. Ozone therapy is also effective in removing the fluid.
Aspiration and examination of the fluid is also important for differential diagnosis. Arthroplasty may be necessary in cases with excessive restriction of functions. Arthroplasty provides a significant reduction in pain as well as restoration and preservation of functions.
Patellofemoral Pain Syndrome
This is a common problem that is seen more often in women. It can cause anterior knee pain, clicking or popping in the knee, and sometimes swelling. All of these symptoms are usually worse with prolonged knee flexion.
Pain usually decreases with rest and does not usually increase with weight-bearing activities. One of the complaints is not being able to stay in a sitting position for a long time without pain. Climbing or descending stairs increases pain.
Sometimes pain can occur with the knee kept straight. In this case, it should be considered that the fat pads between the lower end of the patella and the femoral condyle may be trapped. It should be considered in all women with anterior knee pain. These patients usually have muscle imbalance in the knee.
Excessive strength of the lateral quadriceps muscle compared to the medial quadriceps muscle can be the cause of pain. It is sometimes also expressed as patellofemoral chondromalacia, but it is more accurate to use the term chondromalacia if there is damage to the cartilage. The physical examination may be completely normal.
Getting up from sitting or getting up after squatting can trigger pain. Pain can occur in the anterior knee part with the patella friction test. Direct radiography can be helpful in diagnosis. If necessary, further tests may be requested. Rest, ice, compression, elevation, and anti-inflammatory drug use may be required in treatment.
In the long-term treatment, strengthening the medial quadriceps muscle is important. Terminal knee extension exercises, isometric quadriceps strengthening exercises in extension can be preferred to strengthen the vastus medialis muscle. Patellar taping, braces can be used. Local injections and physical therapy applications can be done.
Iliotibial Band Syndrome
It is associated with pain on the outside of the leg when the knee is flexed or extended. Risk factors include running on inclined surfaces, limb length discrepancies, excessive pronation in the foot, and muscle tightness.
Bursitis Of The Knee
Bursas are soft tissues that contain synovial fluid. They can be found between muscle groups, at the attachment points of tendons to bones, or as subcutaneous sacs.
These sacs help to reduce friction at the joint. There are 12 bursas in the knee joint. Injury or damage to a bursa is called bursitis. Bursa can be damaged in a number of ways.
Direct trauma, as seen in athletes, can cause bleeding into the bursa area. The bleeding that occurs here is perceived as foreign fluid and causes an inflammatory response, leading to acute bursitis.
Bursitis is common in carpenters and people who work in cleaning due to repetitive microtrauma. Anatomical misalignment in the lower extremities can also cause this complaint. The patient may come to us with a swollen bursa around the knee, and pain and swelling in the knee.
In the differential diagnosis, conditions such as fracture, ligament injury, meniscus tear, arthritis, tendinitis, and muscle tear are considered. Bursitis can also develop secondary to an infection in the body and can be accompanied by infection. Again, in rheumatic diseases, especially in patients with rheumatoid arthritis and gout, there is a tendency to develop bursitis.
The patient should be asked about whether they have had any trauma recently, the onset time, duration, and location of pain and swelling, factors that increase and decrease complaints. Repetitive activities that cause pressure or friction in the knee area are questioned. On physical examination, swelling may be palpable or tenderness may be detected.
Redness and heat increase can be found in newly onset cases. Limited range of motion of the knee joint, thickening in the area where the bursa is located can be detected in chronic cases.
The diagnosis is made clinically, and blood or radiological imaging is requested to rule out other diagnoses. Drainage of fluid in a swollen bursa can be both therapeutic and helpful in the differential diagnosis of other infections and trauma. In treatment, it is recommended to protect the affected area, to rest the area, to apply ice for 20 minutes every 20 minutes for 24 to 48 hours to relieve pain, and to keep the painful area elevated. Various drugs are used to reduce pain and inflammation. Physical therapy may be required to increase muscle strength and reduce stress on the bursa.
Aspiration and drainage of the existing fluid, followed by compression in that area is one of the treatment options.
In bursitis that does not respond to treatment, corticosteroid injection or ozone injection can be done to the affected area. In rare cases, surgical removal of the bursa may be necessary.
Pes Anserin Bursiti
The patient complains of pain in the lower anterior part of the knee when climbing stairs. Complaints occur when bending and straightening the knee. There is tenderness on examination.
In this bursitis, also known as servant’s knee, there is swelling in the bursa on the anterior surface of the knee cap bone and occurs as a result of frequent kneeling. I usually do not complain of pain unless there is direct pressure on the bursa.
