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Iliotibial band (ITB) syndrome is an overuse problem that is often seen in bicyclists, runners, and long-distance walkers. It causes pain on the outside of the knee just above the joint. It rarely gets so bad that it requires surgery, but it can be very bothersome. The discomfort may keep athletes and other active people from participating in the activities they enjoy.

This article will help you understand:

• how ITB syndrome develops
• how the condition causes problems
• what treatment options are available

Anatomy

What is the ITB, and what does it do?

The ITB is actually a long tendon. (Tendons connect muscles to bone.) It attaches to a short muscle at the top of the pelvis called the tensor fascia lata. The ITB runs down the side of the thigh and connects to the outside edge of the tibia (shinbone) just below the middle of the knee joint. You can feel the tendon on the outside of your thigh when you tighten your leg muscles. The ITB crosses over the side of the knee joint, giving added stability to the knee.

The lower end of the ITB passes over the outer edge of the lateral femoral condyle, the area where the lower part of the femur (thighbone) bulges out above the knee joint. When the knee is bent and straightened, the tendon glides across the edge of the femoral condyle.

Lateral Femoral Condyle

A bursa is a fluid-filled sac that cushions body tissues from friction. These sacs are present where muscles or tendons glide against one another. A bursa rests between the femoral condyle and the ITB.

Muscles or Tendons Glide

Normally, this bursa lets the tendon glide smoothly back and forth over the edge of the femoral condyle as the knee bends and straightens.

Causes

How does ITB syndrome develop?

The ITB glides back and forth over the lateral femoral condyle as the knee bends and straightens. Normally, this isn’t a problem. But the bursa between the lateral femoral condyle and the ITB can become irritated and inflamed if the ITB starts to snap over the condyle with repeated knee motions such as those from walking, running, or biking.

Irritated ITB

People often end up with ITB syndrome from overdoing their activity. They try to push themselves too far, too fast, and they end up running, walking, or biking more than their body can handle. The repeated strain causes the bursa on the side of the knee to become inflamed.

Some experts believe that the problem happens when the knee bows outward. This can happen in runners if their shoes are worn on the outside edge, or if they run on slanted terrain. Others feel that certain foot abnormalities, such as foot pronation, cause ITB syndrome. (Pronation of the foot occurs when the arch flattens.)

Recently, health experts have found that runners with a weakened or fatigued gluteus medius muscle in the hip are more likely to end up with ITB syndrome. This muscle controls outward movements of the hip. If the gluteus medius isn’t doing its job, the thigh tends to turn inward. This makes the knee angle into a knock-kneed position. The ITB becomes tightened against the bursa on the side of the knee. This is also called a valgus deformity of the knee.

People with bowed legs may also be at risk of developing ITB syndrome. The outward angle of the bowed knee makes the lateral femoral condyle more prominent and can make the snapping worse. This condition is also called a varus deformity of the knee.

Symptoms

What does ITB syndrome feel like?

The symptons of ITB syndrome commonly begin with pain over the outside of the knee, just above the knee joint. Tenderness in this area is usually worse after activity. As the bursitis grows worse, pain may radiate up the side of the thigh and down the side of the leg. Patients sometimes report a snapping or popping sensation on the outside of the knee.

Diagnosis

The diagnosis of ITB syndrome can usually be made without any complicated tests. When you visit First Choice Physical Therapy, our Physical Therapist will take a history of the problem and ask about any other injuries that may have occurred in the past. Generally, no swelling is visible. The snapping sensation usually cannot be heard.

Pain on the outside of the knee can be caused from conditions other than ITB syndrome. Our Physical Therapist will perform an examination of the knee and will look at your entire leg. You may want to bring the shoes that you use to run or walk with you to your appointment.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Our Treatment

Non-surgical Rehabilitation

Most cases of ITB syndrome can be treated with simple measures. When you begin your Physical Therapy at First Choice Physical Therapy, we will first use heat, ice, and ultrasound to help calm pain and inflammation.

During our Physical Therapy program the problems that are causing your symptoms will be evaluated and treated. Our Physical Therapist may use stretching and strengthening exercises, in combination with a knee brace, kneecap taping, or shoe inserts to improve muscle balance and joint alignment of the hip and lower limb. Your Physical Therapist will probably ask you about your sport activities and may give you tips on your warm up and training schedule, footwear, and choices of terrain.

A key element of our treatment is examining your training schedule. Your Physical Therapist can work with you to adjust the distance you run, your footwear, and the running surfaces you choose.

We may recommend foot orthotics to improve your foot and lower limb alignment. Wearing orthotics in your shoes may allow you to resume normal walking immediately, but you should probably cut back on more vigorous activities for several weeks to allow the inflammation and pain to subside.

Our Physical Therapist will choose strengthening and stretching exercises to correct muscle imbalances, such as weakness in the gluteus medius muscle or tightness in the ITB.

Treatments such as ultrasound, friction massage, and ice may also be used to calm inflammation in the ITB. Our Physical Therapy sessions sometimes include iontophoresis, in which our Physical Therapist uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can’t tolerate injections.

Although recovery time varies, if your treatment is nonsurgical, you should be able to return to normal activity within four to six weeks.

Post-surgical Rehabilitation

If you’ve undergone surgery, our Physical Therapist will create a personalized plan for your rehabilitation. You will first have a period of rest, which may involve using crutches. Then we will start you on a careful and gradual exercise program.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, improve muscle and joint alignment, and return you to your sport or activity without additional problems. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Surgery

Surgery is rarely needed to correct ITB problems. Surgery consists of removing the bursa and releasing, or lengthening, the ITB just enough so that the friction is reduced when the knee is bent and straightened.

The meniscus is a commonly injured structure in the knee. The injury can occur in any age group. In younger people, the meniscus is fairly tough and rubbery, and tears usually occur as a result of a forceful twisting injury. The meniscus grows weaker with age, and meniscal tears can occur in aging adults as the result of fairly minor injuries, even from the up-and-down motion of squatting.

This guide will help you understand:

• where the meniscus is located in the knee
• how an injured meniscus causes problems
• what can be done for an injured meniscus

Anatomy

What is a meniscus, and what does it do?

There are two menisci between the shinbone (tibia) and thighbone (femur) in the knee joint. (Menisci is plural for meniscus.)

Menisci

The C-shaped medial meniscus is on the inside part of the knee, closest to your other knee. (Medial means closer to the middle of the body.) The U-shaped lateral meniscus is on the outer half of the knee joint. (Lateral means further out from the center of the body.)

These two menisci act like shock absorbers in the knee. Forming a gasket between the shinbone and the thighbone, they help spread out the forces that are transmitted across the joint. Walking puts up to two times your body weight on the joint. Running puts about eight times your body weight on the knee. As the knee bends, the back part of the menisci takes most of the pressure.

Articular cartilage is a smooth, slippery material that covers the ends of the bones that make up the knee joint. The articular cartilage allows the surfaces to slide against one another without damage to either surface.

Aricular Cartilage

By spreading out the forces on the knee joint, the menisci protect the articular cartilage from getting too much pressure on one small area on the surface of the joint. Without the menisci, the forces on the knee joint are concentrated onto a small area, leading to damage and degeneration of the articular cartilage, a condition called osteoarthritis.

The menisci add stability to the knee joint. They convert the surface of the shinbone into a shallow socket, which is more stable than its otherwise flat surface. Without the menisci, the round femur would slide on top of the flat surface of the tibia.

Conversion of Shinbone to Shallow Socket

Causes

How do meniscal problems develop?

Meniscal injuries can occur at any age, but the causes are somewhat different for each age group. In younger people, the meniscus is a fairly tough and rubbery structure. Tears in the meniscus in patients under 30 years old usually occur as a result of a fairly forceful twisting injury. In the younger age group, meniscal tears are more likely to be caused by a sport activity. The entire inner rim of the medial meniscus can be torn in what is called a:

Bucket Handle Tear

The meniscus can also have a flap torn from the inner rim.

The tissue that forms the menisci weakens with age, making the menisci prone to degeneration and tearing. People of older ages often end up with a tear as result of a minor injury, such as from the up-and-down motion of squatting. Most often, there isn’t one specific injury to the knee that leads to the degenerative type of meniscal tear. These tears of the menisci are commonly seen as a part of the overall condition of osteoarthritis of the knee in aging adults. Degenerative tears cause the menisci to fray and become torn in many directions.

Menisci Degeneration and Tearing

Symptoms

What does a torn meniscus feel like?

The most common problem caused by a torn meniscus is pain. The pain may be felt along the edge of the knee joint closest to where the meniscus is located. Or the pain may be more vague and involve the whole knee.

The knee may swell, causing it to feel stiff and tight. This is usually because fluid accumulates inside the knee joint. This is sometimes called water on the knee. This is not unique to meniscal tears, since it can also occur when the knee becomes inflamed.

The knee joint can also lock up if the tear is large enough. Locking refers to the inability to completely straighten out the knee. This can happen when a fragment of the meniscus tears free and gets caught in the hinge mechanism of the knee, like a pencil stuck in the hinge of a door.

A torn meniscus can cause long-term problems. The constant rubbing of the torn meniscus on the articular cartilage may cause the joint surface to become worn, leading to knee osteoarthritis.

Diagnosis

Diagnosis begins with a history and physical exam. Your Physical Therapist at First Choice Physical Therapy will try to determine where the pain is located, whether you’ve had any locking, and if you have any clicks or pops with knee movement.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

When you visit First Choice Physical Therapy, our initial treatments for a torn meniscus focus on decreasing pain and swelling in your knee. Rest and anti-inflammatory medications, such as aspirin, can help decrease these symptoms. You may need to use crutches until you can walk without a limp.

Our Physical Therapist will treat your swelling and pain with the use of ice, electrical stimulation, and rest periods with your leg supported in elevation. Exercises are used to help you regain normal movement of joints and muscles. Exercises to improve knee range of motion and strength are added gradually. Our Physical Therapist may also help you to obtain and use a knee brace.

Although recovery time varies, nonsurgical rehabilitation for a meniscal injury typically lasts six to eight weeks. You can return to your sporting activities when your quadriceps and hamstring muscles are back to nearly their full strength and control, you are not having swelling that comes and goes, and you aren’t having problems with the knee giving way.

Post-surgical Rehabilitation 

Rehabilitation proceeds cautiously after surgery on the meniscus, and treatments will vary depending on whether you had part of the meniscus taken out or your surgeon repaired or replaced the meniscus.

