Fixed and moving parts, including bones, cartilage, muscles, ligaments, and tendons, enable the knee to function normally. Any disruption to these structures results in dysfunction and pain and swelling are the most common symptoms.

In all joints, the bones are kept from grinding against each other by a padding called cartilage. Bones are joined to bones by strong, elastic bands of tissue called ligaments. Tendons are tough cords of tissue that connect muscle to bone. Muscles work in opposing pairs to bend and straighten joints. While muscles are not technically part of a joint, they are important because strong muscles help support and protect joints.

Some knee problems result from injury, such as a direct blow or sudden movements that strain the knee beyond its normal range of movement. These injuries are common following sporting accidents in all age groups. Other problems, such as osteoarthritis in the knee, result from wear and tear on its parts.

The ends of the three bones in the knee joint are covered with articular cartilage, a tough, elastic material that helps absorb shock and allows the knee joint to move smoothly. Separating the bones of the knee are pads of connective tissue cushions called the meniscus. The meniscus is crescent-shaped and positioned between the tibia and femur on the outer and inner sides of each knee. The two menisci in each knee act as shock absorbers, cushioning the lower part of the leg from the weight of the rest of the body as well as enhancing stability.

• The medial collateral ligament (MCL) provides stability to the inner (medial) part of the knee.
• The lateral collateral ligament (LCL) provides stability to the outer (lateral) part of the knee.
• The anterior cruciate ligament (ACL), in the center of the knee, limits rotation and the forward movement of the tibia.
• The posterior cruciate ligament (PCL), also in the center of the knee, limits backward movement of the tibia.
• Other ligaments are part of the knee capsule, which is a protective, fiber-like structure that wraps around the knee joint. Inside the capsule, the joint is lined with a thin, soft tissue called synovium.

Osteoarthritis may be caused by excess stress on the joint from deformity, repeated injury, or excess weight. It most often affects middle-aged and older people. A young person who develops osteoarthritis may have an inherited form of the disease or may have experienced continuous irritation from an unrepaired torn meniscus or ligament injury. Rheumatoid arthritis often affects people at an earlier age than osteoarthritis.

Rheumatoid arthritis of the knee may require physical therapy and more powerful medications. In people with arthritis of the knee, a seriously damaged joint may need to be replaced with an artificial one.

Newer Treatment Modalities

A new procedure designed to stimulate the growth of cartilage by using a patient's own cartilage cells is being used to repair cartilage injuries in the knee. Unfortunately this is not suitable for all patients.

The use of growth factors injections is an option for patient with early cartilage injuries and it is also applicable for repair of soft tissue damage such as hamstring injuries.

For large or symptomatic cartilage defects various surgical options such as cartilage debridement, radio frequency smoothening, microfracture treatment, local cartilage transplants (mosaicplasty), autologous cartilage implantation (ACI) and osteotomy are available. These procedures, in general, do not provide total cure and may only partially alleviate symptoms.

Newer Cartilage Regeneration Techniques (ACI & MACI)

We have been performing cartilage transplant operation in our clinic for a selected group of patients with siaolted cartilage lesions with a reasonably good success rate using ACI techniques and MACI (Membrane autologous chondrocyte implantation) techniques.

These surgeries involve two procedures - first to harvest the patient's own cartilage cells which are then sent to the laboratory for culture. Through a second operation the cultured cells, which take up to 6 weeks to grow in the laboratory, are then transplanted into the defect in the knee joint. This is followed by a 6 month rehabilitation program.

Growth Factors and Stem Cell Treatment

These are very new exciting and promising techniques that are currently available to treat a select group of patients with cartilage and joint injuries. Early results are promising and the practice is currently in the process of offering these procedures for a select group of patients where the potential for regeneration of damaged muscle, tendon and cartilage exists.

• Warming up the joint by riding a stationary bicycle, then straightening and raising the leg (but not straightening it too much).
• Extending the leg while sitting (a weight may be worn on the ankle for this exercise).
• Raising the leg while lying on the stomach.
• Exercising in a pool (walking as fast as possible in chest-deep water, performing small flutter kicks while holding onto the side of the pool, and raising each leg to 90 degrees in chest-deep water while pressing the back against the side of the pool).

If the patient is elderly or the tear is in an area with a poor blood supply, the doctor may cut off a small portion of the meniscus to even the surface. However, osteoarthritis is more likely to develop in the knee, after 10-20 years following meniscal resection.

