Wednesday, February 13, 2008

My "achin" knees

So my daughter was in class and heard a sudden....eyyyyyooowwww!! Teacher then exclaims, does anyone know a sportsmedicine doctor.....index fingers proceeded to head to the general direction of my offspring. Apparently the teacher, Mrs. M was getting out of her car and as she placed her foot down, one of her knees (probably the knee cap or patella in particular) caused a sudden excruciating pain but then backed off and just ached from that point on. Improvement is probably already happening but with certain positions, the intensity returns just like the car, immobilizing her suddenly then leaving as fast as it came.
I didn't get much more information from my daughter but don't need it. As I always preach, 80% of a diagnosis can be attained from history taking alone. Physical exam backs up the history/diagnosis and tests like blood or xray support the physical exam. In 14 years I have come accustomed to the usual issues that befall the knee. With no preexisting issues like arthritis or surgery, the standard history like this is most likely a patellar injury.

To review the anatomy of the knee, we have a hinge joint like a door that opens and closes. Very simple movement, but this joint in particular is complicated in that it must be able to jump and sprint like a rabbit but at the same time be ready to hold in place up to 200 to 400 pounds (all this for an average of 70-80 years). The two big bones that make the knee are the thigh bone (or femur) and the shin bone (the tibia). These two bones rest on each other with little wafer-cusions (cartilage)between them. To be able to move these bones in a hurry and hold a great quantity of weight, we need long but thick muscles (the front thigh or quads). The Quad muscles originate from around the hip and insert to a small point on the shin. When the leg is straight, quads are straight, when the knee is bent like a squat, the muscle has to rub against something to get from the hip down to the shin. Like a spagetti noodle rubbing over the edge of a fork, it will eventually break so our creator made this thing called the patella that helps guide the muscle over the rough edge of a bent knee. This knee cap (patella) has a smooth surface that comes to a point like the bow of a ship. This bow sits in a groove in the thigh bone. As long as the "bow" is in the "groove" muscle works well, we sprint and lift weight without a problem for 80 years.

Great architecture right? Yes except for when the knee is bent and then is pivoted slightly. When the "bow" of the knee cap has enough force in the wrong direction, it will slip out of the "groove" and crack, scrape, chip the edge of the bow (knee cap). This smooth surface that coats the undersurface of the patella is very delicate and when a large ridge of bone pushes up against it, the soft surface dents, cracks, rubs off, chips. Next time you eat a thight bone from KFC, looks at the white soft cartilage that lines the joint you just broke open. its softer than bone but harder than muscle, easily chewed (or dented,scraped,rubbed,chipped).

I think with her mechanism of injury, our teacher, Mrs M. has suffered a patellar chondral contusion. (Bruise to the cartilage of the knee cap). As with all bruises or scrapes to skin, it takes about 10-14 days to have that scab fall off and skin to heal up right? Well in the case of a knee cap scrape, the knee is constantly being exposed to friction while we are asking it the heal up, this postpones the healing process. Keeping the knee straight (like "Fester from Gunsmoke" or "Madmax" from the Mel Gibson movies) will allow the patella to heal faster but without a big knee immobilizer and crutches from the ER, it's hard to remember to keep the knee straight. What usually happens is we have great intentions in the morning but as the day goes on, occasionally we get into a bad position and eyyyyyoooowww! That little scab to the backside of the knee cap tears open again and then its another 10-14 days of healing.

The Saguil Approach is to use ice during the first three days for 10 minutes at the top of every hour. After that its 10 minutes three times a day. An antiinflammatory is helpful and the good ones can be prescribed by me or the over the counters are sometimes used, (but I think they cause too much stomach upset.) I like using supplements like IF relief from Natures Sunshine or Zyflamend from New Chapter. Anything with turmeric, boswelia, white willow bark, shark cartilage, oregano...all good for speeding up the healing process. Acupuncture works great! (but it is a temporary relief while waiting for the "scab" to heal. Arnica and tea tree oil help. It always is useful for the physical therapist to show you some exercises to strengthen the quads and keep them holding down the patella in the right position. The gifted therapist who knows Maconnel taping can assist the knee cap in staying in the right "groove" for as long as the tape stays on the skin. When this fails and pain continues to the 3-4 week mark, time for xrays and a possible mri. The problem is; the only true way to diagnose a patellar surface injury is to visualize it directly with a surgical scope. Most of the surgeons (and me included) will try a steroid shot as a last ditch effort to reduce inflammation before considering surgical evaluation.