Patients are strongly advised to follow their Physical Therapist’s recommendations about how much weight can be borne while standing or walking. After a partial meniscectomy, we may instruct you to place a comfortable amount of weight on your operated leg using a walking aid. After a meniscal repair, however, you may be instructed to keep your knee straight in a locked knee brace and to put only minimal or no weight on your foot when standing or walking for up to six weeks.

First Choice Physical Therapy patients usually need only a few Physical Therapy visits after meniscectomy. We may recommend additional treatments if there are problems with swelling, pain, or weakness. Rehabilitation is slower after a meniscal repair or allograft procedure. At first, expect to see our Physical Therapist two to three times a week. If your surgery and rehabilitation go as planned, you may only need to do a home program and see our Physical Therapist every few weeks over a six-to eight-week period.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach

Surgery

If the knee keeps locking up and can’t be straightened out, surgery may be recommended as soon as reasonably possible to remove the torn part that is getting caught in the knee joint. But even a less severely torn meniscus may not heal on its own. If symptoms continue after nonsurgical treatment, surgery will probably be suggested to either remove or repair the torn portion of the meniscus.

Surgeons use an arthroscope (mentioned earlier) during surgery for an injured meniscus. Small incisions are made in the knee to allow the insertion of the camera into the joint.

Partial Meniscectomy

The procedure to take out the damaged portion of the meniscus is called a partial meniscectomy. The surgeon makes another small incision. This opening is needed to insert surgical instruments into the knee joint. The instruments are used to remove the torn portion of the meniscus, while the arthroscope is used to see what is happening.

Surgeons would rather not take out the entire meniscus. This is because the meniscus helps absorb shock and adds stability to the knee. Removal of the meniscus increases the risk of future knee arthritis. Only if the entire meniscus is damaged beyond repair is the entire meniscus removed.

Meniscal Repair

Whenever possible, surgeons prefer to  a torn meniscus, rather than remove even a small piece. Young people who have recently torn their meniscus are generally good candidates for:

Repair

Older patients with degenerative tears are not.

To repair the torn meniscus, the surgeon inserts the arthroscope and views the torn meniscus. Some surgeons use sutures to sew the torn edges of the meniscus together. Others use special fasteners, called suture anchors, to anchor the torn edges together.

Special Fasteners

Meniscal Transplantation

Surgeons are beginning to experiment with different ways to replace a damaged meniscus. One way is by transplanting tissue, called an allograft, from another person’s body. Further investigation is needed to see how well these patients do over a longer period of time.

Osteoarthritis (OA) is a common problem for many people after middle age. OA is sometimes referred to as degenerative, or wear and tear, arthritis. OA commonly affects the knee joint. In fact, knee OA is the most common cause of disability in North America. In the past, people were led to believe that nothing could be done for their problem. Now there are many ways health professionals like Physical Therapists can treat knee OA so patients have less pain, better movement, and enhanced quality of life.

This guide will help you understand:

• how OA develops
• how OA of the knee causes problems
• how doctors treat the condition

Anatomy

Which parts of the knee are affected?

The main problem in OA is degeneration of the articular cartilage. Articular cartilage is the smooth lining that covers the ends of the leg bones where they meet to form the knee joint. The cartilage gives the joint freedom of movement by decreasing friction. The layer of bone just below the articular cartilage is called subchondral bone.

Subchondral Bone

When the articular cartilage degenerates, or wears away, the bone underneath is uncovered and rubs against bone. Small outgrowths called bone spurs or osteophytes may form in the joint.

Bone Spurs/Osteophytes

Causes

How does knee OA develop?

OA of the knee can be caused by a knee injury earlier in life. It can also come from years of repeated strain on the knee. Fractures of the joint surfaces, ligament tears, and meniscal injuries can all cause abnormal movement and alignment, leading to wear and tear on the joint surfaces. Not all cases of knee OA are related to a prior injury, however. Scientists believe genetics makes some people prone to developing degenerative arthritis. Obesity is linked to knee OA. Losing only 10 pounds can reduce the risk of future knee OA by 50 percent.

Scientists believe that problems in the subchondral bone may trigger changes in the articular cartilage. Normally, the articular cartilage protects the subchondral bone. But some medical conditions can make the subchondral bone too hard or too soft, changing how the cartilage normally cushions and absorbs shock in the joint.

Symptoms

What does knee OA feel like?

Knee OA develops slowly over several years. The symptoms are mainly pain, swelling, and stiffening of the knee. Pain is usually worse after activity, such as walking. Early in the course of the disease, you may notice that your knee does fairly well while walking, then after sitting for several minutes your knee becomes stiff and painful. As the condition progresses, pain can interfere with simple daily activities. In the late stages, the pain can be continuous and even affect sleep patterns.

Diagnosis

When you visit, First Choice Physical Therapy, our Physical Therapist will take a history and do a physical exam. The diagnosis of OA can usually be made on the basis of the initial history and examination.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

OA can’t be cured, but Physical Therapies are available to ease symptoms and to slow down the degeneration. Recent information shows that mild cases of knee OA may be maintained and in some cases improved without surgery.

Medication

Patients may also want to consult with their doctor or pharmacist regarding the use of pain relief or over-the counter anti-inflammatory medication. Acetaminophen (Tylenol) is a mild pain reliever with few side effects. Some people may also get relief of pain with anti-inflammatory medication, such as ibuprofen and aspirin. Talk to your doctor or pharmacist if you have questions or concerns regarding these medications.

Medical studies have shown that glucosamine and chondroitin sulfate can also help people with knee OA. These supplements seem to have nearly the same benefits as anti-inflammatory medicine with fewer side affects. Many therapists feel the research supports these supplements and are encouraging their patients to use them.

Physical Therapy

Your Physical Therapist plays a critical role in the nonoperative treatment of knee OA. Physical Therapy may be needed to ease pain and improve mobility, strength, and function. Our primary goals are to help you learn how to control symptoms, maximize the health of your knee and prolong the time before surgery is needed. Although the time required for recovery varies, you will probably progress to a home program within two to four weeks

We begin by recommending ways to calm pain and symptoms, which might include the use of rest, heat, or topical rubs.

Our Physical Therapists then teach patients how to protect the arthritic knee joint. This starts with tips on choosing activities that minimize impact and twisting forces on the knee. People who modify their activities can actually slow down the effects of knee OA. For instance, people who normally jog might decide to walk, bike, or swim to reduce impact on their knee joint. Sports that require jumping and quick starts and stops may need to be altered or discontinued to protect the knee joint.

Our Physical Therapist may suggest that shock-absorbing insoles placed in your shoes to reduce impact and protect the joint. In advanced cases of knee OA, or when the knee is especially painful, we may recommend a cane or walker to ease joint pressure when walking. People who walk regularly are encouraged to choose a soft walking surface, such as a cinder or grass track.

A new type of knee brace, called a knee unloading brace, can help when OA is affecting one side of the knee joint. For example, a bowlegged posture changes the way the knee joint lines up. The inside (medial) part of the knee joint gets pressed together. The cartilage suffers more damage, and greater pain and problems occur. The unloading brace pushes against the outer (lateral) surface of the knee, causing the medial side of the joint to open up. In this way, the brace shares the pressure and unloads the arthritic medial side of the joint. A knee unloading brace can help relieve pain and allow people to do more of their usual activities.

For mild cases of knee OA, our Physical Therapist may give you a heel wedge to wear in your shoe. By tilting the heel, the wedge alters the way your knee lines up, which works like the unloading brace mentioned above to take pressure off the arthritic part of the knee.

We will use range-of-motion and stretching exercises to improve your knee motion. Our Physical Therapist will also show you strengthening exercises for the hip and knee to help steady you knee and give additional joint protection from shock and stress. People with knee OA who have strong leg muscles have fewer symptoms and prolong the life of their knee joint. Your Physical Therapist will also suggest tips for getting your tasks done with less strain on the joint.

Post-Surgical Rehabilitation

Physical Therapy treatments after surgery depend on the type of surgery performed. Rehabilitation is generally slower and more cautious after knee replacement procedures and certain types of tibial osteotomies. After simple procedures such as arthroscopy, you may begin fairly aggressive exercise therapy immediately.

Your Physical Therapy treatments usually begin the next day after surgery. Our first few rehabilitation sessions are used to ease pain and swelling, help you begin gentle knee motion and thigh tightening exercises, and get you up and walking safely. You may need to use either a walker or crutches after surgery. We may instruct some patients to limit how much weight they place on the knee for about four to six weeks.

After going home from the hospital, a Physical Therapist may see you for a short period of home therapy before beginning outpatient Physical Therapy. Our outpatient treatments are designed to improve knee range of motion and strength and to safely progress your ability to walk and do daily activities.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, maximize knee mobility, and improve muscle strength and control. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Physician Review

Radiological Testing 

X-rays can help in the diagnosis and may be the only special test required in the majority of cases. X-rays can also help doctors rule out other problems, since knee pain from OA may be confused with other common causes of knee pain, such as a torn meniscus or kneecap problems. In some cases of early OA, X-rays may not show the expected changes.

Magnetic resonance imaging (MRI) may be ordered to look at the knee more closely. An MRI scan is a special radiological test that uses magnetic waves to create pictures that look like slices of the knee. The MRI scan shows the bones, ligaments, articular cartilage, and menisci. The MRI scan is painless and requires no needles or dye.

If the diagnosis is still unclear, arthroscopy may be necessary to actually look inside the knee and see if the joint surfaces are beginning to show wear and tear. Arthroscopy is a surgical procedure in which a small fiber-optic TV camera is inserted into the knee joint through a very small incision, about one-quarter of an inch long. The surgeon can move the camera around inside the joint while watching the pictures on a TV screen. The structures inside the joint can be poked and pulled with small surgical instruments to see if there is any damage.

Medication

Your physician may prescribe medicine to help control your pain. Acetaminophen (Tylenol) is a mild pain reliever with few side effects. Some people may also get relief of pain with anti-inflammatory medication, such as ibuprofen and aspirin. Newer anti-inflammatory medicines called COX-2 inhibitors show promising results and don’t cause as much stomach upset and other intestinal problems.

Medical studies have shown that glucosamine and chondroitin sulfate can also help people with knee OA. These supplements seem to have nearly the same benefits as anti-inflammatory medicine with fewer side affects. Many doctors feel the research supports these supplements and are encouraging their patients to use them.