Recovery after meniscal repair takes several weeks, and postoperative activity is slightly more restricted than when the meniscus is removed. Nevertheless, putting weight on the joint actually fosters recovery. Regardless of the form of surgery, rehabilitation usually includes walking, bending the legs, and doing exercises that stretch and build up leg muscles. The best results of treatment for meniscal injury are obtained in people who do not show articular cartilage changes and who have an intact ACL.

ACL Reconstruction

The PCL is most often injured by a direct impact, such as in an automobile accident or football tackle.

Associated injuries include lateral collateral liagment and posterolateral capsule. Instabilities vary from patient to patient and results of reconstruction are highly variable.

Patients often complain of giving way or pain due to cartilage wear and tear from abnormal loads.

Tendinitis of the patellar tendon is sometimes called jumper's knee because in sports that require jumping, such as basketball, the muscle contraction and force of hitting the ground after a jump strain the tendon. After repeated stress, the tendon may become inflamed or tear.

Rehabilitating a partial or complete tear of a tendon requires an exercise program that is similar to but less vigorous than that prescribed for ligament injuries. The goals of exercise are to restore the ability to bend and straighten the knee and to strengthen the leg to prevent repeat injury. A rehabilitation program may last 6 months, although the patient can return to many activities before then.

Osgood-Schlatter disease is most often diagnosed by the symptoms. An X-ray may be normal, or show an injury, or, more typically, show that the growth area is in fragments.

Lack of a blood supply can cause bone to break down (avascular necrosis). The involvement of several joints or the appearance of osteochondritis dissecans in several family members may indicate that the disorder is inherited.

If fragments are loose, the surgeon may scrape down the cavity to reach fresh bone and add a bone graft and fix the fragments in position. Fragments that cannot be mended are removed, and the cavity is drilled or scraped to stimulate new cartilage growth. Research is being done to assess the use of cartilage cell and other tissue transplants to treat this disorder.

As the fetus develops, these pouches normally combine to form one large synovial cavity. If this process is incomplete, plicae remain as four folds or bands of synovial tissue within the knee. Injury, chronic overuse, or inflammatory conditions are associated with this syndrome.

Diagnosis is by physical examination, an X-ray of the heel and sometimes an MRI.

Tendon rupture can be treated by surgical reattachment or medical therapy. The latter consists of rest, pain control and serial casting. Tendonitis is treated similarly. Rehabilitation is important for complete recovery in both conditions.

Tailor's Bunion, or bunionette, involves the little toe. As with the big toe, the little toe moves towards the other toes and forms a bump on the outer surface of the little toe. Similar symptoms occur as with as bunion.

Bunions usually affect women. They can be caused by an abnormality in foot function, or arthritis, but is more commonly caused by wearing improper fitting footwear. Tight, narrow dress shoes with a small restrictive toe area can cause the foot to begin to take the shape of the shoe, which leads to the formation of a bunion. Women who have bunions normally wear dress shoes that are too small for their feet. Their toes are compressed together in their shoes causing the toe bone to protrude on the side of the foot.

The continued practice of wearing these restrictive shoes will worsen the problem and increase the likelihood of corrective surgery being done.

Here are some tips on preventing the progression of bunions.

• Soaking feet in warm water can alleviate the problem
• Properly fitted shoes should help reduce the pain and discomfort (i.e. shoes with a high, wide toe box and rocker soles)
• Orthotics can help to provide extra comfort, support, and protection
• Using forefoot products such as bunion shields, bunion night splints, and bunion bandages. These conservative treatments can limit the progression of the bunion formation, relieve pain and provide a healthy environment for the foot.

If the problem persists or worsens, do not hesitate to consult your doctor

The causes include repetitive hand or wrist movements, pregnancy, birth control pill use, hypothyroidism (thyroid dysfunction), diabetes and Rheumatoid arthritis.

Classical symptoms are pain (usually a burning sensation), numbness and tingling (especially in the fore and middle finger). These symptoms may be present in the forearm as well. They are worse at night and may be temporarily relieved by shaking of the hand. Home treatment measures such as anti-inflammatory drugs can relief the symptoms. Using a wrist splint at all times and avoiding activities that aggravate the problem are other simple steps that you can take. If symptoms persist, please consult your doctor.

If symptoms do not improve one may consider a surgical removal of the offending disc. This can be done as a microdiscectomy through a small incision in the back. In degenerative disc prolapse a larger incision may be required. Single level disc removals require a day or two in hospital and the patient is usually ambulant or walking about in a day.

It is best to avoid excessive walking or activity following this type of surgery. It is recommended that one does not carry or lift heavy objects following disc surgery. Rehabilitation following surgery is important.