Knee Problems.

Painful knees are a very common complaint leading patients to seek specialist medical advice. It can affect all age groups for many different causes.

Painful knees can affect your lifestyle in so many ways; from stopping you play your favourite sports to simply making standing up from a sitting position very difficult and painful. It can be completely debilitating even affecting your sleep.

The knee is the joint where the bones of the upper leg meet the bones of the lower leg, allowing hinge-like movement while providing stability and strength to support the entire weight of the body.

The knee joint is composed of three bones. The knee is junction where the femur (the large upper leg bone) meets the tibia (the lower leg bone) and has a small protective bone in front called the patella (commonly known as the kneecap).

The smooth ends of the bones are covered with cartilage, which allow the bones to glide smoothly. Separating the two large bones are pads of connective tissue called the Meniscus (commonly called cartilage), these work as shock absorbers protecting the bones from knocks and blows, but they also enhance the knees stability
Further strength and stability comes from ligaments in the joint, are called the anterior and posterior cruciate ligaments, they hold the bones in the correct position and strengthen the joint. There are also two large ligaments which run at each side of the knee offering stability.

Common causes of knee pain.
Osteoarthritis / Arthrosis:

The so called Osteoarthritis in Britain, or correctly Arthrosis means wear and tear of the knee joint, and is the most common form of knee arthritis. It is usually a slowly progressive degenerative disease in which the joint cartilage gradually wears away, causing increasing pain as the bone surfaces start to rub directly.

It most often affects middle-aged and older people but may affect younger patients that have played extreme levels of sport.

The pain and symptoms associated with osteoarthritis normally develops gradually over the years .The joint may become very stiff and swollen, making it difficult to bend or straighten the knee. The knee starts to look deformed and the pain increases in intensity and becomes more constant.

The knee may be warm to the touch. Generally arthritis pain and swelling are worse in the mornings or after a long period of inactivity. Pain may also increase after activities such as walking, stair climbing, or kneeling. The pain may often cause a feeling of weakness in the knee. Many people report that changes in the weather along with humidity also affect the degree of pain from chronic arthritis.

Post-traumatic arthritis
: may develop years after an injury to the knee. This type of arthritis is very similar to osteoarthritis and may develop after a fracture of the knee surface, after a ligament injury, or a meniscal tear.

Rheumatoid arthritis: (RA) is an inflammatory type of arthritis that can destroy the joint cartilage. The disease is auto-immune i.e. the body attacking itself. It can occur with any age and generally affects both of the knees along with other joints in the body. The joint pain caused by RA is normally a rapid onset. I.e. it typically starts one morning after a change of weather.

Gouty arthritis: this is not a true arthritis but the symptoms mimic those of arthritis. The gout crystals collect in the knee muscles, tendons and on the joint surfaces and cause acute inflammation inside the joint .This condition normally starts suddenly, the knee could be warm to touch and the patient suffers an intense pain and is often unable to walk. The pain is not improved much by resting.

Psoriasis arthritis: Psoriatic arthritis causes inflammation in and around the joints, causing arthritis symptoms. It usually affects people who already have psoriasis, a skin condition that causes a red, scaly rash, especially on the elbows, knees, back, buttocks and scalp. However, some people develop the arthritis symptoms first, while others never develop the skin disease.

Meniscus /Cartilage injuries:

Meniscal tear can occur with any age group both young and old; it is a very common knee injury. The knee meniscus (shock absorbers) inside the joint can be torn with the shearing forces of rotation that are applied to the knee during sharp, sudden motions.

There is a high incidence with the aging population, whom suffer an underlying disease such as osteoarthritis. 

The patient with a meniscal tear may experience a popping sensation with a certain activity or an abnormal movement of the knee, together with intense pain. Occasionally, it is associated with swelling and warmth in the knee.

It is often be associated with "locking" or "buckling."  Of the knee, i.e.: the patient being unable to straighten the leg fully.

The tear in the meniscus may lead to a fluid collection at the back of the knee joint called a Bakers cyst.

Ligament injuries
There are four main ligaments which give the knee its strength and stability.

Inside the joint there is the Anterior Cruciate (the ACL), and the Posterior Cruciate ligament (the PCL). Also, either side of the knee is the Lateral Collateral, and the Medial Collateral ligaments.

Ligament damage and subsequent pain may be caused by sudden jerking movements of the knee.
Damage to the strong knee ligaments may allow tiny abnormal movements, which as ligaments becomes looser allows the bones to move, thus causing pain. The knee joint becomes unstable, and if the ligaments are torn the knee can give way completely.
Ligaments which are torn completely may need surgical repair.