If you aren’t able to get your symptoms under control, a cortisone injection may be prescribed. Cortisone is a powerful anti-inflammatory medication, but it has secondary effects that limit its usefulness in the treatment of OA. Multiple injections of cortisone may actually speed up the process of degeneration.

Repeated injections also increase the risk of developing a knee joint infection, called septic arthritis. Any time a joint is entered with a needle, there is the possibility of an infection. Most physicians use cortisone sparingly, and avoid multiple injections unless the joint is already in the end stages of degeneration, and the next step is an artificial knee replacement.

A new type of injectable medication has become available in the United States. Hyaluronic acid has been used in Europe and Canada for several years. Doctors inject three to five doses into the joint over a one-month period. The medicine helps lubricate the joint, ease pain, and improve people’s ability to get back to some of the activities they enjoy. Some people have had good results for up to eight months after getting these treatments.

Surgery

In some cases, surgical treatment of OA may be appropriate.

In cases of advanced OA where surgery is called for, patients may also see a Physical Therapist before surgery to discuss exercises that will be used just after surgery and to begin practicing using crutches or a walker.

Arthroscopy

Surgeons can use an arthroscope (mentioned earlier) to check the condition of the articular cartilage.

They can also clean the joint by removing loose fragments of cartilage. People have reported relief when doctors simply flush the joint with saline solution.

A burring tool may be used to roughen spots on the cartilage that are badly worn. This promotes growth of new cartilage called fibrocartilage, which is like scar tissue.

This procedure is often helpful for temporary relief of symptoms for up to two years.

Proximal Tibial Osteotomy

OA usually affects the side of the knee closest to the other knee (called the medial compartment) more often than the outside part (the lateral compartment). OA in the medial compartment can lead to bowing of the knee. As mentioned earlier, a bowlegged posture places more pressure than normal on the medial compartment. The added pressure leads to more pain and faster degeneration where the cartilage is being squeezed together.

Surgery to realign the angles in the lower leg can help shift pressure to the other, healthier side of the knee. The goal is to reduce the pain and delay further degeneration of the medial compartment.

One procedure to realign the angles of the lower leg is called a proximal tibial osteotomy. In this procedure, the upper (proximal) part of the shinbone (tibia) is cut, and the angle of the joint is changed. This converts the extremity from being bowlegged to straight or slightly knock-kneed. By correcting the joint deformity, pressure is taken off the cartilage. A proper joint angle actually allows the cartilage to regrow, a process called regeneration.

This surgical procedure is not always successful. Generally, it will reduce your pain but not eliminate it altogether. The advantage to this approach is that very active people still have their own knee joint, and once the bone heals there are no restrictions on activities.

A proximal tibial osteotomy in the best of circumstances is probably only temporary. It is thought that this operation buys some time before a total knee replacement becomes necessary. The benefits of the operation usually last for five to seven years if successful.

Artificial Knee Replacement

An artificial knee replacement is the ultimate solution for advanced knee OA.

Surgeons prefer not to put a new knee joint in patients younger than 60. This is because younger patients are generally more active and might put too much stress on the joint, causing it to loosen or even crack. A revision surgery to replace a damaged prosthesis is harder to do, has more possible complications, and is usually less successful than a first-time joint replacement surgery.

Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). A joint surface damaged by OCD doesn’t heal naturally. Even with surgery, OCD usually leads to future joint problems, including degenerative arthritis and osteoarthritis.

This guide will help you understand:

• where in the knee the condition develops
• how doctors diagnose the problem
• what treatment options are available

Anatomy

What part of the knee is affected?

OCD mostly affects the femoral condyles of the knee. The femoral condyle is the rounded end of the lower thighbone, or femur. Each knee has two femoral condyles, referred to as the medial femoral condyle (on the inside of the knee) and the lateral femoral condyle (on the outside). Like most joint surfaces, the femoral condyles are covered in articular cartilage. Articular cartilage is a smooth, rubbery covering that allows the bones of a joint to slide smoothly against one another.

Femoral Condyles

The problem occurs where the cartilage of the knee attaches to the bone underneath. The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the:

Osteochondritis Lesion

The lesions usually occur in the part of the joint that holds most of the body’s weight. This means that the problem area is under constant stress and doesn’t get time to heal. It also means that the lesions cause pain and problems when walking and putting weight on the knee. It is more common for the lesions to occur on the medial femoral condyle, because the inside of the knee bears more weight.

Causes

How does the condition develop?

Juvenile Osteochondritis Dissecans

Children as young as nine or ten can develop this condition. But the disease behaves much differently in children and for this reason is given a separate name, juvenile osteochondritis dissecans (JOCD), meaning osteochondritis dissecans of children.

OCD and JOCD cause the same kind of damage to the knee, but they are separate diseases. In the child who is still growing, the problem is much more likely to heal itself. In the adult, the bones are not growing. For this reason, the treatment and prognosis of OCD and JOCD can be very different.

Many doctors think that JOCD is caused by repeated stress to the bone. Most young people with JOCD have been involved in competitive sports since they were very young. A heavy schedule of training and competing can stress the femur in a way that leads to JOCD. In some cases, other muscle or bone problems can cause extra stress and contribute to JOCD.

Osteochondritis Dissecans

Sometimes JOCD is not treated or does not heal completely. When this happens, JOCD develops into OCD. OCD can occur any time from early adulthood on, but most patients are adults under age 50. The cases of OCD that are first diagnosed in early adulthood probably began as JOCD. When a person gets OCD later in life, it is probably a brand new problem.

Doctors aren’t sure what causes OCD. There is less of a link between strenuous, repetitive use and OCD. Many people who develop OCD don’t have any particular risk factors.

Because OCD leads to damage to the surface of the joint, the condition can lead to problems with bone degeneration and osteoarthritis. The damage to the joint surface affects the way that the joint works. Like a machine that is out of balance, over time this imbalance can lead to abnormal wear and tear on the joint. This is one cause of degenerative arthritis and osteoarthritis.

Symptoms

What do OCD and JOCD feel like?

OCD and JOCD cause the same symptoms. The symptoms start out mild and grow worse with time. Both problems usually start with a mild aching pain. Moving the knee becomes painful, and it may be swollen and sore to the touch. Eventually, there is too much pain to put full weight on that knee. These symptoms are fairly common in athletes. They are similar to the symptoms of sprains, strains, and other knee problems.

As the condition becomes worse, the area of bone that is affected may collapse, causing a notch to form in the smooth joint surface. The cartilage over this dead section of bone (the lesion) may become damaged. This can cause a snapping or catching feeling as the knee joint moves across the notched area. In some cases the dead area of bone may actually become detached from the rest of the femur, forming what is called a loose body. This loose body may float around inside of the knee joint. The knee may catch or lock when it is moved if the loose body gets in the way.

Diagnosis

When you visit First Choice Physical Therapy, our Physical Therapist will ask many questions about your medical history. We will ask about your current symptoms and about other knee or joint problems you have had in the past. Our Physical Therapist will then examine the painful knee by feeling it and moving it. You may be asked to walk, move, or stretch your knee. This may hurt, but it is important that we know exactly where and when your knee hurts.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

How is this condition treated?

Many cases of JOCD can be completely healed with careful treatment. OCD will probably never completely heal, but it can be treated. There are two methods of treating JOCD: nonsurgical treatment to help the lesions heal, and surgery. Surgery is usually the only effective treatment for OCD.

Non-surgical Rehabilitation

Nonsurgical treatments help in about half the cases of JOCD. Our goals are to help the lesions heal before growth stops in the thighbone and to protect the injured area of cartilage while improving knee motion and strength. Even if imaging tests show that growth has already stopped, it is usually worth trying nonsurgical treatments. When these treatments work, the knee seems as good as new, and the JOCD doesn’t seem to lead to arthritis.

Initially, it is crucial to stop doing everything that causes pain to the knee. This means stopping exercise and sports. It may require using crutches or wearing a cast for a couple of months when symptoms are present.

When you begin Physical Therapy at First Choice Physical Therapy, as knee symptoms ease, we can begin exercises that don’t involve placing weight through your foot. The exercises will be done carefully and should not cause any pain. Our Physical Therapist may advise that you do exercises in a pool to help you stay limber and fit while protecting the knee during this period.

Range-of-motion and stretching exercises are used to improve knee motion. Our Physical Therapist may issue shock-absorbing shoe insoles to reduce impact and protect your knee joint. We will also show you strengthening exercises for the hip and knee to help steady the knee and give it additional protection from shock and stress.

Although the time required for recovery varies, nonsurgical treatment of JOCD can take from 10 to 18 months. Some patients who are too near the end of bone growth may not benefit with nonsurgical treatment. When these problems develop, our Physical Therapist may refer you for surgical evaluation.

Post-surgical Rehabilitation

If you have surgery, your surgeon may have you use a continuous passive motion (CPM) machine after surgery to help the knee begin to move and to alleviate joint stiffness.

With the exception of arthroscopic removal of a loose body, our Physical Therapists advise patients to avoid putting too much weight on their foot when standing or walking for up to six weeks. This gives the area time to heal. Weight bearing is usually restricted for up to four months after transplant procedures.

Patients are strongly advised to follow the recommendations about how much weight is safe. You may require a walker or pair of crutches for up to six weeks to avoid putting too much pressure on the joint when you are up and about.

After surgery, your first few Physical Therapy treatments are designed to help control the pain and swelling from the surgery. Our Physical Therapists will also work with you to make sure that you are only putting a safe amount of weight on the affected leg.

We choose exercises to help improve knee motion and to get the muscles toned and active again. At first, emphasis is placed on exercising the knee in positions and movements that don’t strain the healing part of the cartilage. As the program evolves, our Physical Therapist will choose more challenging exercises to safely advance the knee’s strength and function.

Ideally, patients will be able to resume their previous lifestyle activities. Some of our patients may be encouraged to modify their activity choices, especially if an allograft was used.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, ensure safe weight bearing, and improve your strength and range of motion. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Surgery

If the lesion becomes totally or partially detached, surgery is needed to remove the loose body or to fix it in place. Your surgeon will need to gather lots of information about your knee and your problem before surgery.

This may require additional bone scans, X-rays, or MRIs. Your surgeon may also use an arthroscope, a tiny camera inserted into the knee to look at your knee before doing surgery to fix the problem. These tests are important because your surgeon needs to know the exact location and the size of the lesion to determine what kind of surgery will work best.