Patellar And Quadriceps Tendonitis
This tendonitis, also called runner’s knee, is an overuse injury and is usually seen in athletes or athletes who do not train enough. Excessive loads on the adhesion area of the tendon cause micro-tears and healing does not occur because the load exceeds the healing capacity.
Osgood Schlatter Disease
It is a traction apophysitis of the tuberositas tibia. It is most common between 10-14 years of age. It is associated with overuse and is more common in active sportsmen. Patients have more intense pain and tenderness over the tibial tubercle. The pain is localised in a certain area. Generally, there is no pain at rest or normal walking. If sportive activities are not changed and loading is continued, rest pain may also start.
Fragmentation in the tibial tubercle can be seen on lateral radiograph. It responds to rest; if symptoms persist, the fragment should be removed.
Mistakes made in sportive activities should be identified and corrected. After a pain-free period, stretching exercises should be started and gradual return to activity should be provided.
A piece of the joint cartilage separates along with the underlying bone, forming a “loose body” (joint mouse). It is more common in men and is generally seen in the second decade. Pain occurs during and after activity.
There is often mild effusion and tenderness over the lesion, and weakness in the quadriceps muscle is an early sign. It can be seen on radiographs. In doubtful cases, further testing may be required.
Rest is recommended until the lesion heals. Isometric quadriceps and hamstring exercises should be performed. If the complaints do not go away or the piece breaks off, it should be removed.
Ligament Injuries In The Knee
Anterior Cruciate Ligament Injuries
The most common knee ligament injury. It can be alone or with other ligaments. The main complaints are pain, swelling, and limited range of motion in the knee. In chronic cases, there may be a feeling of emptiness in the knee. Direct radiography may be required to distinguish any associated bone problems.
Magnetic resonance imaging is useful in confirming the diagnosis. In acute treatment, rest, compression, elevation, and local cold application are recommended. In the long term, the choice of treatment depends on the patient’s age, activity level, and any associated injuries. If the patient is active and young, the surgical option is prioritized.
Rehabilitation is always required in treatment. Early repair is not recommended in the first three weeks in anterior cruciate ligament injuries.
An initial rehabilitation program is started immediately after the injury and continued until surgery or a more aggressive rehabilitation method is started. Rehabilitation should also be started immediately after surgical treatment.
Posterior Cruciate Ligament Injuries
In this injury, it can be injured alone or with other ligaments. On physical examination, there may be bruising behind the knee, swelling in the knee, and limited range of motion in the knee. Pain and difficulty walking are seen.
Magnetic resonance imaging is useful in confirming the diagnosis. Rest, compression, elevation, and local cold application are recommended for acute treatment. Surgery may be considered if there are other ligament injuries. It usually has a good outcome.
Medial/Lateral Collateral Ligament Injuries
The medial collateral ligament is most commonly injured. Meniscus and cruciate ligament injuries may accompany. It presents with pain. Treatment is the same as the principles applied in other ligament injuries.
The menisci in the knee help to distribute body weight and act as shock absorbers.
The menisci play an important role in joint lubrication and allow for normal knee movement. Meniscus injuries can lead to an environment where degenerative changes in the joint cartilage progress more rapidly, which can lead to early osteoarthritis.
Meniscus tears can be associated with anterior cruciate ligament or medial collateral ligament tears. Degenerative tears can occur with age. Patients with isolated meniscus tears may present with locking, catching, or giving way in the knee weeks after injury.
If there are associated ligament tears, they generally present with an acute clinical picture, with pain and loss of motion. The physical examination may be completely normal, but if it is new, there may be joint fluid accumulation and pain at the joint line. In the diagnosis, direct radiography is initially sufficient to rule out a fracture.
The diagnosis is confirmed by Magnetic Resonance Imaging. Treatment is started with ice, eleveation, anti-inflammatory treatment and use of brace.
Three to six weeks of avoiding weight-bearing activities and strengthening muscles with rehabilitation constitute conservative treatment in people without any mechanical symptoms and in elderly athletes. If there is still restriction in movements and complaints continue after this period, or if there are recurrent episodes of pain and swelling, it is appropriate to refer the patient to surgery. In active athletes who continue to participate in sports, patients with mechanical complaints, those who still experience swelling during sports activities, or resistant cases should be referred for arthroscopic evaluation.
Tears in the outer meniscus region have a higher potential for recovery with treatment and are usually repaired. Tears in the inner meniscus are usually treated by partial removal. The rehabilitation program after removal of the meniscus begins with joint range of motion and stretching exercises and then moves on to strengthening exercises.
After the patient has gained full joint range of motion, isokinetic exercises and endurance exercises are added to the treatment. Subsequently, sports-specific exercises are transitioned to.