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Sports Injuries

The Knee

One of most common sites of sports related injuries/problems.

What are the important differences between the male and female knee?

It is much more common for women to experience pain over the front of their knees than men with any sport but especially running based activities. It can vary from a nuisance to incapacitating pain.

Why does this happen? The alignment of a woman's leg is frequently different to a man's. Knee pain may arise from problems in the knee, the hip, the foot or a combination of all three. This different alignment can be seen as knee caps that point in, toes that turn in on walking or flat feet causing one side of the joint to take more pressure than the other. Why this causes a problem in some women but not in others, is unknown. If you have any of these but do not have any symptoms do not worry about it.

How do I know if this is my problem? Typically the pain will occur with kneeling, bending or squatting, is worse on stairs or inclines and aggravated by driving or running.

What should I do if this sounds like me? Ensure good footwear for sport, with an arch support, physiotherapy and avoid where possible aggravating activities. Surgery has a specific role but only after conservative treatments have been exhausted.

It is important to note that there is no treatment that guarantees cure, and success in treatment is a reduction in the severity and frequency of symptoms.

There are no problems as specific to the male knee as to the female knee but contact sports mean that more men present with injury related knee problems.

Does age play a role? Over 50% of people over the age of 45-50 who tear the cartilage (meniscus) in their knee have any recollection of a specific injury! Typically you will present with acute pain over the inside of the joint, be unable to fully straighten the knee (compared to the other side), experience pain in bed at night and pain with twisting the knee. To actually damage a ligament requires a violent force and these injures are over diagnosed.

Leisure and sport related problems that affect all knees: most other knee problems relate to injury or surgery for previous injury in the past.

If I have pain in my knee, what should I look for? Nearly all injuries to the knee occur as a result of a "twisting force", eg. a foot getting stuck in the mud in a tackle, pivoting on a squash court, a ski not releasing in a fall, landing awkwardly after jumping as in netball.

Immediate: If you hear a snap or pop followed by rapid swelling of the knee within an hour or two, especially if the knee feels "wobbly" you should seek urgent advice (next 48-72 hours). Rapid swelling usually indicates bleeding, most commonly from a damaged anterior cruciate ligament.
(A number injuries will respond to rest, ice and anti inflammatories with or without physiotherapy).

After 2 - 4 weeks: Persistent swelling (which may be quite subtle), repeated giving way, acute pain on the inside or outside of the knee with twisting, an inability to fully straighten the knee (compare with the other knee) or pain in bed at night may well indicate a torn cartilage.

The cartilage (meniscus) has a poor blood supply and cannot heal naturally (it can occasionally can be repaired). What often happens is because of restrictions the knee feels easier but "you know its not right" but "you still struggle on".

An MRI scan will help in confirming the doctors opinion and is valuable in cases of uncertainty but should not be thought of a substitute for good experienced clinical examination.

There is no doubt the advent of arthroscopy has revolutionised the management of knee injuries, it is minimally invasive and low risk. A negative arthroscopy (which is rare) can however afford enormous reassurance.

Opinion and Philosophy on Anterior Cruciate Ligament Reconstruction:

Mr Taylor believes that early intervention in knee injuries is very important and age today is  rarely a factor with many more people active into later life. He particularly feels that historically women's knees have been treated less aggressively which is a mistake. Also early intervention and reconstruction of the anterior cruciate ligament is vital not only to stabilise the knee but decrease the risk of osteoarthritis.

The Anterior Cruciate Ligament: There is good evidence that early reconstruction (within  6 to a maximum of 12 months) not only stabilises the knee but reduces the risk of premature arthritis. The operation is now done arthroscopically (through the telescope) and the hospital stay is 24 hours. Driving can be resumed in 2 - 4 weeks but full sport takes at least 6 months. Return to sedentary occupations can be as early as 1 week but heavy manual work may require 6 - 12 weeks.

What does an anterior cruciate ligament reconstruction involve?

There are two main techniques using your own tissue, the most frequent is the arthroscopic hamstring reconstruction and thReconstuction should be undertakene arthroscopically assisted bone - patella - bone graft.

There is some evidence that the bone-patella-bone graft is stronger and used in high performance athletes but this is not a universally held view. There is no doubt that the recovery is more difficult for the patient.

The hamstring technique is the gold standard but all techniques do have a risk of graft rupture of 5-10%. Revision reconstruction is always possible and is often carried out in two stages using either the patients own tissue or a cadaveric graft. Mr Taylor avoids using synthetic grafts but feels they may have a place in patients over 60.

Techniques of Anterior Cruciate Reconstruction: Arthroscopic Hamstring; Bone Patella Bone; Cadaveric.

Other Procedures:

Arthroscopy : Meniscal (Cartilage) repair : Chondral grafting.

Meniscal Repair:

The meniscus acts as a weight distributor in the knee. Its complete surgical removal is analogous to converting the heel on a mans shoe to a stiletto in that there is much more weight over a smaller area so the wear is greater.

Unfortunately only a relatively small number of cartilage tears can be repaired effectively but every attempt is made to preserve as much cartilage as possible. This minimises the risk of arthritis but this small risk has to be balanced against persevering with disabling symptoms.

Chondral Grafting:

The articular cartilage is the lining cartilage of all joints and is like the tread on a car tyre. In arthritis it gradually wears away. Occasionally after an injury there is a localised defect which can be grafted with cartilage. This technique is rarely suitable in osteoarthritis and not in rheumatoid arthritis.