Arthroscopic Method

In some cases, your surgeon will be able to use the arthroscope to do the surgery. If the arthroscope can be used, the procedure requires smaller incisions than for an open surgery. This may reduce the time needed before the knee can be moved and exercised.

Open Method

Open surgery is needed when your surgeon can’t get a picture of the entire lesion, when it is unclear how the fragment would best fit into the bone, or when it would be too difficult to replace the fragment using the arthroscope. Open surgery usually requires larger incisions than arthroscopic surgery to allow the surgeon to see into the knee and perform the operation.

Fragment Repair

If the loose bone fragment is in a weight-bearing area of your bone, your surgeon will try to reattach it if at all possible. Your surgeon may use tiny metal pins or screws to hold the fragment in place. This sometimes proves difficult. The damaged fragment often doesn’t fit perfectly into the bone anymore. And the bone around the fragment has often changed in ways that mean your surgeon will need to rebuild it.

Despite the difficulties, reattaching the fragment generally results in much better knee function than removing it. Your knee will not be as good as new, but a careful plan of exercise and follow-up care can help you use your knee again without pain.

Allograft Transplant

In rare cases, the lesion must be removed from a weight-bearing area. Your surgeon may try to fill in the hole using an allograft. An allograft is an actual transplant of bone and cartilage from a donor into your knee. The bone is usually obtained from a bone and tissue bank.

In this case, bone material is transplanted into the hole left in the bone. Allografts have risks, including graft rejection and infection. But they can be very successful in returning function to the knee.

Osteochondral Autograft

An autograft is a procedure for grafting tissue from the patient’s own body. The place where the graft is taken is called the donor site. In this case, surgeons graft a small amount of bone (osteo) and cartilage (chondral) from the donor site to put into the lesion. Usually, the donor site for this procedure is on the joint surface of the injured knee. Surgeons are careful to take the graft from a spot that won’t cause a lot of problems, usually on the top and outside border of the knee cartilage. Even then, people sometimes end up with problems around the donor site. Surgeons have gotten good results with this surgery, but it is challenging to contour the graft to be just the same shape as the covering of the joint.

Autologous Chondrocyte Implantation

A new technology called autologous chondrocyte implantation is currently being developed. It involves using cartilage cells (chondrocytes) to help regenerate articular cartilage. This technology looks promising for treating JOCD and OCD but is still very much experimental.

The patella, or kneecap, can be a source of knee pain when it fails to function properly. Alignment or overuse problems of the patella can lead to wear and tear of the cartilage behind the patella. This produces pain, weakness, and swelling of the knee joint. Several different problems can affect the patella and the groove it slides through in the knee joint. These problems can affect people of all ages.

This guide will help you understand:

• how the kneecap works
• why kneecap problems develop
• what can be done to treat these problems

Anatomy

What is the patella, and what does it do?

The patella (kneecap) is the moveable bone on the front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone. The large quadriceps tendon together with the patella is called the quadriceps mechanism. Though we think of it as a single device, the quadriceps mechanism has two separate tendons, the quadriceps tendon on top of the patella and the patellar tendon below the patella.

Tightening up the quadriceps muscles places a pull on the tendons of the quadriceps mechanism. This action causes the knee to straighten. The patella acts like a fulcrum to increase the force of the quadriceps muscles.

The underside of the patella is covered with articular cartilage, the smooth, slippery covering found on joint surfaces. This covering helps the patella glide (or track) in a special groove made by the thighbone, or femur. This groove is called the femoral groove.

Two muscles of the thigh attach to the patella and help control its position in the femoral groove as the leg straightens. These muscles are the vastus medialis obliquus (VMO) and the vastus lateralis (VL). The VMO runs along the inside of the thigh, and the VL lies along the outside of the thigh. If the timing between these two muscles is off, the patella may be pulled off track.

Causes

How do these problems develop?

Problems commonly develop when the patella suffers wear and tear. The underlying cartilage begins to degenerate, a condition sometimes referred to as chondromalacia patella. Wear and tear can develop for several reasons. Degeneration may develop as part of the aging process, like putting a lot of miles on a car. The patellofemoral joint is usually affected as part of osteoarthritis of the knee.

One of the more common causes of knee pain is a problem in the way the patella tracks within the femoral groove as the knee moves. The quadriceps muscle helps control the patella so it stays within this groove. If part of the quadriceps is weak for any reason, a muscle imbalance can occur. When this happens, the pull of the quadriceps muscle may cause the patella to pull more to one side than the other. This in turn causes more pressure on the articular cartilage on one side than the other. In time, this pressure can damage the articular cartilage.

Weakness of the muscles around the hip can also indirectly affect the patella and can lead to patellofemoral joint pain. Weakness of the muscles that pull the hip out and away from the other leg, the hip abductor muscles, can lead to imbalances to the alignment of the entire leg – including the knee joint and the muscle balance of the muscles around the knee. This causes abnormal tracking of the patella within the femoral groove and eventually pain around the patella. Many patients are confused when their Physical Therapist begins exercises to strengthen and balance the hip muscles, but there is a very good reason that the therapist is focusing on this area.

A similar problem can happen when the timing of the quadriceps muscles is off. There are four muscles that form the quadriceps muscle group. As mentioned earlier, the VMO is one of these four muscles. The VMO is the section of muscle on the inside of the front of the thigh. The VL runs down the outside part of the thigh. People with patellofemoral problems sometimes have problems in the timing between the VMO and the VL. The VL contracts first, before the VMO. This tends to pull the patella toward the outside of edge of the knee. The result is abnormal pressure on the articular surface of the patella.

Another type of imbalance may exist due to differences in how the bones of the knee are shaped. These differences, or anatomic variations, are something people are born with. Some people are born with a greater than normal angle where the femur and the tibia (shinbone) come together at the knee joint. Women tend to have a greater angle here than men. The patella normally sits at the center of this angle within the femoral groove. When the quadriceps muscle contracts, the angle in the knee straightens, pushing the patella to the outside of the knee. In cases where this angle is increased, the patella tends to shift outward with greater pressure. This leads to a similar problem as that described above. As the patella slides through the groove, it shifts to the outside. This places more pressure on one side than the other, leading to damage to the underlying articular cartilage.

Biomechanical issues in the foot can change the alignment and rotation of the tibia and alter the angle of pull of the patella tendon. This too can lead to tracking problems of the patella in the femoral groove or breakdown of the patella tendon itself.

Finally, anatomic variations in the bones of the knee can occur such that one side of the femoral groove is smaller than normal. This creates a situation where the groove is too shallow, usually on the outside part of the knee. People who have a shallow groove sometimes have their patella slip sideways out of the groove, causing a patellar disclocation. This is not only painful when it occurs, but it can damage the articular cartilage underneath the patella. If this occurs repeatedly, degeneration of the patellofemoral joint occurs fairly rapidly.

People who have a high-riding patella are also at risk of having their patella dislocate. In this condition, called patella alta, the patella sits high on the femur where the groove is very shallow. Here the sides of the femoral groove provide only a small barrier to keep the high-riding patella in place. A strong contraction of the quadriceps muscle can easily pull the patella over the edge and out of the groove, leading to a patellar dislocation. Patella alta is most common in girls, especially those who have generalized laxity (looseness) in their joints.

Symptoms

What do patellar problems feel like?

When people have patellofemoral problems, they sometimes report a sensation like the patella is slipping. This is thought to be a reflex response to pain and not because there is any instability in the knee.

Others report having pain around the front part of the knee or along the edges of the kneecap. These symptoms may be due to problems with the way the patella lines up in the femoral groove. But symptoms of patellar pain can happen even when the patella appears to be lined up properly.

Patellofemoral problems exist when there is damage to the articular cartilage underneath the patella. This does not necessarily mean that the knee will be painful. Some people never have problems. Others experience vague pain in the knee that isn’t centered in any one spot. Sometimes pain is felt along the inside edge of the patella, though it may be felt anywhere around or behind the patella. Typically, people who have patellofemoral problems experience pain when walking down stairs or hills. Keeping the knee bent for long periods, as in sitting in a car or movie theater, may cause pain.

The knee may grind, or you may hear a crunching sound when you squat or go up and down stairs. If there is a considerable amount of wear and tear, you may feel popping or clicking as you bend your knee. This can happen when the uneven surface of the underside of the patella rubs against the femoral groove. The knee may swell with heavy use and become stiff and tight. This is usually because of fluid accumulating inside the knee joint, sometimes called water on the knee. This is not unique to problems of the patella but sometimes occurs when the knee becomes inflamed.

Diagnosis

When you visit First Choice Physical Therapy, your diagnosis will begin with out Physical Therapist taking a complete history of your knee problem followed by an examination of the knee, including the patella. Diagnosing problems with the patella can be confusing. The symptoms can be easily confused with other knee problems, because the symptoms are often similar.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Although the time required for recovery varies, patients with patellofemoral problems often benefit from four to six weeks of Physical Therapy. The aim of treatment is to calm pain and inflammation, to correct muscle imbalances, and to improve function of the patella.

Treatment for a patellar problem begins by decreasing the inflammation in the knee. Your Physical Therapist at First Choice Physical Therapy may suggest rest and anti-inflammatory medications, such as aspirin or ibuprofen, especially when the problem is coming from overuse. Physical Therapy can help in the early stages by decreasing pain and inflammation. Our therapist may use ice massage, ultrasound and electrical stimulation to limit pain and swelling.

As the pain and inflammation become controlled, our Physical Therapist will work with you to improve flexibility, strength, and muscle balance in the knee.

Muscle imbalances are commonly treated with stretching and strengthening exercises. Flexibility exercises are often designed for the thigh and calf muscles. Our Physical Therapist will use guided exercises to maximize control and strength of the quadriceps muscles.

Bracing or taping the patella can help you do exercises and activities with less pain. Most braces for patellofemoral problems are made of soft fabric, such as cloth or neoprene. You slide them onto your knee like a sleeve. A small buttress pads the side of the patella to keep it lined up within the groove of the femur. An alternative to bracing is to tape the patella in place. Our Physical Therapist applies and adjusts the tape over the knee to help realign the patella. The idea is that by bracing or taping the knee, the patella stays in better alignment within the femoral groove. This in turn is thought to improve the pull of the quadriceps muscle so that the patella stays lined up in the groove. Patients report less pain and improved function with these forms of treatment. Our Physical Therapist will also examine and address any biomechanical issues with the foot and ankle with manual therapy or strengthening.  He or she may also suggest special shoe inserts, called orthotics, to improve your knee alignment and function of the patella.

