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Dealing with Knee Problems


DR DAVID SU
Medical Director
The Orthopaedic Centre

DR DAVID SU

Dr David Su, Medical Director at The Orthopaedic Centre, shares the common causes of chronic knee pain and other knee problems like knee osteoarthritis and Anterior cruciate ligament (ACL) tears.

Chronic knee pain for people below 45 is commonly caused by overdoing and overuse from sports. As for those above 45, the common cause is age-related wear and tear leading to degenerative knee conditions. Three common knee pain problems are Patellofemoral Pain Syndrome (runner’s knee), knee osteoarthritis and knee ligament and cartilage injuries.

Runner’s knee happens when the kneecap is misaligned and rubs against the lower end of the femur. This is often caused by repetitive stress on the knees due to an excessive running or cycling routine. Dr David Su recommended that runners incorporate cross-training in their fitness routine to get a good mix of load on joints and muscles. Some supplements can help to stimulate the formation and repair of the cartilage or keep it from deteriorating.

Knee osteoarthritis, which is the wearing away of the knee cartilage, is the most common form of knee arthritis. There is no cure for this degenerative disease but there are ways to decelerate the cartilage erosion. Shedding 5kg of weight, especially for those who are overweight, can reduce knee pain by 50%. Knee joint injections like hyaluronic acid and platelet rich plasma (PRP) therapy are common temporary measures as well.

ACL tear is the most common ligament injury, especially for soccer players. Physical therapy is often used to restore the knee. However, orthopaedic specialists may advise for ACL reconstruction in the case of complete ACL tears.

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DR Kannan
Senior Consultant
Centre for Foot and Ankle Surgery, Singapore

Article 3: Heel pain

Q: My 42 yr old aunt does a lot of running. She has heel pain problem, the pain goes where the Achilles tendon attaches to the heel bones, which interfere with her normal activities, particularly when she exercises. What are the causes factors? What can she do?

She most likely has Achilles tendon inflammation. There are two types of Achilles tendinosis (inflammation of the tendon), based upon which part of the tendon is inflamed- insertional tendinosis and non-insertional.

Pain occurring in the area where the Achilles tendon attaches to the heel bone is known as insertional Achilles tendinitis involving the lower portion of the tendon. This type of Achilles tendinosis is more common in the middle to older age group. A small group of patients may also have associated plantar heel pain (pain on the sole of the heel) due to plantar fasciitis (inflammation of the plantar fascia).

In non-insertional Achilles tendinitis, fibers in the middle portion of the tendon have begun to degenerate. Tendinitis of the middle portion of the tendon more commonly affects younger people.

Bone spurs (extra bone growth) often form with insertional Achilles tendinosis as a response to repetitive stress to the tendon. The tendinosis is typically not related to a specific injury and is a chronic degenerative condition. The bone spur (extra bone growth) where the Achilles tendon attaches to the heel bone can rub against the tendon and cause pain. Some patients experience pain and swelling that is present all the time and it gets worse throughout the day with activity.

In most cases, nonsurgical treatment options will provide pain relief, although it may take a few months for symptoms to completely subside. A structured physiotherapy program helps to condition and strengthen the Achilles tendon.

Surgery should be considered to relieve Achilles tendinosis only if the pain does not improve and it becomes difficult to wear shoes or preform simple day to day activities. It is best to discuss the options with your Orthopedic specialist. The specific type of surgery depends on the location of the tendinitis, amount of bone spurs and the amount of damage to the tendon. The goal of this operation is to remove any excessive bone spurs and repair the damaged part of the Achilles tendon. There are several techniques ranging from keyhole surgery to mini-open surgery for insertional Achilles tendinosis.

Heel pain 

Visual adapted from: https://www.123rf.com/stock-photo/83783048 Last assessed on 20.3.2018

Dr Tan Chyn Hong
Shoulder Knee Elbow
Specialist
The Orthopaedic Centre
TMBBS (Singapore), MRCS (Edinburgh),
MMED (Ortho), FRCS (Edinburgh)

Article 2:

Seeking treatment early may prevent need for replacements

I always observe how patients with knee pain walk into my consultation room. From that, I can tell which leg is hurting, and how bad it is hurting .

After all, knee pain is one of the most common symptoms that I see in my practice.

Mr X hobbled into my clinic one day, complaining of pain in both knees. He could not play golf, and even walking around a shopping centre with his wife was painful.

He had tried medication (painkillers, supplements, traditional Chinese medicine), medicated plasters, gels, walking aids, physiotherapy, lubricant injections and even had special shoes designed to shift the stress away from the knees.

He had read up extensively about the surgical options available and he wanted my opinion.

After looking at his X-ray scans, which showed severe osteoarthritis, and considering his age of 69, I recommended the most reliable operation for someone in his situation: A total knee replacement.

He then asked a question that I had heard many times before.

Was there any way to preserve his knee and avoid replacing it with metal and plastic?

My answer was no, not in his case - his arthritis was too advanced.

But I have wondered if I could have preserved his knees had he come to see me years earlier.

VITAL PARTS OF THE KNEE

Knee preservation surgery is a broad concept that uses minimally invasive keyhole techniques (arthroscopy) to preserve the vital components of the knee.

Knee arthritis occurs when there is cartilage damage, which causes pain and stiffness. Vital components of the knee that contribute to its longevity are the meniscus, cartilage and ligaments.

The meniscus is a crescent-shaped structure made of cartilage. It absorbs shock and stabilises the knee. Forty years ago, surgeons routinely removed the entire meniscus when it was torn.

We now know that removing the whole meniscus is a bad idea. Without it, the knee will almost always develop arthritis .

There is now a big push to repair a meniscal tear and even if you cannot repair it, only the torn potion should be removed.

The cartilage is the white shiny layer covering the ends of the bones. It has lubricating and shock-absorbing qualities. Once you damage it, however, it has limited potential of healing itself.

But we know that cartilage damage in the knee should be treated early. By the time the damage is widespread, there is little doctors can do to regenerate the cartilage.

The patient may have no choice but to undergo a knee replacement with metal and plastic components.

Mr Y, 49, a university lecturer, was fortunate. He sought help early and managed to preserve his knees.

An avid basketball player, he started to experience pain in both knees after a game. It worsened to a point where he could not stand in front of his class for more than 15 minutes.

Magnetic resonance imaging scans showed cartilage damage, as well as "loose bodies" in his knees - little pieces of bone and cartilage that form during the degeneration process. These free-floating objects occasionally jam up the knee, causing a sudden locking sensation.

It is like having a pebble in your shoe when you are walking.

The loose bodies accelerate cartilage damage, grinding away the cartilage when the knee moves.

The advantage of keyhole surgery is that even if both knees are operated on at the same time, the patient can often walk out of the hospital the next day.

Mr Y eventually underwent keyhole cartilage regeneration and removal of loose bodies in both knees. He is now able to stand and teach for an hour.

More importantly, he started playing "old man basketball". He described it as more passing, less running and jumping, and playing with people his own age.

If he continues to take care of his knees and modify his activities to avoid further wear and tear, he might not require a knee replacement at all.

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