If knee control is not precise and the knee moves in unplanned ways such as laterally when it shouldn’t, then the menisci (cartilages) within the knee will suffer increased stresses. The menisci have as one of their roles the guiding of the large femoral condyles into particular movement patterns and if the condyles move abnormally this can be damaging. During the movements the large femoral condyles can roll over the edges of the menisci which are trapped between them and the flat upper surface of the tibial condyles.
Damage to the menisci can take many different patterns, including splitting, tearing and losing pieces of the edge. A split can develop along the circumference of the meniscus while both ends remain attached, a so called “bucket handle tear”. Part of the meniscus can become detached in a damaging manoeuvre such as twisting and become a loose body, moving about inside the joint and jamming between the joint surfaces at times. When this occurs during weight bearing then the knee can give way, and it can make the knee difficult to straighten. The cartilage cannot heal as such as the blood supply is very poor.
As the cartilage continues to erode it can guide the femoral condyles less and less, perhaps increasing the forces which are transmitted across from the femoral condyles to the tibial surface. As the surfaces suffer increased forces they can also degenerate, leading the osteoarthritic changes within the knee. Before modern arthroscopic management a common procedure was to remove the meniscus entirely if it was giving trouble, leading to osteoarthritic changes some years later. Any significant problem with a knee leads to wasting of the medial part of the quadriceps muscle and much effort is expended in strengthening this area.
However, strengthening of the medial lower quadriceps will not be very effective if no attention is paid to the knee’s range of motion and its accessory movements. Restoring the accessory movements can help the knee’s overall function and if full extension is restored then the function of the medial quadriceps muscle will gradually return towards normal naturally. Without full extension then no amount of exercise will restore the muscle function. Modern arthroscopic operative techniques involve slim probes to view the interior of the knee, and the minimum is done internally to remove the troublesome parts, leaving the vast majority of structures intact.
Hundreds of millions of people in the world suffer some degree of osteoarthritis, making it the most prevalent degenerative joint condition in the world, affecting almost all the elderly in some way. It is more likely that osteoarthritis will develop if there has been damage to the joint or ligaments, surgery to the menisci or a family history. If the lateral, medial or cruciate ligaments are damaged the knee may develop unwanted extra movement and so generate excessive forces within the joint which can facilitate breakdown of the joint surfaces. The lateral stresses caused by shearing movements in the joint can be of a high level.
Early stages of knee change with age can include some clicking and grating with the knee only feeling uncomfortable if it is held in one posture for too long. If we lack the stresses at the end ranges of the joint because we do not perform vigorous activities any longer then the joint capsule can become tight. This can make it more vulnerable to injury during movement and can compress the joint to some degree, increasing the forces across the weight bearing surfaces. The cartilage can wear down and the bone underneath, which usually has some pliability, increases in density in a process known as sclerosis.
A typical arthritic knee can exhibit enlargement, pain, heat, limited ranges of motion and swelling, crepitus on joint motion and functional disability. There can be repeated cycles of swelling and pain which worsen as the joint gradually becomes worse. There may be difficulty sleeping as a comfortable position is so difficult to find and a limitation in walking ability. The medial joint line can develop tenderness and inability to manage the other knee pressure or the joint gapping which occurs when we lie on the side, with comfort demanding a pillow between the knees.
Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in Nottingham visit his website.
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