Post-surgical Rehabilitation

Most patients take part in formal Physical Therapy after knee surgery for patellofemoral problems. Patients undergoing a patellar shaving usually begin rehabilitation right away. More involved surgeries for patellar realignment or restorative procedures for the articular cartilage require a delay before going to therapy. And rehabilitation may be slower to allow the bone or cartilage to heal before too much strain can be put on the knee.

When you begin your First Choice Physical Therapy program, our first few Physical Therapy treatments are designed to help control the pain and swelling from the surgery. Our Physical Therapist will choose exercises to help improve knee motion and to get the quadriceps muscles toned and active again. Muscle stimulation, using electrodes over the quadriceps muscle, may be needed at first to get the muscle moving again.

As your program evolves, our Physical Therapist will choose more challenging exercises to safely advance the knee’s strength and function. The key is to get the soft tissues in balance through safe stretching and gradual strengthening.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, ensure you place only a safe amount of weight on the healing knee, and improve your strength and range of motion. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

X-rays may be ordered on the initial visit to your doctor. An X-ray can help determine if the patella is properly aligned in the femoral groove. Several X-rays taken with the knee bent at several different angles can help determine if the patella seems to be moving through the femoral groove in the correct alignment. The X-ray may show arthritis between the patella and thighbone, especially when the problems have been there for awhile. This is often refered to as chondromalacia patella.

Diagnosing problems with the patella can be confusing. The symptoms can be easily confused with other knee problems, because the symptoms are often similar. In these cases, other tests, such as magnetic resonance imaging (MRI), may be suggested. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. Usually, this test is done to look for injuries, such as tears in the menisci or ligaments of the knee. Recent advances in the quality of MRI scans have enabled doctors to see the articular cartilage on the scan and determine if it is damaged. This test does not require any needles or special dye and is painless.

In some cases, arthroscopy may be used to make the definitive diagnosis when there is still a question about what is causing your knee problem. Arthroscopy is an operation that involves placing a small fiber-optic TV camera into the knee joint, allowing the surgeon to look at the structures inside the joint directly. The arthroscope allows your doctor to see the condition of the articular cartilage on the back of your patella. The vast majority of patellofemoral problems are diagnosed without resorting to surgery, and arthroscopy is usually reserved to treat the problems identified by other means.

Surgery

If nonsurgical treatment fails to improve your condition, surgery may be suggested. The procedure used for patellofemoral problems varies. In severe cases a combination of one or more

of the following procedures may be necessary.

Arthroscopic Method

Arthroscopy is sometimes useful in the treatment of patellofemoral problems of the knee. Looking directly at the articular cartilage surfaces of the patella and the femoral groove is the most accurate way of determining how much wear and tear there is in these areas. Your surgeon can also watch as the patella moves through the groove, and may be able to decide whether or not the patella is moving normally. If there are areas of articular cartilage damage behind the patella that are creating a rough surface, special tools can be used by the surgeon to smooth the surface and reduce your pain. This procedure is sometimes referred to as shaving the patella.

Cartilage Procedure

In more advanced cases of patellar arthritis, surgeons may operate to repair or restore the damaged cartilage. The type of surgery needed for articular cartilage is based on the size, type, and location of the damage. Along with surgical treatment to fix the cartilage, other procedures may also be done to help align the patella so less pressure is placed on the healing cartilage.

Lateral Release

If your patella problems appear to be caused by a misalignment problem, a procedure called a lateral release may be suggested. This procedure is done to allow the patella to shift back to a more normal position and relieve pressure on the articular cartilage. In this operation, the tight ligaments on the outside (lateral side) of the patella are cut, or released, to allow the patella to slide more towards the center of the femoral groove. These ligaments eventually heal with scar tissue that fills in the gap created by the surgery, but they no longer pull the patella to the outside as strongly as before the surgery. This helps to balance the quadriceps mechanism and equalize the pressure on the articular cartilage behind the patella.

Ligament Tightening Procedure

In some cases of severe patellar misalignment, a lateral release alone may not be enough. For problems of repeated patellar dislocations, the surgeon may also need to realign the quadriceps mechanism. In addition to the lateral release, the tendons on the inside edge of the knee (the medial side) may have to be tightened as well.

Bony Realignment

If the misalignment is severe, the bony attachment of the patellar tendon may also have to be shifted to a new spot on the tibia bone. Remember that the patellar tendon attaches the patella to the lower leg bone (tibia) just below the knee. By moving a section of bone where the patellar tendon attaches to the tibia, surgeons can change the way the tendon pulls the patella through the femoral groove. This is done surgically by removing a section of bone where the patellar tendon attaches on the tibia. This section of bone is then reattached on the tibia closer to the other knee.

Usually, the bone is reattached onto the tibia using screws. This procedure shifts the patella to the medial side. Once the surgery heals, the patella should track better within the center of the groove, spreading the pressure equally on the articular cartilage behind the patella.

View animation of the bony realignment procedure

Arthroscopic procedures to shave the patella or a simple lateral release can usually be done on an outpatient basis, meaning you can leave the hospital the same day. If your problem requires the more involved surgical procedure where bone must be cut to allow moving the patellar tendon attachment, you may need to spend one or two nights in the hospital.

Bursitis of the knee occurs when constant friction on the bursa causes inflammation. The bursa is a small sac that cushions the bone from tendons that rub over the bone. Bursae can also protect other tendons as tissues glide over one another. Bursae can become inflamed and irritated causing pain and tenderness.

This guide will help you understand:

• what part of the knee is affected
• what causes this condition
• how doctors diagnose this condition
• what treatment options are available

Anatomy

What parts of the body are involved?

The pes anserine bursa is the main area affected by this condition. The pes anserine bursa is a small lubricating sac between the tibia (shinbone) and the hamstring muscle. The hamstring muscle is located along the back of the thigh.

There are three tendons of the hamstring: the semitendinosus, semimembranosus, and the biceps femoris. The semitendinosus wraps around from the back of the leg to the front. It inserts into the medial surface of the tibia and deep connective tissue of the lower leg. Medial refers to the inside of the knee or the side closest to the other knee.

Just above the insertion of the semitendinosus tendon is the gracilis tendon. The gracilis muscle adducts or moves the leg toward the body. The semitendinosus tendon is also just behind the attachment of the sartorius muscle. The sartorius muscle bends and externally rotates the hip. Together, these three tendons splay out on the tibia and look like a goosefoot. This area is called the pes anserine or pes anserinus.

The pes anserine bursa provides a buffer or lubricant for motion that occurs between these three tendons and the medial collateral ligament (MCL). The MCL is underneath the semitendinosus tendon.

Causes

What causes this problem?

Overuse of the hamstrings, especially in athletes with tight hamstrings is a common cause of goosefoot. Runners are affected most often. Improper training, sudden increases in distance run, and running up hills can contribute to this condition.

It can also be caused by trauma such as a direct blow to this part of the knee. A contusion to this area results in an increased release of synovial fluid in the lining of the bursa. The bursa then becomes inflamed and tender or painful.

Anyone with osteoarthritis of the knee is also at increased risk for this condition. And alignment of the lower extremity can be a risk factor for some individuals. A turned out position of the knee or tibia, genu valgum (knock knees), or a flatfoot position can lead to pes anserine bursitis.

Symptoms

What does the condition feel like?

The patient often points to the pes anserine as the area of pain or tenderness. The pes anserine is located about two to three inches below the joint on the inside of the knee. This is referred to as the anterior knee or proximedia tibia. Proximedia is short for proximal and medial. This term refers to the front inside edge of the tibia.

Some patients also have pain in the center of the tibia. This occurs when other structures are also damaged such as the meniscus (cartilage). The pain is made worse by exercise, climbing stairs, or activities that cause resistance to any of these tendons.

Diagnosis

When you visit First Choice Physical Therapy, we will take a history and do a physical examination. A history and clinical exam will help our Physical Therapist differentiate pes anserine bursitis from other causes of anterior knee pain, such as patellofemoral syndrome or arthritis. We will also assess hamstring tightness. This is done in the supine position (lying on your back). Our Physical Therapist will flex (bend) your hip to 90 degrees. Your knee is then straightened as far as possible. The amount of knee flexion is an indication of how tight the hamstrings are. If you can straighten your knee all the way in this position, then you do not have tight hamstrings.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

The goal of First Choice Physical Therapy treatment for overuse injuries such as pes anserine bursitis is to reduce the strain on the injured tissues. Stopping the activity that brings on or aggravates the symptoms is the first step toward pain reduction.

Reducing Inflammation 

Bedrest is not required but it may be necessary to modify some of your activities. This will give time for the bursa to quiet down and for the pain to subside. Our Physical Therapist will advise you to avoid stairs, climbing, or other irritating activities. This type of approach is called relative rest.

We may recommend the use of ice and anti-inflammatory medications in the early, inflammatory phase. The ice is applied three or four times each day for 10-15 minutes at a time. Ice cubes wrapped in a thin layer of toweling or a bag of frozen vegetables applied to the area work well.

Our Physical Therapists often instruct athletes to perform an ice massage. A cup of water is frozen in a Styrofoam container. The top edge of the container is torn away leaving a one-inch surface of ice that can be rubbed around the area. The Styrofoam protects the hand of the person holding the cup while applying the ice massage. The pes anserine area is massaged with the ice for 3-5 minutes or until the skin is numb. Caution is advised to avoid frostbite.

Over-the-counter nonsteroidal antiinflammatory drugs (NSAIDs) such as Ibuprofen may be advised. In some cases, the physician will prescribe stronger NSAIDs. Our Physical Therapist can also use a process called iontophoresis. Using an electric charge, an antiinflammatory drug can be pushed through the skin to the inflamed area. This method is called transdermal drug delivery. Iontophoresis puts a higher concentration of the drug directly in the area compared to taking medications by mouth. This process does not deliver as much drug as a local injection.

Increasing Flexability 

Improving flexibility is a key part of the prevention and treatment of this condition. Your Physical Therapist will advise that you perform hamstring stretches at least twice a day for a minimum of 30 seconds each time. Holding the stretch for a full minute has been proven even more effective. Some patients must perform this stretch more often – even once an hour if necessary.

