The Knee Joint – Part Four

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.

It is important to look at the accessory movements and the ranges of motion of the knee if strengthening is going to be effective for the inside quadriceps. The knee can be improved functionally by restoring the joint’s accessory movements and the ability of the medial quadriceps to function will be greatly enhanced by restoring knee extension. Muscle strengthening exercises will not be effective without the joint’s range being restored. The introduction of slim modern arthroscopes for knee surgery has meant easy visualisation of the knee interior and the ability to do the surgical minimum to achieve the desired goal.

Osteoarthritis is one of the commonest joint conditions in the world, affecting hundreds of millions of people and occurring almost universally to some degree in elderly people. A family history, meniscal surgery, joint trauma or ligament injury can all predispose the joint to later osteoarthritis. Damage to and stretching of either the medial or lateral ligaments can cause some sloppiness of the control of movement in the knee, causing increased forces to be generated across the joint and contribute towards articular surface breakdown. Shearing movements, causing a lateral stress as the joints are in contact, exert high forces on the surfaces.

The knee can start to develop a grating or clicking as it ages with small degrees of degeneration and is only painful if kept in one position for excessive periods. The joint capsule can become tighter if we do not perform the strong movements any longer which stress the joint to the ends of its ranges. This can increase joint compression which increases the stresses across the joint surfaces and make the joint more likely to be injured during stressful movements. As the process continues the cartilage wears down and the underlying bone, which normally has some elasticity, becomes denser and harder.

The symptoms of an osteoarthritic knee are typically pain, increased temperature, range of motion limitation, oedema, enlargement, joint crepitus and inability to do functional tasks. As the joint deteriorates it can go through cycles of pain and swelling, with walking become more restricted. Due to the difficulty of finding a comfortable resting position sleeping may become a challenge. Tenderness of the medial joint line means that pressure from another knee is not well tolerated in sleeping on the side, meaning a pillow is often required to allow comfortable resting.

Jonathan Blood Smyth is the Superintendent of Physiotherapy 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 London visit his website.

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