Bursitis of the knee
(Pre-patellar Bursitis)
A bursa is a thin sack filled with the body's own natural lubricating fluid. This slippery sack allows different tissues such as muscle, tendon, and skin slide over bony surfaces without friction. This bursa is normally very thin (like a plastic bag with the
air sucked out of it).

Typically a bursa exists in front of the kneecap (between the kneecap and the skin), called Pre-patellar Bursa. This bursa presents a potential space that can become inflamed and infected. This is what is known as Pre-patellar Bursitis. This condition usually occurs spontaneously. On occasions may be associated to micro ruptures of the skin around the kneecap or insect bites. It is also associated with mild trauma.

Normally the Pre-patellar Bursitis starts with swelling and redness in front of the kneecap. Symptoms of pre patellar bursitis are usually aggravated by kneeling, and relieved when sitting still.

Treatment of pre-patellar bursitis begins with avoidance of the aggravating activity. In some individuals, drainage or excision of the bursa may be indicated. In cases of infection, it is very important that antibiotics are given to treat this. Normally surgical drainage is necessary. The fluid can then be sent for analysis.

Episodes of Pre-patellar Bursitis could repeat time and time again. If so, surgical removal of the bursa should be considered.
Fractures and serious trauma injuries are not described in this article because the obvious nature of the conditions, and need of urgent specialist attention.

When to see a Specialist
If you experience any severe sudden pain after a trip, fall, or awkward movement which does not settle with rest and painkillers.
If you are unable to fully straighten your leg or feel it is “locked”. A knee locked in the flexed position is an Orthopaedic Emergency. Please seek specialist advice immediately.
If you have severe swelling with or without pain which does not settle quickly with rest.
When your normal painkillers stop taking effect and your knee pain keeps you awake at night.
When your knee pain stops your normal daily activities.

Your diagnosis:
The specialist will take your full medical history and examine you. He may ask for investigations, including an X-ray or an MRI scan, and perhaps a blood test to confirm your diagnosis. Once your Specialist has all the results he will explain what they mean and what treatments are available for you.

Treatments for knee pain
Depending on your diagnosis your specialist may suggest one of several non operative (conservative) treatments. He may prescribe anti-inflammatory tablets to help with your pain. Physiotherapy under doctors guidance may be prescribed or you be given exercises to do at home yourself. You may be advised on certain movements or types of activities to avoid. Your doctor may give you instructions to rest and use crutches for a while to allow your knee to heal. You may be offered an injection of steroid and local anesthetic into the knee to help the pain and to reduce the inflammation. You may need fluid drained from the knee to relieve pressure or to send for analysis.

Knee replacement surgery:
This is a very common operation to replace the worn out or damaged joints with prosthetic, or a manmade joint. A full knee replacement may also be needed for some fractures affecting the knee surfaces.
The prosthesis is made up mainly of two pieces, the upper part (femoral) and lower part (tibial) components. The knee is opened and the two ends of the bones are removed and the surfaces cleaned and prepared. The surgeon then fits the new joint surfaces carefully choosing from a range of several sizes the correct fit. On occasions, the kneecap surface may also be replaced. He will then try the knee to observe its movement before carefully closing.
The aim of this operation is to improve the pain and to restore function of the knee joint.
After the operation a period of physiotherapy is needed to recover the lost muscle strength of the leg and to regain full movement of the new knee joint.

Key Hole Surgery /Arthroscopy/Menisectomy/ACL repair:
This operation is performed under anaesthesia. The specialist uses a thin telescope (Arthroscope) to work inside of the knee joint through tiny holes. A camera is connected to the arthroscope, and the images of the inside of the joint are relayed on to a large screen in the operating theatre. This allows the surgeon to assess the knee visually, carefully looking for any injuries, broken pieces of bone or debris. The doctor may find broken ligaments disease, or tears of the meniscus or soft tissue. He may choose to repair or remove the broken meniscus, and clean debris from inside the joint. The major ligaments i.e.: the ACL may also be repaired with this minimal invasive technique. The hospital stay is shorter and with a more rapid recovery time than with open surgery.


Dr Miguel Bañuls LMS, MSc, MCh Consultant Orthopaedic Surgeon.
Dr Bañuls is pleased to offer a comprehensive Orthopaedic service that speaks your language. Dr Bañuls is British trained and fluent in English.
Dr Bañuls has a very special interest in spinal surgery and the treatment of all general orthopaedic problems; he offers Arthroscopic surgery of the knee and shoulder. Dr Bañuls continues to develop and apply new advances and techniques as they develop.

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