Do not bounce during the stretch. Hold the position at a point of feeling the stretch but not so far that it is painful or uncomfortable. Deep breathing can help ease the discomfort. Try to stretch a little more as you breathe out.

Strengthening Exercises 

Quadriceps strengthening is also important. This is especially true if there are other areas of the knee affected. The quadriceps muscle along the front of the thigh extends the knee and helps balance the pull of the hamstrings.

Some times our Physical Therapists recommend a special type of exercise program called closed kinetic chain (CKC), performed for about six to eight weeks, to assist with quadriceps strengthening. The CKC may include single-knee dips, squats and leg presses. Resisted leg-pulls using elastic tubing are also included. This exercise program is gradually progressed during the eight-week session.

Prognosis for Pes Anserine Bursitis

Pes anserine bursitis is considered a self-limiting condition. This means it usually responds well to treatment and will resolve without further intervention. Athletes may have to continue our program of hamstring stretching and CKC quadriceps strengthening on a regular basis.

Athletes may return to sports or play when the symptoms are gone and are no longer aggravated by certain activities. Protective gear for the knee may be needed for those individuals who participate in contact sports. During our rehab process, activity level and duration are gradually increased. If the symptoms don’t come back, the athlete can continue to progress to full participation in all activities.

At First Choice Physical Therapy, our goal is to help speed your recovery so that you can more quickly return to your everyday activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Post-surgical Rehabilitation

If the bursa is removed, you follow the same steps of rehab and recovery outlined under Nonsurgical Treatment.

Surgery

Surgery is rarely needed for pes anserine bursitis. The bursa may be removed if chronic infection cannot be cleared up with antibiotics.

Plica syndrome is an interesting problem that occurs when an otherwise normal structure in the knee becomes a source of knee pain due to injury or overuse. The diagnosis can sometimes be difficult, but if this is the source of your knee pain, it can be easily treated.

This article will help you better understand:

• what a plica is
• how plica syndrome can cause problems
• what doctors can do to treat the condition

Anatomy

What is a plica, and what does it do?

Plica is a term used to describe a fold in the lining of the knee joint. Imagine the inner lining of the knee joint as nothing more than a sleeve of tissue. This sleeve of tissue is made up of synovial tissue, a thin, slippery material that lines all joints. Just as a tailor leaves extra folds of material at the back of sleeves on a shirt to allow for unrestricted motion of the arms, the synovial sleeve of tissue has folds of material that allow movement of the bones of the joint without restriction.

Four plica synovial folds are found in the knee, but only one seems to cause trouble. This structure is called the medial plica. The medial plica attaches to the lower end of the patella (kneecap) and runs sideways to attach to the lower end of the thighbone at the side of the knee joint closest to the other knee. Most of us (50 to 70 percent) have a medial plica, and it doesn’t cause any problems.

Causes

How does a plica cause problems in the knee?

A plica causes problems when it is irritated. This can occur over a long period of time, such as when the plica is irritated by certain exercises, repetitive motions, or kneeling.

Activities that repeatedly bend and straighten the knee, such as running, biking, or use of a stair-climbing machine, can irritate the medial plica and cause plica syndrome.

Injury to the plica can also happen suddenly, such as when the knee is struck in the area around the medial plica.

This can occur from a fall or even from hitting the knee on the dashboard during an automobile accident.

This injury to the knee can cause the plica, and the synovial tissue around the plica, to swell and become painful.

The initial injury may lead to scarring and thickening of the plica tissue later.

The thickened, scarred plica fold may be more likely to cause problems later.

Symptoms

What does plica syndrome feel like?

The primary symptom caused by plica syndrome is pain. There may also be a snapping sensation along the inside of the knee as the knee is bent. This is due to the rubbing of the thickened plica over the round edge of the thighbone where it enters the joint. This usually causes the plica to be tender to the touch. In thin people, the tissue that forms the plica may be actually be felt as a tender band underneath the skin. In rare cases where the plica has become severely irritated, the knee may become swollen.

Snapping Sensation

Diagnosis

When you visit First Choice Physical Therapy, we will begin your diagnosis with a history and physical exam. The examination is used to try and determine where the pain is located and whether or not the band of tissue can be felt.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

What can be done for plica syndrome?

The majority of people with plica syndrome will get better without surgery. The primary goal when treating the plica is to reduce the inflammation. This may require limiting activities like running, biking, or using a stair-climbing machine.

Non-surgical Rehabilitation

When you begin Physical Therapy at First Choice Physical Therapy, we may first suggest anti-inflammatory medications such as ibuprofen or aspirin to reduce the inflammation. Our Physical Therapist may also use ice packs or ice massage to help reduce the inflammation and swelling in the area of the plica. Ice massage is easy and effective. Simply freeze water in a paper cup. When needed, tear off the top inch, exposing the ice. Rub three to five minutes around the sore area until it feels numb.

Additionally, we may apply treatments such as ultrasound and friction massage to calm inflammation in the plica. Our therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can’t tolerate injections.

Once the inflammation is reduced, our Physical Therapist will begin treatments involving stretching and strengthening exercises for the leg.

Although the time required for recovery varies, if your treatment is nonsurgical, you should be able to return to normal activity within four to six weeks.

Post-surgical Rehabilitation

When you begin post-surgical Physical Therapy, our first few rehabilitation sessions will be designed to ease pain and swelling and help you begin gentle knee motion and thigh tightening exercises. Patients rarely need to use crutches after this kind of surgery.

As our program evolves, our therapist will choose more challenging exercises. Patients do closed chain exercises by keeping their foot on a surface while working the knee joint. These exercises mimic familiar activities like squatting down, lunging forward, and going up or down steps. These exercises help keep pressure off the kneecap while getting a challenging workout for the leg muscles. Our Physical Therapist will work with you to make sure you are not having extra pain in your knee during the exercises. We may also have you do stretches for the soft tissues along the edge of the kneecap as well as flexibility exercises for the hamstrings, quadriceps, and calf muscles.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, increase the strength of your quadriceps muscles, and maximize the range of motion in your knee. When your recovery is well under way, regular visits to our office will end. Although we  will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Surgery

If all nonsurgical attempts to reduce your symptoms fail, surgery may be suggested. Usually, an arthroscope (mentioned earlier) is used to remove the plica. The small TV camera is inserted into the knee joint through one-quarter inch incisions. Once the plica is located with the arthroscope, small instruments are inserted through another one-quarter inch incision to cut away the plica tissue and remove the structure. The area where the plica is removed heals back with scar tissue. There are no known problems associated with not having a plica, so you won’t miss it.

A popliteal cyst, also called a Baker’s cyst, is a soft, often painless bump that develops
on the back of the knee. A cyst is usually nothing more than a bag of fluid. These cysts occur most often when the knee is damaged due to arthritis, gout, injury, or inflammation in the lining of the knee joint. Surgical treatment may be successful when the actual cause of the cyst is addressed. Otherwise, the cyst can come back again.

This guide will help you understand:

• how a popliteal cyst develops
• why a cyst can cause problems
• what can be done for the condition

Anatomy

What is a popliteal cyst?

The knee joint is formed where the thighbone (femur) meets the shinbone (tibia). A slick cushion of articular cartilage covers the surface ends of both of these bones so that they slide against one another smoothly. The articular cartilage is kept slippery by joint fluid made by the joint lining (the synovial membrane). The fluid is contained in a soft tissue enclosure around the knee joint called the joint capsule.

Knee Joint

A popliteal cyst is a small, bag-like structure that forms when the joint lining produces too much fluid in the knee. The extra fluid builds up and pushes through the back part of the joint capsule, forming a cyst. The cyst squeezes out toward the back part of the knee in the area called the popliteal fossa, the indentation felt in the back part of the knee between the two hamstring tendons and the top part of the calf muscle.

Popliteal Fossa

Most people will be able to feel the cyst in the hollow area right behind the knee joint.

Causes

Why does a popliteal cyst develop?

A popliteal cyst may form after damage to the joint capsule of the knee. The weakening of the joint capsule in the damaged area can cause the small sac of fluid to form. This can lead to a bulging of the joint capsule, much like what occurs when an inner tube bulges through a weak spot in a tire. The cyst may become larger over time.

A popliteal cyst can actually be a response to other conditions that cause swelling in the knee joint. This swelling is most often from problems of osteoarthritis or rheumatoid arthritis in the knee joint. It can also be caused by trauma, either from a direct blow to the knee or from repetitive activities that lead to overuse in the knee joint. A popliteal cyst is not from of a blood clot in the leg, although sometimes it can be mistaken for a blood clot.

Symptoms

What does a popliteal cyst feel like?

The symptoms caused by a popliteal cyst are usually mild. You may have aching or tenderness with exercise or your knee may feel unsteady, as though it’s going to give out. You may feel pain from the underlying cause of the cyst, such as arthritis, an injury, or a mechanical problem with the knee, for instance a tear in the meniscus. Along with these symptoms, you may also see or feel a bulge on the back of your knee. Anything that causes the knee to swell and more fluid to fill the joint can make the cyst larger. It is common for a popliteal cyst to swell and shrink over time.

Sometimes a cyst will suddenly burst underneath the skin, causing pain and swelling in the calf. A ruptured popliteal cyst gives symptoms just like those of a blood clot in the leg, called thrombophlebitis. For this reason, it is important to determine right away the cause of the pain and swelling in the calf. Once the cyst ruptures, the fluid inside the cyst simply leaks into the calf and is absorbed by the body. In this case, you will no longer be able to see or feel the cyst. However, the cyst will probably return in a short time.

Diagnosis

When you visit First Choice Physical Therapy, we will ask you to describe the history of your problem. Then our Physical Therapist will examine your knee and leg. A physical exam is usually all that is needed to diagnose a popliteal cyst. Unless the cyst has ruptured, further testing is typically not needed.

Ruptured Cyst

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

What can be done for the condition?

There are two types of treatment for popliteal cysts: surgical and nonsurgical. Whether or not the cyst has ruptured, how painful the cyst has become, or how much it interferes with the normal use of your knee will determine which is the best course of treatment for you. In adults the treatment is most often nonsurgical. If surgery is needed, it is usually done on an outpatient basis, meaning you can leave the hospital the same day. Unless there is a lot of discomfort from the cyst, surgery is rarely required.

Non-surgical Rehabilitation

Nonsurgical treatments are usually most effective when the underlying cause of the cyst is addressed. In other words, the effects of arthritis, gout, or injury to the knee need to be controlled.

Your Physical Therapist at First Choice Physical Therapy may use massage treatments, compression wraps, and electrical stimulation to reduce knee swelling. We may also use flexibility and strengthening exercises for the lower limb to help improve muscle balance in the knee.

Our Physical Therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can’t tolerate injections.

Although the time required for recovery varies, with nonsurgical rehabilitation, a popliteal cyst may improve in two to four weeks. Improvement, however, depends a great deal on improvement in the underlying condition (the problems that are causing the knee to swell). As long as the joint continues to swell, the size of the cyst will ebb and flow. If the knee is kept from swelling, the cyst won’t swell.

If nonsurgical methods fail, complete removal of the cyst may be needed. Once they are reassured that the cyst is not dangerous, many people simply ignore the problem unless it becomes very painful.

Post-surgical Rehabilitation

If you have surgery to remove the cyst, you can resume your daily activities and work as soon as you are able. You should keep your knee propped up for several days to avoid swelling and throbbing. Take all medicines exactly as prescribed, and be sure to keep all follow-up appointments.

You may need to use crutches or a cane for awhile, and avoid vigorous exercise for six weeks after surgery. Although the time required for recovery is different for each patient, you should be able to resume driving about two weeks after surgery. Your Physical Therapist can then develop a personalized program to help you regain the strength in your leg.

Surgery

The goal of surgery is to remove the cyst and repair the hole in the joint lining where the cyst pushed through. Unfortunately, about half of the time the cyst comes back, or recurs, after being removed. Surgeons are cautious when suggesting surgery to remove a popliteal cyst because they are prone to recur. The cure is often permanent, but preventing further cysts depends a great deal on the success of treating the underlying cause. You should be aware that there is a very real chance that your cyst may return after being removed and there is no guarantee that the surgery will be successful.

Surgery can take more than an hour to complete. It is performed either under a general anesthetic, which causes you to sleep during the surgery, or using spinal anesthesia, which numbs the lower half of your body only. With spinal anesthesia, you may be awake during the surgery, but you won’t be able to watch what’s happening.

An incision will be made in the skin over the cyst.

The cyst is then located and separated from the surrounding tissues. The area of the joint capsule where the cyst appears to be coming from is identified.

A synthetic patch may be sewn in place to cover the hole in the joint capsule left by the removal of the cyst.

Your knee will be bandaged with a well-padded dressing and a splint for support.

Your surgeon will want to check your knee within five to seven days. Stitches will be removed after 10 to 14 days.

You may have some discomfort after surgery, and you will be given pain medicine to control the discomfort.

A popliteal cyst forms very near the major nerve and blood vessels of the leg. It is possible that these structures can be injured during surgery.

If an injury happens, it can be a serious complication. Injury to the nerves can cause numbness or weakness in the foot and lower leg. Injury to the blood vessels may require surgery to repair them.

In addition, it is uncommon but possible that another cyst can occur.

The posterior cruciate ligament (PCL) is one of the less commonly injured ligaments of the knee. Understanding this injury and developing new treatments for it have lagged behind the other cruciate ligament in the knee, the anterior cruciate ligament (ACL), probably because there are far fewer PCL injuries than ACL injuries.

This article will help you understand:

• where the PCL is located
• how a PCL injury causes problems
• how doctors treat the condition

Anatomy

Where is the PCL, and what does it do?

Ligaments are tough bands of tissue that connect the ends of bones together. The PCL is located near the back of the knee joint. It attaches to the back of the femur (thighbone) and the back of the tibia (shinbone) behind the ACL.

PCL

The PCL is the primary stabilizer of the knee and the main controller of how far backward the tibia moves under the femur. This motion is called posterior translation of the tibia. If the tibia moves too far back, the PCL can rupture.

Ruptured PCL

More recent research has shown us that the PCL also prevents medial-lateral (side-to-side) and rotatory movements. This confirms the suspicion that the PCL’s effect on knee joint function is more complex than previously thought.

The PCL is made of two thick bands of tissue bundled together. One part of the ligament tightens when the knee is bent; the other part tightens as the knee straightens. This is why the PCL is sometimes injured along with the ACL when the knee is forced to straighten too far, or hyperextend.

Both bundles of the PCL not only change length with knee flexion and extension, but they also change their orientation (direction of the fibers) from front-to-back and side-to-side. This function allows the ligament to keep the tibia from sliding too far back or slipping from side-to-side.

Causes

How do PCL injuries occur?

PCL injuries can occur with low-energy and high-energy injuries. The most common way for the PCL alone to be injured is from a direct blow to the front of the knee while the knee is bent. Since the PCL controls how far backward the tibia moves in relation to the femur, if the tibia moves too far, the PCL can rupture.

Sometimes the PCL is injured during an automobile accident. This can happen if a person slides forward during a sudden stop or impact and the knee hits the dashboard just below the kneecap. In this situation, the tibia is forced backward under the femur, injuring the PCL. The same problem can happen if a person falls on a bent knee. Again, the tibia may be forced backward, stressing and possibly tearing the PCL.

Other parts of the knee may be injured when the knee is violently hyperextended, but other ligaments are usually injured or torn before the PCL. This type of injury can happen when the knee is struck from the front when the foot is planted on the ground.

Symptoms

What does an injured PCL feel like?

The symptoms following a tear of the PCL can vary. The PCL is not actually enclosed inside the knee joint like the ACL. So unlike an ACL tear, which swells the joint with blood, PCL injuries don’t make the knee swell as much. Most patients with a PCL injury sense a feeling of stiffness and some swelling. Some patients may also have a feeling of insecurity and giving way of the knee, especially when trying to change direction on the knee. The knee may feel like it wants to slip.

The pain and moderate swelling from the initial injury will usually be gone after two to four weeks, but the knee may still feel unstable. The symptom of instability and the inability to trust the knee for support are what requires treatment. Also important in the decision about treatment is the growing realization by orthopedic surgeons that long-term instability leads to early arthritis of the knee.

Diagnosis

When you visit First Choice Physical Therapy, our Physical Therapist will take your history and do a physical exam. The history and physical examination are probably the most important tools in diagnosing a ruptured or deficient PCL. During the physical examination, we will perform special stress tests on the knee. Three of the most commonly used tests are the posterior Lachman test, the posterior sag test, and the posterior drawer test. The posterior drawer test is a very sensitive and specific test for PCL injuries. Our Physical Therapistwill place your knee and leg in various positions and then apply a load or force to the joint. Any excess motion or unexpected movement of the tibia relative to the femur may be a sign of ligament damage and insufficiency.

We will also do tests to see if other knee ligaments or joint cartilage have been injured. Damage to the PCL along with damage to the posterolateral corner (PLC) of the joint cartilage often leads to rotatory instability. This means the tibia slides back on the femur and twists or rotates at the same time. Rotatory instability can affect your ability to walk properly.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

At First Choice Physical Therapy, initial treatment for a PCL injury focuses on decreasing pain and swelling in the knee. Rest and mild pain medications, such as acetaminophen, can help decrease these symptoms. Our therapist may advise use of a long-leg brace and crutches at first to limit pain. Most patients are given the okay to put a normal amount of weight down while walking.

Less severe PCL tears are usually treated with a progressive rehabilitation program. Patients intending to return to high-demand activities may require a functional knee brace before returning to these activities. These braces are designed to replace knee stability when the PCL doesn’t function properly. They help keep the knee from giving way during moderate activity, but they can give a false sense of security and won’t always protect the knee during sports that require heavy cutting, jumping, or pivoting. These braces are not the type you can buy at the drugstore. Most Physical Therapists will recommend wearing a brace for at least one year after a reconstruction, so even if you decide to have surgery, a brace is probably a good investment.

When you visit, First Choice Physical Therapy, our Physical Therapist will treat your swelling and pain with the use of ice, electrical stimulation, and rest periods with your leg supported in elevation.

We will use exercises to help you regain normal movement of joints and muscles. Range-of-motion exercises should be started right away with the goal of helping you swiftly regain full movement in your knee. These include the use of a stationary bike, gentle stretching, and careful pressure applied to the knee by the Physical Therapist.

Our therapist will also give you exercises to do for improving the strength of the quadriceps muscles on the front of the thigh. As your symptoms ease and strength improves, we will guide you in specialized exercises to improve knee stability.

Nonsurgical treatment of an injured PCL will typically last six to eight weeks. You will be able to return to your sport activities when your quadriceps muscles are back to near their normal strength, your knee stops swelling intermittently, and you no longer have problems with the knee giving way.

Post-surgical Rehabilitation

You may use a continuous passive motion (CPM) machine immediately after your operation to help the knee begin to move and to alleviate joint stiffness. The machine straps to the leg and continuously bends and straightens the joint. This continuous motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint.

Our Physical Therapist may also have you wear a protective knee brace for up to six weeks after surgery. You’ll probably use crutches for two to four weeks in order to keep your knee safe and will probably be instructed to put only a limited amount of weight down while you’re up and walking.

Patients usually take part in formal Physical Therapy after PCL reconstruction. The first few Physical Therapy treatments are designed to help control the pain and swelling from the surgery. Therapists will begin to focus on range of motion exercises within three weeks. They take care to avoid letting the tibia sag back under the femur, as this can put strain on the healing graft.

Strengthening exercises for the quadriceps muscle on the front of the thigh are safe to begin right away. Muscle stimulation and biofeedback, which both involve placing electrodes over the quadriceps muscle, may be needed at first to get the muscle going again and help retrain it. As the rehabilitation program evolves, our Physical Therapist will choose more challenging exercises to safely advance the knee’s strength and function.

When you get full knee movement, your knee isn’t swelling, and your strength is improving, you’ll be able to gradually get back to your work and sport activities. Our Physical Therapist may prescribe the use of a functional brace for athletes who intend to return quickly to their sport.

Ideally, you’ll be able to resume your previous lifestyle activities. However, we usually advise athletes to wait at least six months before returning to their sport. And most patients are encouraged to modify their activity choices.

Overall, although recovery time varies, you will probably be involved in a progressive rehabilitation program for four to six months after surgery to ensure the best result from your PCL reconstruction. In the first six weeks following surgery, you can expect to see the Physical Therapist about two to three times a week. If your surgery and rehabilitation go as planned, it is possible that you may only need to do a home program and see your therapist every few weeks over the four to six month period.

Physician Review

Failure to diagnose a PCL injury can be a major cause of failure of surgery to repair a ruptured anterior cruciate ligament (ACL). The doctor may order X-rays of the knee to rule out a fracture. Ligaments and tendons do not show up on X-rays.

The magnetic resonance imaging (MRI) scan is probably the most accurate test without actually looking into the knee. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. The pictures show the anatomy, and any injuries, very clearly. This test does not require any needles or special dye and is painless.

In some cases, arthroscopy may be used to make the definitive diagnosis if there is a question about what is causing your knee problem. Arthroscopy is a type of operation where a small fiber-optic TV camera is placed into the knee joint, allowing the surgeon to look at the structures inside the joint directly. The vast majority of PCL tears are diagnosed without resorting to this type of surgery, though arthroscopy is sometimes used to repair a torn PCL.

Arthoscopy

Surgery

If the PCL alone is injured, nonsurgical treatment may be all that is necessary. When other structures in the knee are injured, patients generally do better having surgery within a few weeks after the injury. Long-term studies show that without reconstructive surgery, over time, knee instability and joint degeneration develop.

If the symptoms of instability are not controlled by a brace and rehabilitation program, then surgery may be suggested. The main goal of surgery is to keep the tibia from moving too far backwards under the femur and to get the knee functioning normally again. New studies also suggest the need to restore medial-lateral (side-to-side) and rotational stability, too.

Even when surgery is needed, most surgeons will have their patients attend Physical Therapy for several visits before the surgery. This is done to reduce swelling and to make sure you can straighten your knee completely. This practice reduces the chances of scarring inside the joint and can speed your recovery after surgery.

Most surgeons now favor reconstruction of the PCL using a piece of tendon or ligament to replace the torn PCL. This surgery is most often done using the arthroscope (mentioned earlier). Incisions are usually still required around the knee, but the surgery doesn’t require the surgeon to open the joint. The arthroscope is used to perform the work needed on the inside of the knee joint. Most PCL surgeries are now done on an outpatient basis, and most patients stay either one night in the hospital, or they go home the same day as the surgery.

In a typical surgical reconstruction, the torn ends of the PCL must first be removed. Once this has been done, the type of graft that will be used is determined. One of the most common tendons used for the graft material is the patellar tendon. This tendon connects the kneecap (patella) to the tibia.

About one third of the patellar tendon is removed, with a plug of bone at either end. The bone plugs are rounded and smoothed. Holes are drilled in each bone plug to place sutures (strong stitches) that will pull the graft into place. Then holes are drilled in the tibia and the femur to place the graft. These holes are placed so that the graft will run between the tibia and femur in the same direction as the original PCL. The graft is then pulled into position using sutures placed through the drill holes. Screws are used to hold the bone plugs in the drill holes.

Another very common graft involves using two of the three or four strips, the graft has nearly the same strength as a patellar tendon graft.

The gracilis and semitendinosus tendons can be taken out without really affecting the strength of the leg because bigger and stronger hamstring muscles will take over the function of the two tendons that are removed.

Other materials are also used to replace the torn PCL. In some cases, an allograft is used. An allograft is tissue that comes from someone else. This tissue is harvested from tissue and organ donors at the time of death and sent to a tissue bank. The tissue is checked for any type of infection, sterilized, and stored in a freezer. When needed, the tissue is ordered by the surgeon and used to replace the torn PCL. The advantage of using an allograft is that the surgeon does not have to disturb or remove any of the normal tissue from your knee to use as a graft. For this reason the operation also usually takes less time.

Prepatellar bursitis is the inflammation of a small sac of fluid located in front of the kneecap. This inflammation can cause many problems in the knee.

This guide will help you understand:

• how prepatellar bursitis develops
• why the condition causes problems
• what can be done for your pain

Anatomy

Where is the prepatellar bursa, and what does it do?

A bursa is a sac made of thin, slippery tissue. Bursae occur in the body wherever skin, muscles, or tendons need to slide over bone. Bursae are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts.

The prepatellar bursa is located between the front of the kneecap (called the patella) and the overlying skin. This bursa allows the kneecap to slide freely underneath the skin as we bend and straighten our knees.

Causes

How does prepatellar bursitis develop?

Bursitis is the inflammation of a bursa. The prepatellar bursa can become irritated and inflamed in a number of ways.

In some cases, a direct blow or a fall onto the knee can damage the bursa. This usually causes bleeding into the bursa sac, because the blood vessels in the tissues that make up the bursa are damaged and torn. In the skin, this would simply form a bruise, but in a bursa blood may actually fill the bursa sac. This causes the bursa to swell up like a rubber balloon filled with water.

The blood in the bursa is thought to cause an inflammatory reaction. The walls of the bursa may thicken and remain thickened and tender even after the blood has been absorbed by the body. This thickening and swelling of the bursa is referred to as prepatellar bursitis.

Prepatellar bursitis can also occur over a longer period of time. People who work on their knees, such as carpet layers and plumbers, can repeatedly injure the bursa. This repeated injury can lead to irritation and thickening of the bursa over time. The chronic irritation leads to prepatellar bursitis in the end.

The prepatellar bursa can also become infected. This may occur without any warning, or it may be caused by a small injury and infection of the skin over the bursa that spreads down into the bursa. In this case, instead of blood or inflammatory fluid in the bursa, pus fills it. The area around the bursa becomes hot, red, and very tender.

Prepatellar Bursa Infection

Symptoms

What does prepatellar bursitis feel like?

Prepatellar bursitis causes pain and swelling in the area in front of the kneecap and just below. It may be very difficult to kneel down and put the knee on the floor due to the tenderness and swelling. If the condition has been present for some time, small lumps may be felt underneath the skin over the kneecap. Sometimes these lumps feel as though something is floating around in front of the kneecap, and they can be very tender. These lumps are usually the thickened folds of bursa tissue that have formed in response to chronic inflammation.

The bursa sac may swell and fill with fluid at times. This is usually related to your activity level, and more activity usually causes more swelling. In people who rest on their knees a lot, such as carpet layers, the bursa can grow very thick, almost like a kneepad in front of the knee.

Finally, if the bursa becomes infected, the front of the knee becomes swollen and very tender and warm to the touch around the bursa. You may run a fever and feel chills. An abscess, or area of pus, may form on the front of the knee. If the infection is not treated quickly, the abscess may even begin to drain, meaning the pus begins to seep out.

Diagnosis

How do health care providers identify the condition?

When you visit First Choice Physical Therapy, our Physical Therapist will take a history and do a physical exam. The diagnosis of prepatellar bursitis is usually obvious from the physical examination. In cases where the knee swells immediately after a fall or other injury to the kneecap, X-rays may be necessary to make sure that the kneecap isn’t fractured. Chronic bursitis is usually easy to diagnose without any special tests.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

When you visit First Choice Physical Therapy, our treatment usually starts by trying to control the inflammation. Our Physical Therapist may suggest the use of heat, ice, and ultrasound to help calm pain and swelling. We may also suggest specialized stretching and strengthening exercises used in combination with a knee brace, taping of the patella, or shoe inserts. We use these exercises and aids to improve muscle balance and joint alignment of the hip and lower limb, easing pressure and problems in the bursa.

Our therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can’t tolerate injections.

Chronic prepatellar bursitis will usually improve over a period of time from weeks to months. The fluid-filled sac is not necessarily a problem, and if it does not cause pain, it is not always a cause for alarm or treatment. The sac of fluid may come and go with variation in activity. This is normal.

Post-surgical Rehabilitation

If surgery is required, you and your Physical Therapist will come up with a plan for your rehabilitation. Initially you will have a period of rest, which may involve using crutches. Then we will begin a careful and gradual exercise program.

At First Choice Physical Therapy, our goal is to help speed your recovery so that you can more quickly return to your everyday activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Physician Review

In cases where the knee swells immediately after a fall or other injury to the kneecap, X-rays may be necessary to make sure that the kneecap isn’t fractured. Chronic bursitis is usually easy to diagnose without any special tests.

If your doctor is uncertain whether or not the bursa is infected, a needle may be inserted into the bursa and the fluid removed. This fluid will be sent to a lab for tests to determine whether infection is present, and if so, what type of bacteria is causing the infection and what antibiotic will work best to cure the infection.

View animation of draining the prepatellar bursa:

If an infection is found to be causing the prepatellar bursitis, the bursa will need to be drained with a needle, perhaps several times over the first few days. You will be placed on antibiotics for several days. If the infection is slow to heal, the bursa may have to be drained surgically. To drain the bursa surgically, a small incision is made in the skin, and the bursa is opened. The skin and bursa are kept open by inserting a drain tube into the bursa for several days. This allows the pus to drain and helps the antibiotics clear up the infection.

Prepatellar bursitis that is caused by an injury will usually go away on its own. The body will absorb the blood in the bursa over several weeks, and the bursa should return to normal. If swelling in the bursa is causing a slow recovery, a needle may be inserted to drain the blood and speed up the process. There is a slight risk of infection in putting a needle into the bursa.

Chronic prepatellar bursitis is sometimes a real nuisance. The swelling and tenderness gets in the way of kneeling and causes pain. For people who need to kneel, this creates a hardship both in their occupation and recreational activities. Patients with prepatellar bursitis may benefit from two to four weeks of Physical Therapy.

Surgery

Surgery is sometimes necessary to remove a thickened bursa that has not improved with any other treatment. Surgical removal is usually done because the swollen bursa is restricting your activity.

To remove the prepatellar bursa, an incision is made over the top of the knee (either straight up and down or across the knee). Since the bursa is in front of the patella, the knee joint is never entered. The thickened bursa sac is removed, and the skin is repaired with stitches. You may need to stay off your feet for several days to allow the wound to begin to heal and to prevent bleeding into the area where the bursa was removed.

Some types of bursae will probably grow back after surgery, because the skin needs to slide over the kneecap smoothly. The body will form another bursa as a response to the movement of the patella against the skin during the healing phase. If all goes well, the bursa that returns after surgery will not be thick and painful, but more like a normal bursa.

Anatomy

Causes

Symptoms

Diagnosis

Our Treatment

Physician Review

Surgery

Anatomy

Causes

Symptoms

Diagnosis

Our Treatment

Physician Review

Surgery